There comes a time where we all need a little extra help! Transitioning loved ones to a senior living community can be stressful and overwhelming. Many questions can arise, and information is key in making this important decision.

What are the Different Types of Senior Living?

The following Senior Living Community categories can be stand-alone or be part of a campus that includes several levels of care. Traditionally, types of Senior Living may be referred to as Levels of Care.

Independent Living (Private Pay)

Independent Living is perfect for individuals 55+ who are able to manage their activities of daily living and personal affairs. Think of someone who you’d label as “self-sufficient”. These campuses offer a variety of apartment sizes and fees are dependent on size and add-on services. For example, add-on services might include things like meal plans, housekeeping, and internet, however add-on services are not always included. No state licensure is needed to operate an independent living facility.

Independent Living (Housing Authority Communities and Senior Housing)

For a more budget-friendly option, there are options outside of private pay independent living. These may be referred to as Housing Authority Communities or Senior Housing. These housing options are designated for financially limited seniors. Instead of a staff, you may see a Property Manager overseeing operations. If you or a loved one need additional financial assistance, consider looking into Illinois’ Community Care Program through Medicaid. This program can provide services such as personal care and household assistance.

Assisted Living

Easily shown by its name, Assisted Living facilities are designed to accommodate individuals 55 and older who need assistance with personal care. However, this personal care is not the level of care provided in nursing homes. Care services vary due to ownership, but may include services like meals, transportation, or medication management. Additionally, these facilities may look similar to independent living as they usually are single apartments (rarely shared) offered in a variety of sizes. Assisted Living communities are licensed by the Illinois Department of Public Health.

Supportive Living Facility

For seniors who are 65+ and in need of financial aid through Medicaid, Supportive Living Facilities may be the perfect match. These facilities offer the same access to assistance as an Assisted Living Facility; however, they are licensed by the Illinois Department of Health and Family Services. Supportive Living Facilities are required to hire Certified Nursing Assistants (CNAs).

• Long Term Care provides personal and nursing care to persons who are unable to care for themselves. These facilities can be private pay or Medicaid or a combination of both.

• Rehabilitation Nursing Facility provides short-term rehabilitation services (typically post-hospital) such as Physical Therapy, Occupational Therapy, and Speech Therapy.

Memory Care

Memory care facilities are created to provide care to those living with Alzheimer’s and Dementia. Since care for those with dementia is so unique, these facilities are secured for safety and staff are required to undergo specialized training. Additionally, these communities are required to document what distinguishes the facility as appropriate for those with dementia. Your loved one can expect a smaller community with activities tailored for those with memory loss.

What Should you Take into Account When Choosing a Community?

• Level of care needed
  • Will you need temporary care or long term? What kind of support do you need?
• Payment Source
  • Will you opt for Private Pay or depend on help from Medicaid or other financial support (i.e. Veteran and spouse benefits)?
• Your lifestyle, interests, and preferences (i.e. gardening, walking areas, exercise, meal service)
• Transportation Options
• Ratings based on state inspections
  • Inspection scores can be found at IDPH’s website.
• Location
  • Is your personal support system close by?
  • What locations will make visiting convenient for them?
  • Are you near places you like to visit? (ex. Church, parks, favorite coffee shop)
• Ownership and Management

What Resources Can You Use to Research?

Marion Area	Belleville Area
Williamson County Housing Authority	Programs and Services for Older People (PSOP)
Jackson County Housing Authority	St. Clair County Office of Housing & Urban Development
City of Marion Housing Authority	Southwestern Illinois Visiting Nurses Association (SIVNA)
Egyptian Area Agency on Aging	Age Smart (Area Agency on Aging)

For a more general overview, check out websites like www.caring.com or A Place for Mom.

When is the Best Time to Consider Senior Living?

