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Palliative Care Across the Continuum of Illness: An Introduction to Palliative Care

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Title: Palliative Care Across the Continuum of Illness: An Introduction to Palliative Care


1
Palliative Care Across the Continuum of Illness
An Introduction to Palliative Care
  • Melissa Schepp, MD
  • Director, Palliative Care
  • St. Josephs Hospital, Atlanta GA

2
LEARNING OBJECTIVES
  • Identify the principles of Palliative Care
  • Understand how Palliative Care applies across the
    spectrum of illness

3
Definition of Palliative Care (National Quality
Forum)
  • Palliative Care refers to patient- and
    family-centered care that optimizes
    quality-of-life by anticipating, preventing, and
    treating suffering.
  • Palliative care throughout the continuum of
    illness involves addressing physical,
    intellectual, emotional, social, and spiritual
    needs and facilitating patient autonomy, access
    to information, and choice

4
  • Palliative care comes from the word palliate,
    which means to ease.

5
What Is Palliative Care?
  • Specialty (ABMS 2008)
  • Addresses quality of life for seriously ill
    patients and their families
  • Covers a spectrum of care which encompasses
  • Multiple disciplines (MD, Nurse, Chaplain, SW)
  • Alleviation of symptoms
  • Assistance with information sharing/decision
    making
  • Coordination of resources

6
OLD VS NEW APPROACH
Medicare Hospice Benefit
Old
Life Prolonging Care
Disease Progression
Life Prolonging
New
Hospice Care
Care
Bereavement
Palliative Care
Diagnosis of serious illness
Death
7
PALLIATIVE CARE VS HOSPICE
Palliative Care
  • All of hospice
  • is palliative
  • care, but not
  • all of
  • palliative
  • care is
  • hospice

Hospice
8
Palliative Care, Why?
  • 1 Reason
  • Medical Progress
  • has changed the way we live
  • has changed the way we are sick
  • has changed the way we die

9
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12
Modern End of LifeProtracted Course
  • 85 of people in the US will experience one of
    these trajectories at the end of life
  • 20 Cancer
  • 25 Organ Failure
  • 40 Dementia/Frailty
  • Average American 2-4 years of disability before
    death

13
CURRENT NEEDS OF SERIOUSLY ILL PATIENTS and THEIR
FAMILIES
  • High degree of unmanaged or under-managed
    symptoms in patients with chronic and/or
    debilitating illnesses
  • Poor to non-existent communication regarding
    patient goals of care
  • Lack of coordination with patient and family
    preferences-need for advanced care planning

14
International Comparison of Spending on Health,
19802006
Average spending on healthper capita (US PPP)
Total expenditures on healthas percent of GDP
Data OECD Health Data 2008 (June 2008).
15
Inpatient Hospital Spending per Capita
Adjusted for Differences in Cost of Living
a
a
b
b
a2003 b2002
Source The Commonwealth Fund, calculated from
OECD Health Data 2006.
16
High Spending Poor OutcomesMortality Amenable
to Health Care
Deaths per 100,000 population
Countries age-standardized death rates before
age 75 including ischemic heart disease,
diabetes, stroke, and bacterial
infections. Data E. Nolte and C.M. McKee,
"Measuring the Health of Nations Updating an
Earlier Analysis," Health Affairs Jan.-Feb. 2008,
27(1)58-71 analysis of World Health Organization
mortality files. Source Commonwealth Fund
National Scorecard on U.S. Health System
Performance, 2008.
16
17
FINANCIAL IMPACT OF CURRENT MODEL OF CARE
  • Major financial crisis
  • Locally
  • Nationally

18
WHAT SERIOUSLY ILL PATIENTS WANT
  • Appropriate treatment of pain and other symptoms
  • Achieve a sense of control
  • Communication regarding their care
  • Coordinated care throughout the course of illness
  • Avoid inappropriate prolongation of the dying
    process
  • Relieve burdens on family
  • Strengthen relationships with loved ones
  • Sense of safety in the healthy care system

19
Hospital-Based Palliative Care Growth (2000-2009)
  • 658(24.5) ?168(63) 138
  • (Hospitals over 50 beds)
  • 85 of hospitals with gt300 beds
  • More likely in not-for-profit hospitals
  • Growth of Palliative Care in US Hospitals
    2011Snapshot, CAPC

20
BENEFITS TO HOSPITALS
  • Improved patient and family satisfaction
  • Improved quality of care for patients and their
    families
  • Meets the needs of an aging population
  • Assists in compliance with hospital care quality
    (Joint Commission)
  • Transition of patient to appropriate level of
    care-often reducing length of stay, especially in
    the ICU
  • Decreased hospital costs and resource utilization
  • Improved staff satisfaction and retention

21
PALLIATIVE CARE (THIS IS THE MESSAGE!)
  • Improve Quality of Life (Its about the living)
  • Goals of CarePlan of Care
  • Ensure patients treatments are goal-directed
  • NOT disease-directed
  • NOT technology driven

22
DO NOT ALLOW YOUR AWE FOR TECHNOLOGY AND OUR
ABILITY TO KEEP A BODY FUNCTIONING BLUR YOUR
DEFINITION OF LIFE.
23
THIS IS A SKILLLets put ourselves out of
business
  • Palliative Care teams must provide education and
    support to hospital staff regarding
  • symptom management
  • communication issues
  • ethical dilemmas
  • family conference/goal setting
  • resource utilization

