Palliative Medicine for the Physician

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Palliative Medicine for the Physician

• Rebecca L. Strickland, M.D.
• Internal Medicine, PGY-3

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Palliative Medicine

• What is it?
• When do I use it ?
• What resources are out there to help me and my
  patient?

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Objectives

• Define Palliative Medicine and Hospice
• Review Studies Which Support Its Use
• Learn Hospice Criteria For Admission
• Local Resources Explored- Assistance For Your
  Patients and You

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Definitions

• Palliative Medicine The active total care of
  patients, controlling pain and minimizing
  emotional, social and spiritual problems at a
  time when disease is not responsive to active
  treatment-- World Health Organization

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Palliative Medicine Objectives

• To care, not cure.
• To control suffering
• Maximize the quality of life
• Maximize the quality of death

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Eric Cassell on Suffering

• Occurring when a threat to the integrity of a
  person is perceived and continues until the
  threat passes or until the integrity of the
  person is reestablished.
• It is understood mostly in terms of physical pain
  but emotional and spiritual pain are also
  recognized parts of suffering.

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History of Palliative Medicine

• 1967 in London, England by Dr. Cicely
  Saunders,the first hospice house opens
• She recognized the need for effective symptom
  control, care of the patient and family as a
  unit, an interdisciplinary team approach, the use
  of volunteers, the continuum of care and family
  follow-up after a patients death.

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History

• 1970s Palliative medicine movement continues
  with the concept of death awareness
• Elizabeth Kubler-Ross develops theories on death
  and dying
• 1974 First hospice house in U.S. opens in New
  Haven, Connecticut

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National Hospice Study

• 2 years in duration
• 5,853 patients enrolled
• 25 hospices and 14 conventional care sites
  (inpatient, outpatient and combination
  oncological care sites)
• Selected and financed by the Health Care
  Financing Administration (HCFA)

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National Hospice Study

• Cancer patients admitted to the demonstration
  hospices between October 1,1980 and September 30,
  1982, and dying by December 1983
• Medicare Conventional Care (CC) cancer patients
  (from the 14 conventional sites) who were served
  during this period and died by June 1983 were the
  comparison sample.

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National Hospice Study

• Evaluated costs in relation to time proximity to
  time of death
• Compared total cost of each patients care during
  each 30 day time period (total inpatient,
  ancillary costs from inpatient days, home care
  costs etc.)

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Estimated Total Medicare Health Care Costs Per
Month Over Each of the Last 6 months of Life
(Adjusted for Patient Mix)
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Summary of Cost Savingsover the Last Year of Life

• HC vs. CC 2,221 saved/year
• HB vs. CC 585 saved/year
• The costs for hospice are higher and the savings
  are lower if the patient is enrolled for a longer
  period of time, but the savings are still evident
  

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Quality of Death Wallston KA et al.

• Secondary analysis of National Hospice Study data
• Comparison of home-care or hospital-based hospice
  with conventional care

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Quality of Death

• Developed by weighting physician reports of what
  the last 3 days of life were like as compared to
  how the patient stated they would like them to
  be.
• 13 situational elements examined
• Analysis of variance and analysis of covariance
  were done to rule out results obtained by chance
  or artifact

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Quality of Death

• The QOD for the two groups of hospice patients
  remained significantly higher (PCC patients and there was no difference between
  the two hospice groups

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The Lancet (April, 1984) A Randomized,
Controlled Trial of Hospice Care

• Terminally-ill cancer patients in a Veterans
  Administration Hospital
• Randomized to hospice (137) or conventional
  care (110)
• No significant differences in measures of pain,
  symptoms, ADLs or affect

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The Lancet A Summary

• Hospice patients expressed more satisfaction with
  the care that they received and caregivers
  expressed more satisfaction and less anxiety than
  those in the control group
• Hospice was not associated with reduced use of
  hospital inpatient days or therapeutic procedures
  and was at least as expensive as conventional
  care

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The Lancet Summary

• Since satisfaction with care was significantly
  higher with hospice at essentially equal cost,
  hospice should remain a viable option for
  end-of-life care

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The Lancet Downfalls of the Study

• Hospice consults only given the care of the
  patient remained with the conventional primary
  physician with limited help and advice provided
  for the patient and the caregiver by the hospice
  staff while hospitalized.

