Best of palliative care

Transcription

1 Best of palliative care Summer School Palliativmedizin Dr. Eve Rubli Chaire de soins palliatifs gériatriques CHUV Lausanne

2 Geriatric Palliative Care CHUV, Lausanne Endowed professorship, supported by the CHUV, the University of Lausanne and private foundations Attached to the Services of Geriatrics and Palliative Care Since May 2016: Pr Ralf Jox, Dr Eve Rubli (tandem) Aims: Strengthen geriatric palliative care as an academic discipline and collaboratively conduct urgently lacking research Improve the education of various health care professionals on pre- and post-graduate levels Contribute to the provision of best possible care for elderly patients near the end of their lives, in particular outside the hospital

3 Plan 1. Care transitions during the trajectory of dementia (J Am Ger Soc 2016) 2. Emergency department use by dementia patients (Palliat Med 2015) Source: CHUV

4 Diagnosis and Disruption: Population-Level Analysis Identifying Points of Care at Which Transitions Are Highest for People with Dementia and Factors That Contribute to Them Sivanantham S et al. J Am Geriatr Soc 2016, 64: 569 Aims: to examine transitions that individuals with dementia experience longitudinally and to identify points of care when transitions are highest and the factors that contribute to those transitions Background: Transition = physical move from one location to another with a stay of at least 1 night Transitions: necessary or not; inevitable or not; challenge and risks! 80% elderly people have acute hospitalizations before LTCF, 43% confused at admission

5 Study design: Population-based 10-year retrospective cohort study from 2000 to 2011 Methods: Methods Study setting: British Columbia, Canada, 4.6 million inhabitants 7 databases: demographic information, medical services plan payment file, inpatient surgery admission, vital statistics death file Study population: individuals > 65 years old, newly diagnosed with dementia in

6 Sivanantham S et al. J Am Geriatr Soc 2016

7 Sivanantham S et al. J Am Geriatr Soc 2016

8 Transitions for People with Dementia and Factors That Contribute to Them Sivanantham S et al. J Am Geriatr Soc 2016

9 Participant factors associated with transition

10 Association between dementia care and primary care and transitions experienced in year of diagnosis Sivanantham S et al. J Am Geriatr Soc 2016

11 Discussion: Conclusion Over the 10-year trajectory, 2 points of care during which a high number of transitions identified: year of diagnosis and year of and year before death Spike in transition = primarily hospitalizations Take-home message: Year of diagnosis = overwhelming period of distress during which major decisions about care need to be made. It could be an opportunity for a point of intervention Improving advance care planning Increasing caregiver awareness of community support Education and information about the management of dementia

12 Community-based palliative care is associated with reduced emergency department use by people with dementia in their last year of life: A retrospective cohort study Rosenwax L et al. Palliat Med 2015, 29:727 Question: To assess whether community-based palliative care is associated with a different use of emergency departments (EDs) in the last year of life by people who died of dementia Background: Patients with dementia often present to EDs, especially in the last year of life ED treatment of dementia patients associated with distress, complications and unnecessary treatments (indicator of poor quality out-of-hospital care) In cancer patients, community-based palliative care reduced the use of EDs at the end of life also true for dementia?

13 Methods Design: Retrospective cohort study Sample: Patients with diagnosis of dementia who died between Jan 2009 and Dec 2010 in Western Australia (2.5 million inhabitants), obtained from death records Comparative cohort of patients with other terminal diseases amenable to palliative care and no dementia (e.g., cancer, ALS, HF, LF, ESRD, COPD ) Community-based pall care = palliative care at the usual place of residence (home or long-term care facility): symptom control, counselling, respite options, psychosocial support Data on emergency treatment obtained via the Health Department (hospital discharge records etc.)

14 Rosenwax L et al. Palliat Med 2015

15 Use of community-palliative care in last year of life Rosenwax L et al. Palliat Med 2015

16 Rosenwax L et al. Palliat Med 2015

17 Probability of ED visits if no community-based palliative care Pall Care (=1) Rosenwax L et al. Palliat Med 2015

18 Conclusions Discussion: Use of community-based palliative care in dementia very low compared to other diseases (cancer): tradition, lack of knowledge and sensitivity (on all sides), insufficient evidence base, inappropriate care structures? Methodologically sound study, but study design does not allow conclusions on causation and direct effects (prospective studies needed) Take-home Message: Community-based palliative care of patients with dementia may significantly prevent presumably unnecessary and nonbeneficial ED visits

19 Merci de votre attention!