24
TOOL 1Maslows Hierarchy
25
COMMON SYMPTOMS
ANXIETY/INSOMNIA
DYSPNEA
DEPRESSION
NAUSEA/DIARRHEA
FEAR/AGITATION
COUGH
FATIGUE/WEAKNESS
26
TOOL 2Patient Centered Interview
  • F FEELINGS related to the illness, especially
    fears
  • What are you most concerned about?
  • Do you have any specific fears or worries right
    now?
  • I imagine you have had many different feelings as
    you have coped with this illness.
  • Sometimes people have fears that they keep to
    themselves and dont tell their doctor.
  • I IDEAS and explanations of the cause of a
    symptom or illness
  • What do you think might be going on?
  • What do you think this pain means?
  • Do you have ideas about what might have caused
    this illness?
  • F FUNCTIONING, the illness impact on daily
    life
  • How has your illness affected you day to day?
  • What have you had to give up because of your
    illness?
  • What goals do you have now in your life? How has
    your illness affected your goals?
  • How does this illness affect important people in
    your life?
  • E EXPECTATIONS of the doctor the illness
  • What do you expect or hope I can do for you
    today?
  • Do you have expectations about how doctors can
    help?
  • What do you hope this treatment will do for you?

27
TOOL 3Family Meeting
  • Multidisciplinary
  • Format (templates available CAPC)
  • Team data demonstrates
  • 80 rate of multidisciplinary family conferences
    by Day 2 of consult
  • Tangible outcomes
  • Treatment goals
  • Resolution of conflicts
  • Advance Directives
  • Documented in the chart!

28
DIFFICULT DECISIONS
  • Are we preserving life or prolonging death?
  • When is chemo or radiation therapy palliative in
    nature and when is it curative?
  • PEG tube placement?
  • Do I want to be a DNR-what is a DNR?
  • IVFs? Hemodialysis?
  • What is quality of life?
  • Our job as palliative care providers is to
    gently help patients reach conclusions that are
    in line with their goals, then do our best to
    help them achieve those goals.

29
OLD VS NEW APPROACH
Medicare Hospice Benefit
Old
Life Prolonging Care
Disease Progression
Life Prolonging
New
Hospice Care
Care
Bereavement
Palliative Care
Diagnosis of serious illness
Death
30
Concurrent Care
  • Early Palliative Care of Patients with
    Metastatic Non-Small-Cell Lung Cancer Temel, J,
    NEJM 3638
  • 151 patients with new diagnosis metastatic NSC
    Lung Cancer
  • Randomized to Onc Care OR Onc Care Palliative
    Care

31
Results
  • Onc Palliative Care group
  • Reported better QOL
  • Less depression
  • Chose less aggressive care at EOL
  • Lived Longer (11.6 months vs. 8.9 months)

32
Non-hospice Palliative Care
  • Allocate resources by need, not prognosis
    (hospice)
  • Inpatient (ICU!! IPAL-ICU)
  • Outpatient Palliative Care Programs
  • Hospital-Based
  • Hospice/HH Based
  • Long-term Care Facilities
  • 25 of Americans die in NH
  • By 2030 NH population expected to double from 1.5
    million to 3 million

33
  • When a patient is severely ill, he is often
    treated like a person with no right to an
    opinion. It is often someone else who makes the
    decision if and when and where a patient should
    be hospitalized. It would take so little to
    remember that the sick person too has feelings,
    has wishes and opinions, and has-most important
    of all-the right to be heard.
  • Elisabeth Kubler-Ross, MD

34
Recommended Reading
  • Living Long in Fragile Health The New
    Demographics Shape End of Life Care, Joanne
    Lynn, MD (Hastings Center Report)
  • Letting Go. What Should Medicine Do When it Can
    Not Save Your Life?, Atul Gawande (New Yorker
    Article)
  • Handbook for Mortals, Joanne Lynn, MD
  • Hard Choices for Loving People Hank Dunn
    (Patient-Friendly Pamphlet)
  • Palliative Care Transforming the Care of
    Serious Illness, Diane Meier, et al

35
Other Resources
  • Center to Advance Palliative Care (capc.org)
  • American Academy of Hospice and Palliative
    Medicine (AAHPM.org)
  • Education in Palliative and End of Life Education
    (www.epec.net)
  • ELNEC (www.aacn.nche.edu/elnec)
  • EPERC (www.eperc.mcw.edu)
  • Fast Facts

36
REFERENCES
  • Kubler-Ross, E. (1969). On death and dying. New
    York, NY
  • Scribner.
  • Center to Advance Palliative Care (CAPC). (2008).
    Palliative care and hospice care across the
    continuum. http//www.capc.org/palliative-care-acr
    oss-the-continuum.
  • End-of-Life Nursing Education Consortium (ELNEC)
    (2007). Promoting
  • palliative care nursing. ELNEC-Core Training
    Program. City of Hope and American Association of
    Colleges of Nursing.
  • National Consensus Project (NCP) for Quality
    Palliative Care (2004). National consensus
    project for quality palliative care Clinical
    practice guidelines for quality palliative care,
    executive summary. Journal of Palliative
    Medicine, 7(5), 611-627.
  • National Quality Forum. (2006). A national
  • framework and preferred practices for palliative
    and hospice care A consensus report. Washington
    DC.

37
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