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Palliative Medicine for the Physician

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Title: Palliative Medicine for the Physician


1
Palliative Medicine for the Physician
  • Rebecca L. Strickland, M.D.
  • Internal Medicine, PGY-3

2
Palliative Medicine
  • What is it?
  • When do I use it ?
  • What resources are out there to help me and my
    patient?

3
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

4
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

5
Palliative Medicine Objectives
  • To care, not cure.
  • To control suffering
  • Maximize the quality of life
  • Maximize the quality of death

6
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.

7
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.

8
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

9
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)

10
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.

11
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.)

12
Estimated Total Medicare Health Care Costs Per
Month Over Each of the Last 6 months of Life
(Adjusted for Patient Mix)
13
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

14
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

15
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

16
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17
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

18
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

19
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

20
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

21
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.

22
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

23
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

24
Hospice
  • Misunderstood
  • and
  • Under-utilized

25
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.

26
The Interdisciplinary Team
  • Physician
  • Nurses/ Nurses Aides
  • Chaplain(s)
  • OT/PT
  • Social Worker(s)
  • Volunteers
  • Case Managers

27
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

28
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

29
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

30
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.

31
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.

32
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

33
More Hospice Fast Facts
  • Payment Code-- G0065
  • Hospice is also a paid benefit of Medicaid in 43
    states, including North and South Carolina

34
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

35
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.

36
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.

37
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

38
Palliative Medicine Basic Choices
  • Palliative Medicine Consultation
  • Hospice Referral
  • Local Resources

39
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

40
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

41
Hospice Referral
  • Referrals can be made by anyone but the terminal
    diagnosis and life expectancy must be certified
    by a physician

42
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

43
Four levels of Hospice Care
  • Routine Home Care
  • Continuous Home Care
  • Respite Home Care
  • General inpatient Care

44
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

45
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

46
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

47
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.

48
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

49
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.

50
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.

51
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

52
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53
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

54
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.

55
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

56
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

57
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

58
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

59
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

60
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.

61
Community Resources Can Assist You with
Helping Your Patients Meet Their Needs --Do You
Know How to Use Them?
62
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

63
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

64
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.

65
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70
Palliative Medicine Objectives
  • To care when cure is not possible
  • To control suffering
  • To maximize quality of life
  • To maximize quality of death

71
Palliative Medicine
  • What is it?
  • When do I use it ?
  • What resources are out there to help me and my
    patient?

72
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
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