The best time to consider a senior community is before you need it! Touring and making tentative choices can eliminate the urgency in the event of the unexpected. Think of it like choosing a college, it’s best to be educated and take tours before the time comes to make a choice. It’s important to remember to do the investigative work when your friends, family, or support system have time to tour with you. Additionally, make an appointment with the communities you are considering, so the staff can ensure they spend ample time with you.

However, disaster does not have to strike to transition to senior living. Sometimes, this change can be relative to your individual situation. Things like care of your home becoming a burden or loneliness can be the perfect catalyst to make a change.

The International Forum for the Study of Itch defines itching, medically known as “pruritus”, as the unpleasant sensation that provokes an urge to scratch. Conditions specific to the skin, underlying systemic issues, or a combination of both can cause itching. Pruritus is a relatively common and frequently frustrating symptom encountered in end-of-life care.

Common Causes

Dermatologic conditions, such as dryness, wetness, or irritation from eczema, psoriasis, or local irritants, most frequently cause localized pruritus. Skin naturally dries as we age, and hydration of the skin is the primary treatment with emollients and moisturizers. Cooling agents, such as Calamine or Menthol, can be helpful with itching also. If local inflammation is present on the skin, topical steroid creams and ointments are a solution to treat the underlying skin condition in many cases.

Metabolic derangements can also be a cause of itching, including liver failure, kidney failure, and hypothyroidism. Liver failure or liver malignancies can produce cholestasis, a condition that impairs the flow of bile from the liver to the small intestine, causing increased bilirubin levels. This typically causes generalized pruritus that can be worse on the palms and soles. Kidney failure produces a build-up of uremia, and uremic pruritus is a common symptom in individuals with renal failure, particularly those on chronic dialysis treatment. This itching is typically generalized and can be continuous or intermittent. Uncontrolled hypothyroidism can also lead to generalized pruritus and overall skin dryness.

Hematologic disorders, including iron deficiency, leukemia, lymphoma, and polycythemia vera can cause itching that is often aquagenic, meaning exacerbated by contact with water. Other solid organ malignancies, such as breast cancer, anal cancer, and prostate cancer, can generate itching around the tumor site, often associated with an overlying rash. Infestations with scabies or lice and yeast infections can cause itching in the area affected. Treatment of the underlying infecting organism is the treatment of choice.

Patients and Pruritus

Patients with HIV infection and AIDS have a higher prevalence of pruritus. Underlying skin infections, reactions to treatment medications, or subsequent viral-induced neuropathy are all causes. The pruritus may be generalized or localized to the area of the skin issue.

A true allergic cause of pruritus can also be present. This can develop due to a medication allergy or contact dermatitis due to an underlying agent. However, some medications can cause itching, not in the setting of a true allergy. In other words, the medication makes you itch, but you are not allergic to it. In a hospice setting, opioid use is usually the culprit. Some antibiotics, aspirin, and anti-inflammatory agents can also produce the same reaction. With opioids, the pruritus is typically generalized and may even cause hives. Persistent opioid-induced pruritus only occurs in 1% of patients, but up to 10% of patients may have transient symptoms.

Psychogenic itching can also be present. A true cause for the itching cannot be determined, but the scratching can become dramatic. In a hospice setting, this is common for patients with dementia.

Solutions

Regardless of the underlying cause, proper education on skin care strategies for all patients with itching is essential. These include hydration and lubrication of the skin, avoiding fragrances and irritants, and maintaining a cool external environment. Topical treatments are an option in the aforementioned situations. Systemic medications used to treat itching typically work quickly, when effective. Thus, if a prescribed anti-itch medication is not helping within a day, it is reasonable to attempt treatment with another class of medication.

Antihistamines, such as Benadryl or Zyrtec, are useful if the itching is due to a true allergic response. A class of anti-nausea medications, 5HT3 antagonists (ex. Zofran), can be helpful for patients with pruritus due to cholestasis, uremia, or opioid use. An older cholesterol-reducing medication, cholestyramine, can be helpful for cholestatic pruritus. Antidepressants, as a class, may be effective for pruritus due to multiple causes. Finally, two medications, typically used to treat neuropathic pain, gabapentin, and pregabalin, have also been found to be effective for multiple types of itching.