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The LancetDownfalls of the Study

• An inpatient hospice home was utilized much more
  than the traditional home hospice, increasing
  costs.
• Only 3 of the VA hospice cohort died at home as
  compared to 77 of routine hospice patients and
  17 of the general public

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The Lancet The Unofficial Summary

• The VA Hospice Care was not even close to ideal
  hospice care yet patient satisfaction was much
  higher. Costs were approximately equal despite
  the very low numbers of patients who were allowed
  to die at home where total costs are lowest.
• Hospice is a viable medical option

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Hospice

• Misunderstood
• and
• Under-utilized

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Hospice Fast Facts

• As of 1999, the National Hospice Organization
  (NHO) has knowledge of over 3,100 operational or
  planned hospice programs located in the 50
  states, the District of Columbia, Puerto Rico and
  Guam.

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The Interdisciplinary Team

• Physician
• Nurses/ Nurses Aides
• Chaplain(s)
• OT/PT
• Social Worker(s)
• Volunteers
• Case Managers

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Hospice Fast Facts

• NHO estimates that 540,000 patients were served
  by hospice in 1998
• 1995 60 of hospice patients had cancer, 6
  heart-related disease, 4 had AIDS, 2 had
  Alzheimers, 27 had other diagnoses
• 1 of every 2 cancer deaths in the US is cared for
  by hospice

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Hospice Fast Facts

• In 1998, the average length of stay was 51.3 days
• The median length of stay was 25 days
• In 1995, 77 of hospice patients died in their
  own personal residence, 19 died in an
  institutional facility and 4 in other settings

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Hospice Fast Facts

• Medicare per diem rates of reimbursement
• ----94.17 per day of home care
• ---418.93 per day of general inpatient care
• More than 90 of hospice care hours are provided
  in patients homes, thus substituting for more
  expensive inpatient care

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Hospice Fast Facts

• 28 of ALL Medicare costs go towards care of
  people in their last year of life almost 50 of
  those costs are expended in the last 2 months of
  life.
• Because of the documented savings, most private
  insurance companies also have a hospice benefit.

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Hospice Fast Facts

• 1995 study by Lewin-VHI commissioned by NHO
  showed that for every dollar spent on hospice,
  Medicare saved 1.52 in Part A and B
  expenditures.
• 3,192 saved in the last month of life as hospice
  home care days are often substituted for
  expensive hospitalizations.

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More Hospice Fast Facts

• Care of the patient by the PCP is encouraged in
  order to maintain the continuity of care adds
  to the sense of security and confidence in the
  system
• Physician time billable under Medicare Part B
  only one physician per 30 days, 30 minutes of
  care minimum required

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More Hospice Fast Facts

• Payment Code-- G0065
• Hospice is also a paid benefit of Medicaid in 43
  states, including North and South Carolina

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More Hospice Fast Facts

• The PCP may attend the IDT meetings or receive
  updates from the meetings
• Care of the hospice patient may be turned over to
  the hospice medical director at any time ensuring
  appropriate care and symptom management

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1996 Gallup PollCommissioned by NHO

• 9/10 adults would prefer to be cared for at home
  if terminally ill with
• When asked to name their greatest fear associated
  with death, being a burden to family and
  friends was most cited. Pain was the second
  most common.

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1996 Gallup Poll

• Nearly 90 of adults believe it is the familys
  responsibility to care for the dying
• 35 of the adults surveyed reported if terminally
  ill they would ask their doctor to help end their
  life.

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1996 Gallup Poll

• Most adults (62) believe it would take a year or
  more to adjust to the death of a loved one, yet
  few (10) of the public have ever participated in
  a bereavement program of grief counseling
  following a death of a loved one

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Palliative Medicine Basic Choices

• Palliative Medicine Consultation
• Hospice Referral
• Local Resources

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Palliative Medicine Consultation

• Usually an oncologist or internist
• Will see patients and families and assist in
  creating a plan of care acceptable to all
  involved (Family meeting)
• Patient evaluation for symptoms, pain and other
  concerns of the patient

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Palliative Medicine Consultation

• Recommendations for pain and symptom control via
  pharmacologic, invasive and non-invasive
  treatments
• Assistance with discharge placement
• Assistance with a good discharge checklist

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Hospice Referral

• Referrals can be made by anyone but the terminal
  diagnosis and life expectancy must be certified
  by a physician

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Hospice Referral

• Use prognosis guidelines to assist with a timely
  referral to hospice, a life expectancy of 6
  months or less is essential for eligibility

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Four levels of Hospice Care

• Routine Home Care
• Continuous Home Care
• Respite Home Care
• General inpatient Care

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Benefits of Hospice to Patients

• The patient becomes a team member, remains with a
  sense of control
• A sense of security with the ability to contact a
  nurse by phone 24 hrs/day
• Patients and families become better educated to
  make end-of-life decisions
• Relief of financial stress and burden

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Benefits of Hospice to Patients

• Spiritual support to help comfort patient
• Need not be admitted to a hospital for care, can
  choose to die at home, comfortable and out of
  pain
• Patients are better served with adequate symptom
  control, thereby maximizing the quality of life
• Better quality of death

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Benefits of Hospice to Families

• Advance care directives are addressed by the
  patient prior to absolute need, thereby taking
  the burden off families who may otherwise have to
  try to guess the patients wishes
• Family members are taught how to care for the
  patient at home

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Benefits of Hospice to Families

• Support offered to the family by the IDT helps to
  prevent the overwhelming sensations of burden,
  helplessness and burnout.
• The family is comforted to know that the patient
  care is not being compromised, even if the
  patient is dying at home.

