Palliative Care Vs. Curative Medicine

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Palliative Care Vs. Curative Medicine Speaker
Vicki Wilhelm, MDMedical Director, Sentara
Hospice for the Greater Peninsula and Western
Tidewater Region

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Sentara Home Health Hospice Services Greater
Peninsula Phone [phone]Serving
Williamsburg, Middle Peninsula and Peninsula
Region
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What is Restorative Medicine?
A cross-disciplinary approach for 21st century
medicine based on restoring organ function and
repairing tissue damage. It is not simply
treating symptoms and palliating medical
conditions. It combines complementary therapies
combined with lifestyle changes with the ultimate
goal to prevent future diseases and slow down the
progression of existing diseases.
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Curative Medicine

• Seeks a cure for an existent disease or medical
  condition
• Differs from preventive care which aims at
  preventing the appearance of diseases through
  immunization, exercise and lifestyle
  improvements
• Differs from symptomatic treatment which is
  medical therapy of a disease that only affects
  its symptoms not its causes (ex. Analgesic,
  anti-inflammatory, antitussives, antihistaminic,
  etc.)

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What is Palliative Care?

• Interdisciplinary medical care that aims to
  relieve suffering and improve quality of life for
  families and patients with advanced illness.
• It is offered simultaneously with all other
  appropriate medical treatment.
• Palliate From the Latin word pallium, meaning
  cloak
• To make less severe or intense

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Our Definition of Palliative Care

• Interdisciplinary care that
• Changes the medical approach from crisis
  intervention to crisis prevention through advance
  care planning and clarity re the goals of care.
• Assesses and works towards the relief of
  distressing symptoms and improvement of quality
  of life.
• Tends to the whole-person in the context of their
  family and their community.
• Provides access to support for patients and their
  families at any stage of illness and in any
  setting, regardless of prognosis.

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Palliative care is It is NOT

• evidence-based medical treatment
• vigorous care of pain and symptoms throughout
  illness
• care that patients want at the same time as
  efforts to cure or prolong life

• giving up
• provided in place of curative or life-prolonging
  care
• the same as hospice
• the same as comfort care

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What is Hospice?
Hospice is quality, compassionate care for
people with life-limiting or life-threatening
illness or injury. Care is tailored to each
patients needs and wishes with the goal being to
maximize patients quality of life as they travel
along this last journey.
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Why isHospice the Ultimate Gift?
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Goal of Hospice
The goal of hospice is to improve the quality of
life and provide comfort and dignity in
death. Hospice care neither prolongs life nor
hastens death. Hospice focuses on whole person
directed treatments with attention to family as
part of the experience.
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When to ask for Hospice Services

• Early! Crisis avoidance vs. Crisis intervention
• A proactive vs. a reactive approach
• more integrated, organized route to wholistic
  care for a patient and family and
• decreases stress and anxiety for all involved.

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ADMISSION
Admission to Hospice requires a Doctors
order.The Hospice staff can also provide an
evaluation for appropriateness of admission to
hospice and provide a recommendation back to the
provider.
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Disease Trajectories
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Disease Trajectories
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Where does Hospice occur?

1. At home
2. Independent or assisted living facilities
3. Long-term care or skilled care facilities
4. Hospital
5. Hospice inpatient units
6. Hospice House

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Dispelling Hospice Myths

• You do not need to be DNR to enter Hospice
• Hospice is not a 24-hour nurse coverage
• It relies on family and coordinates support
  including HHA
• Hospice patients are offered antibiotics for
  reversible infections
• Medications related to the admitting diagnosis
  are covered under the Hospice Benefit
• Hospice is liberal in its use of Opioids, but
  only in response to symptom management
• Hospice services have been shown to prolong
  survival and reduce costs at end of life.

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Interdisciplinary Hospice Team

• Patient and family
• The patients primary physician
• Hospice physician
• Nurses
• Certified nursing assistants
• Chaplains
• Social workers
• Music Care Services

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The Medicare Hospice Benefit

• Criteria
• Eligible for Part A of Medicare
• Terminally ill with a life expectancy of 6 months
  or less
• Coverage
• Physician services
• Medical care through the hospice Medical Director
• Case management
• Medical appliances and supplies
• Medications related to the terminal illness and
  palliation of symptoms
• Speech therapy
• Short-term inpatient and respite care
• Physical and occupational therapy
• Dietary counseling
• Homemaker and home health aide services
• Counseling and social work services
• Spiritual care
• Volunteer participation
• Bereavement services

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Prognosis

• Important factors to consider
• Co-morbid illnesses
• Rate of decline
• Nutritional status
• Functional status
• Cognitive status
• Age and gender
• Number of hospitalizations in past year
• Will to live
• Other (psychosocial, emotional and spiritual)

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The Prognosis

• A study in 2000 by Christakis and colleagues 10
  found that
• Prognostic accuracy generally erred on the side
  of optimism. Only 20 of physicians prognoses
  were accurate within 33 of actual survival time
• 63 were over-optimistic about life expectancy
• 17 underestimated survival time
• As the duration of the doctor-patient
  relationship increased, prognostic accuracy
  decreased.
• In general, there was an 8-fold overestimation of
  life expectancy for patients who died within 30
  days of the prognostic determination.
• 10 Christakis NA, Lamont EB, BMJ
  2000320469-472

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Medicare Hospice Benefit Eligibility

• Patients must be eligible for Medicare Part A,
• and
• The patients doctor and hospice medical director
  certify that s/he may have six months or less to
  live if their illness runs its normal course,
  and
• Patient chooses a Medicare approved Hospice
  program,
• and
• Patient signs a statement choosing hospice care
  instead of other Medicare-covered treatment
  options

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What does Medicare pay for?

• Physician and Nurse Services
• Medical Equipment
• Medical Supplies
• Medications for pain and symptom management
• Health Aide Services
• Social Worker Services

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Additional Medicare coverage

• Physical and Occupational Therapy
• Speech Therapy
• Dietary Counseling
• Short Term In-Patient Care
• Grief and Loss Counseling for patient and for
  patients family
• Short Term Respite Care (small co-pay applies)

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A patient can continue to qualify for hospice if
they are showing documented signs of decline and
at the time of recertification they still appear
to have less than six months of life expectancy.
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Hospice Medicare benefitdoes not cover

• Treatment intended to cure terminal illness
• Prescription drugs to cure illness rather than
  for symptom control or pain relief
• Room and board
• Care from providers not arranged by the hospice
  team, including
• Emergency Room care
• Inpatient facility care
• Ambulance transportation

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Important Reminder

• Medicare will still pay for covered benefits for
  any health problems that are not related to the
  terminal illness.

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Timing of Referrals to Hospice and Palliative
Care is Late

• Median length of stay in hospice 10 days
• 42 of hospice patients receive care for lt 1 week
  before death
• 4.8 180 days or more
• Median LOS in hospitals before palliative care
  consultation 18 days (CDC Natl Center for
  Health Statistics 2004)
• www.nhpco.org Mount Sinai Hospital Palliative
  Care Consult Service data
• CDC National Center for Health Statistics 2004

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Does hospice provide help to the family after the
patient dies?
Yes, hospice provides continued contact and
support for family and friends for a minimum of
13 months following the death of a loved
one. Team members of Sentara Hospice include
professional chaplains and counselors
specifically trained to provide bereavement
support.
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Why does it take several doctors to treat a
patient but only 1 nurse?
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Sentara Home Care Hospice Services
200 Enterprise DriveNewport News, VA
23603 Phone [phone]Fax [phone]
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