In summary, itching may be a common annoyance for many of us from time to time, but when the itching persists and becomes a hindrance to the quality of life, treatment is necessary. It is always best to treat the underlying cause of the pruritus if known. However, when that is not possible, due to end-stage disease, we must find ways to treat the symptom and minimize morbidity. At Hospice of Southern Illinois, our mission is to improve the quality of life for those touched by terminal illness. Sometimes that means something as simple as making the itch go away.

References:

1. Dalal MD S. Overview of pruritus in palliative care. Uptodate.com. May 10, 2021.
2. Von Gunten C MD, Kammell MD A, Ferris MD, F. Fast Facts Pruritus. Palliative Care Network of Wisconsin. Aug 2020.

In hospice care, our primary goal is to maximize patient comfort while adhering to a patient’s and family’s goals of care. We work to accomplish these goals by employing an interdisciplinary team approach to address all aspects of the patient’s plan of care. Of course, medications are a mainstay of our treatment plan to ensure patient comfort and symptom palliation. A class of medications that can elicit questions on benefit and purpose is certainly antibiotics.

Proper Use of Antibiotics

I would imagine that most of us have been prescribed an antibiotic for some ailment throughout our lives. Over the last ten years, inappropriate antibiotic use has been a focus area for the CDC (Centers for Disease Control) and WHO (World Health Organization). In 2013, both organizations declared antibiotic resistance a national and global threat. In their joint statement, they stated that “Antibiotic use is the most important modifiable driver of antibiotic resistance.” Vast campaigns were employed to educate both prescribers and patients about the risks of inappropriate antibiotic usage. Per Dr. Amesh Adalja, MD, the Infectious Diseases Society of America Spokesperson, “Antibiotics are misused so often because of the belief that these are benign drugs, and that patient satisfaction depends upon being prescribed an antibiotic.”

In a hospice population, our patients are at a higher risk for infection and are at higher risk for more severe infections due to the nature of their underlying illnesses and morbidity. However, our patients are also at higher risk of medication toxicities. Thus, we must balance these two issues based on patient and/or family preference. Hospice-based studies report overall antimicrobial use ranging from 8-37%, and 27% of hospice patients receive at least one antibiotic in the last week of life. At Hospice of Southern Illinois, we strive to focus on “Person-Centered Care”. Hence, we confirm there is evidence to support the treatment, the benefit of treatment outweighs the risks, and the patient and/or family should be involved in the decision-making process.

Are Antibiotics the Right Fit?

When determining if an antibiotic is appropriate in end-of-life care, consider multiple factors. In addition to comfort and symptom goals, we look at estimated prognosis, swallowing function of the patient, and the risk of infection progression and/or recurrence. Regarding antibiotics in hospice care, most of the evidence for symptom benefit exists for urinary tract infections, with a symptom response rate up to 92%. Respiratory illnesses are often viral, and symptom responses can vary from 0-53%. Bloodstream infections, commonly known as sepsis, have the least symptomatic benefit from antibiotics. Also, the administration of antibiotics rarely improves symptoms in the last week of life.

As mentioned above, antibiotics can have side effects, varying from mild to severe and acute to irreversible. These can include nausea, vomiting, loose stools, rash, agitation, secondary yeast infections, electrolyte imbalances, cardiac arrhythmias, seizures, renal toxicity, and anaphylaxis. Equally important, certain antibiotics should also have reduced doses or increased dosing intervals due to declining kidney or liver function. However, this declining function may not always be apparent in a hospice patient as routine laboratory studies are often aborted for patient comfort. There are also multiple possible antibiotic-drug interactions to consider.