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Benefits of Hospice to Families

• Other community agencies can be employed to help
  take care of the patient and assist the family
• Support groups are available
• Family members are better equipped to deal with
  death and bereavement

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General Guidelines for Determining Prognosis

• To assist with determination of non-cancer
  end-stage diseases
• 1. The patients condition is life limiting and
  the patient and/or family has been informed of
  this determination.

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General Guidelines for Determining Prognosis

• 2. The patient and/or family have elected
  treatment goals directed toward symptom relief
  rather than cure of the underlying disease.

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General Guidelines for Determining Prognosis

• 3. The patient has either documented clinical
  progression of the disease as seen in the disease
  specific criteria, multiple E.R. visits,
  increased home nursing needs, a marked decline in
  functional status --or-- Documented recent
  impaired nutritional status related to the
  terminal disease
  

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General Guidelines for Determining Prognosis

• Functional status decline documentation
• Dependence in at least 3 of 6 ADLs bathing,
  dressing,feeding, transfers, continence of stool
  and bladder, and ability to ambulate
  independently to the bathroom
• --or-- A Karnofsky score of 50 or less

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Karnofsky Performance Status Scale

• 100--normal, no complaints
• 80--normal activity with effort
• 70--cares for self unable to carry on normal
  activity or active work
• 60--requires occas. assistance but able to care
  for most of own needs
• 50--requires considerable assistance and
  frequent medical care. Disabled.

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Karnofsky Performance Status Scale

• 40--Unable to care for self, requires
  institutional care, disease may be progressing
  rapidly
• 30--Severely disabled hospital admission
  indicated
• 20--Very sick active supportive tx
• 10--Moribund
• 0--Dead

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Barriers to Providing Palliative Care

• Lack of education of healthcare professionals-
  understanding admission criteria for hospice,
  misunderstandings of control issues,
  uncomfortable talking with patients
• Lack of education of the public
• Late referrals

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Barriers to Providing Palliative Care

• Caregiver stress
• Time factor for physicians
• Legal and regulatory constraints for obtaining
  opioid medications
• Adequate nursing staff to care for the dying
• Fiscal constraints on length of stay

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Approaches to Improving Palliative Care

• EDUCATION! of the public and physicians
• Physicians can then learn to uncover the various
  layers of concerns that are important to those
  who are dying. Once concerns are brought to
  light, much can be done to address them

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Vachon et al. Meta-analysis

• Four studies examined
• Determined major symptoms associated with
  terminal cancer
• Pain, fatigue, appetite disturbances,
  psychological distress and dyspnea were found to
  occur in the majority of patients in at least one
  study

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Vachon et al. Unmet Needs

• Common practical services and instrumental
  activities of daily living
• Housework(29), nursing care(17), financial
  assistance during treatment (17), family housing
  during treatment, shopping, cooking, cleaning etc.

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Community Resources Can Assist You with
Helping Your Patients Meet Their Needs --Do You
Know How to Use Them?
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Community Resources Can Help Meet These Unmet
Needs

• Social workers from the hospital, hospice or
  clinics are excellent resources for locating
  services needed.
• Churches
• Yellow pages of the phone book
• Government pages of the phone book-local social
  service agencies
• Internet

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Forsyth County Resources for Palliative Care and
Unmet Needs

• Hospice of Winston-Salem and Forsyth County, Inc.
• Cancer Services, Inc.
• Human Service Alliance
• Senior Services, Inc.
• American Cancer Society
• First Line Directory of Community Services

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Forsyth County Resources

• Assistance with support groups, living
  arrangements, counseling, Meals on Wheels,
  transportation, respite care, medication and
  treatment, wigs, makeup, in-home aide services,
  housing placement, financial assistance, legal
  services, adult daycare, visitation etc.

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Palliative Medicine Objectives

• To care when cure is not possible
• To control suffering
• To maximize quality of life
• To maximize quality of death

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Palliative Medicine

• What is it?
• When do I use it ?
• What resources are out there to help me and my
  patient?

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Many Thanks To

• Dr. Ramon Velez- for his insight and suggestions
• Dr. Dick Stevenson of Hospice- for his time and
  input
• Christine Brandon--the computer queen