The Importance of Collaborative Planning

It is important to involve the patient and the caregiver early in the care-planning process to discuss and document antibiotic preferences. Planned discussions at the time of hospice admissions or care plan meetings should be utilized, as well as any changes in patient condition. When an infection is suspected based on patient symptomatology or diagnosed based on laboratory or imaging studies, health care providers and caregivers should first focus on whether the infection symptoms are impacting the quality of life. If so, we should then default to our patient’s preferences based on prior discussions.

Non-antibiotic symptom management approaches should always be part of the infection plan of care, with or without antibiotics. Furthermore, these techniques support antibiotic stewardship, compliance with organizational recommendations, and patient advocacy. Please reach out to Hospice of Southern Illinois as your preferred end-of-life care provider. Above all, we take pride in our care of our patients and families and our community at large.

References:

1. Rosenberg JH, Albrecht JS, Fromme EK, et al. Antimicrobial use for symptom management in patients receiving hospice and palliative care: a systematic review. J Palliat Med. 2013: 16(12):1568-1574.
2. Albrecht JS, McGregor JC, Fromme EK, et al. Nationwide analysis of antibiotic use in hospice care in the final week of life. J Pain Symptom Manage. 2013;46(4):483-490.
3. Vitetta L, Kenner D, Sail A. Bacterial infections in terminally ill hospice patients. J Pain Symptom Manage. 2000;20(5):326-334.
4. White P, Kuhlenschmidt H, Vancura B, Navari R. Antimicrobial use in patients with advanced cancer receiving hospice care. J Pain Symptom Manage. 2003;25(5):438-443.
5. Reinbolt R, Shenk A, White P, Navari R. Symptomatic treatment of infections in patients with advanced cancer receiving hospice care. J Pain Symptom Manage. 2005;30(2):175-182.
6. Baghban A, Juthani-Mehta M. Antimicrobial use at the end of life. Infect Dis Clin N Am. 2017;31:639-47.
7. Givens JL, Jones RN, Shaffer ML, Kiely DK, Mitchell SL. Survival and comfort after treatment of pneumonia in advanced dementia patients. Arc Intern Med. 2010:170(13):1102-1107.
8. Nakagawa S, Toya Y, Okamoto Y, et al. Can anti-infectives drugs improve the infection-related symptoms of patients with cancer during the terminal stages of their lives? J Palliat Med. 2010:13(5):535-540.
9. Sinert MS, Schmidt MM, Lovell AG, et al. Guidance for safe and appropriate use of antibiotics in hospice using a collaborative decision support tool. J Hosp Pall Nurs. 2020:22(4)1-7.

By: Kathryn Storm, PharmD PGY2 Pain Management and Palliative Care Pharmacy Resident VA St. Louis Health Care System & Emily Oliver, PharmD PGY2 Hospice and Palliative Care Pharmacy Resident Hospice of Southern Illinois

Steroids are commonly prescribed medications. You may know steroids as a drug that treats allergic reactions or bad colds. However, there’s more than meets the eye when it comes to this customary drug. Steroids, such as prednisone, Medrol DosePaks, hydrocortisone, and methylprednisolone, aid in a wide array of non-traditional reasons in end-of-life care.

Uses of Steroids in Hospice & Palliative Care

In palliative care, steroids manage several different symptoms associated with severe diseases during end-of-life care. In palliative and hospice care, they can help treat fatigue, pain, trouble breathing, nausea, vomiting, and poor appetite. 

When terminally ill patients are feeling fatigued, steroids can help boost their energy. This can help our loved ones feel more like themselves. Therefore, increasing their ability to participate in the activities that mean the most to them. This drug also has anti-inflammatory effects, which makes them beneficial in treating certain pain conditions. Used in conjunction with other medications, such as opioids, steroids soothe pain. They can also assist with breathing issues. They work by opening up the airways in the lungs, and the anti-inflammatory properties help prevent inflammation within the lungs; thus, making breathing easier and more comfortable. Regarding nausea and vomiting, steroids are efficacious in controlling and preventing symptoms. They work by decreasing the chemicals in the brain that lead to feelings of nausea.

Lastly, they can assist patients who lose their appetite during end-of-life care. By promoting our body’s hunger signals, patients feel hungry and able to eat.

Side Effects of Steroids

As with all medications, side effects can happen. The most common side effects include weight gain, insomnia, mood changes or swings, changes in blood pressure, higher blood sugars in patients with diabetes, and fluid retention. If used for long periods, they may also increase the risk of infection. 

In summary, given the wide variety of symptoms, they help manage, steroids used to treat severe disease and end-of-life care are beneficial for patients. They are generally well-tolerated and effective medications for patients in the palliative and hospice care setting. Improving the quality of life and making our loved ones more comfortable are some of the many great uses of steroids.

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Resources: 

1. Cardenas-Mori, J., & Lewis-Ramos, V. (2020). Corticosteroids for common palliative care symptoms #395. Journal of Palliative Medicine, 23(7), 987–989. 

2. Shih, A., & Jackson, K. C. (2007). Role of corticosteroids in Palliative Care. Journal of Pain & Palliative Care Pharmacotherapy, 21(4), 69–76.

State statutes govern Death certificates. Certification and completion of the certificate is typically the responsibility of the attending physician, or the physician in charge of the patient’s care, at the time of death. Effective January 1, 2022, in Illinois, an advanced practice registered nurse may complete and sign a death certificate. According to 410 ILCS 535/ Vital Records Act, the completed and signed by the provider within 48 hours after death, except when the death is subject to the coroner’s or medical examiner’s investigation. Also, each death that occurs in Illinois shall be registered by filing a death certificate with the local registrar of the district in which the death occurred, or the body was found, within seven days after such death and before cremation or removal of the body from the State with the same exception for coroner’s or medical examiner’s cases.

Components of the Document

Regarding the medical section of the document itself, there are two components: the cause of death and contributing conditions. The cause of death is based on the medical opinion of the provider. When there is not 100% certainty as to the cause of death, it is appropriate for the provider to document “unknown” or “probable”. The cause of death includes three sections: mechanism, immediate cause, and underlying cause of death. As an example, a patient’s immediate cause of death could be acute respiratory distress syndrome, due to pneumonia, due to COVID-19. Contributing conditions could include diabetes and obesity as both increases the risk of morbidity and mortality from COVID-19.

The National Center for Health Statistics also collects data from death certificates about risk factors. Death certificates inquire as to whether tobacco contributed to the death. In addition, one section asks if the deceased was pregnant within the year or if the death was work-related.

Deaths that fall under the jurisdiction of the medical examiner or coroner vary by region. The statutes and regulations of local health codes publish reporting requirements. As a general rule, reportable deaths include accidents, suicides, homicides, poisoning, drug intoxication, a disease with potential public health threat, deaths resulting from employment, deaths related to medical or surgical complications, suspicious deaths, deaths of individuals in police custody, and unattended deaths.

Thus, what seems like a simple document, has a large reach in terms of public health. To complete the document comprehensively and accurately, it is imperative to have inclusive medical records. At Hospice of Southern Illinois, we strive to complete death certificates for our families timely and accurately.

2022 is here! A time to celebrate new beginnings, but don’t forget to be proud of all you accomplished in 2021. In this blog, we are celebrating 21 Ways Hospice of Southern Illinois made an impact in 2021. At Hospice of Southern Illinois, we take pride in serving our communities. Since 1981, we have been a grass-roots, volunteer movement with offices in Belleville and Marion, Illinois. Our mission is to help patients and their loved ones in the end-of-life journey. Since our founding, we continue the tradition of focusing on quality of life, peace, and dignity for the patients in the communities we serve.

We are a free-standing, not-for-profit hospice. Our goal is to be your #1 choice in providing hospice care to your family and friends. Above all, thank you for your support in our 40 years of caring. We look forward to serving our communities in 2022!

1. Celebrated 40 years of serving our patients and their families – Hospice of Southern Illinois is an experienced leader in end-of-life care.
2. Served over 44,000 families since 1981 – We are your local, not-for-profit hospice with our roots starting right here in the Metro-East and Southern Illinois.
3. Donation from Carlyle Lion’s Club- In 2021, Hospice of Southern Illinois was one of the Carlyle Lion’s Club’s three recipients of a donation at their annual planning meeting. These funds helped provide supplies to our patients.
4. Flag Day Celebration – In June, Clinton County Vietnam Veterans participated in our flag folding ceremony in honor of Flag Day.
5. Business After Hours– During July of 2021, we hosted the Greater Belleville Chamber of Commerce’s “Business After Hours” event to celebrate our 40th anniversary with our communities. This event had a “Christmas in July” theme! Business After Hours serves as an opportunity for networking and collaboration between our community partners.
6. First Annual Blood Drive – Hospice of Southern Illinois hosted our first blood drive with over 30 donors.
7. Dementia Live – Our Marion and Belleville offices began offering Dementia Live, a training simulation dedicated to better understanding patients with Dementia. Therefore, we can inspire our community to better understand the Dementia population.
8. Volunteer Parade – To replace our Volunteer Luncheon with a more COVID-friendly event, Hospice of Southern Illinois hosted a volunteer drive-thru parade. This event was a way to thank our volunteers. Through our volunteers, Hospice of Southern Illinois is able to bring assistance to our patients, families, and community.
9. African American Health Fair – Our Marion team attended Shawnee Community College’s health fair. This fair featured topics focused on People of Color and allowed us to educate attendees about our hospice services.
10. Employee Appreciation Day– You can’t give from an empty cup! At Hospice of Southern Illinois, our priority is keeping our team’s cup full, so they can continue to provide amazing care and support. Our Marion office hosted a food truck, and our Belleville offices provided a box lunch for all staff.
11. Bringing Life to Hospice featuring Barbara Karnes, RN – American Hospice Pioneer, award-winning nurse, author of Gone From My Sight, and NHPCO Hospice Innovator Award winner Barbara Karnes made a guest appearance on our podcast to share her journey as a hospice provider. She was able to share her unique expertise with our listeners.
12. Golf Tournament in Belleville and Marion – 2021 brought Belleville’s 22^nd and Marion’s 19^th annual golf tournaments. The funds raised from our annual golf tournaments help us care for our patients and further our mission.
13. Hometown Heroes- We awarded goodies to the Highland EMS and Firefighters who exemplified outstanding service after a fire at Cedarhurst of Highland.
14. Honor Flight in Marion – Our volunteers participated in Southern Illinois Veteran’s Honor Flight #7 at the Veteran’s Airport of Southern Illinois, honoring retired military personnel!
15. NHDD Airpod Contest – Our podcast hosted a giveaway to promote awareness of National Healthcare Decision Day!
16. Pet Therapy Program–We welcomed Charlie as Hospice of Southern Illinois’ newest therapy pet. Charlie visits patients in long term care and assisted living facilities to bring joy to patients and families.
17. Valentines from Students – Hospice of Southern Illinois partnered with area schools to create Valentine’s cards for residents at long-term care and assisted living facilities.
18. Reuniting Families– A local Mother and Daughter were reunited at Aviston Countryside Manor after 7 months of separation due to COVID-19 protocols. Watch the video on our Facebook page!
19. Flowers from Women of Hope Women of Hope provided flowers for Hospice of Southern Illinois. As a result, our volunteers were able to make 75 bouquets for patients and families!
20. Assisted Living Garden– Our Hospice Volunteer department planted a garden for a local assisted living facility.  Collaborating with our facilities on activities to boost resident’s morale. 
21. Great Place To Work – Last but not least, we are proud to be Great Place to Work Certified for the second year in a row! Much gratitude to our hospice team for their commitment to our organization.