Objectives. End-of-Life Exercise. Palliative Care Can Help Patients and Decrease 30-Day Hospital Readmissions.

Transcription

1 Palliative Care Can Help Patients and Decrease 30-Day Hospital Readmissions. Objectives Describe how palliative care meets the needs of the patient and family. Discuss how out-patient palliative care can be utilized upon hospital discharge. Discuss how palliative care might help to prevent frequent readmissions to the hospital. Discuss any misunderstandings about hospice and palliative care. End-of-Life Exercise Terminal illness; worsening prognosis Now in your final days or weeks Who should be present? Where should you be? 1

2 SUPPORT Study: Phase I Results 46% of DNR orders were written within 2 days of death. Of patients preferring DNR, <50% of their MDs were aware of their wishes. 38% of those who died spent >10 days in ICU. Half of patients had moderate-severe pain >50% of time in last 3 days of life. JAMA 1995;274: The Cure - Care Model: The Old System Life Prolonging Care Disease Progression Palliative/ Hospice Care D E A T H 2

3 Barriers to Hospice Care Physician Uncertainty of 6 month prognosis maintain focus on cure and prevention difficult to transition avoid the talk Patient / Family -- denial of disease severity denial of prognosis giving up What Do Patients with Serious Illnesses Want? Pain and symptom control Avoid inappropriate prolongation of the dying process Achieve a sense of control Relieve burdens on family Strengthen relationships with loved ones Singer et al. JAMA 1999;281(2): What Do Family Caregivers Want? Study of 475 family members 1-2 years after bereavement Loved one s wishes honored Inclusion in decision processes Practical help (transportation, medicines, equipment) Personal care needs (bathing, feeding, toileting) Honest information To be listened to Tolle et al. Oregon report card

4 Palliative Care Interdisciplinary care that aims to relieve suffering and improve quality of life for patients with advanced illness and their families. It is offered simultaneously with all other appropriate medical treatment. Focus is on management of symptoms and goals of care (not just pain management). Palliative Care s Place in the Course of Illness Life Prolonging Therapy Death Diagnosis of serious illness Palliative Care Medicare Hospice Benefit Who Provides Palliative Care? Various models: hospital, hospice, nursing facility, insurance company Possible team members Physicians Advanced Practice RN s RN s Social Workers, Chaplains, Volunteers 4

5 Why Palliative Care? Hospitals will need palliative care to effectively treat the growing number of persons with serious, advanced and complex illnesses. Remember the SUPPORT study Chronically Ill, Aging Population Is Growing The number of people over age 85 will double to 10 million by the year The 63% of Medicare patients with 2 or more chronic conditions account for 95% of Medicare spending. US Census Bureau, CDC, The Hospital Perspective For hospitals, palliative care is a key tool to: provide service excellence, patient-centered care increase patient and family satisfaction improve staff satisfaction and retention meet JCAHO quality standards rationalize the use of hospital resources reduce costs; decrease hospital re-admissions 5

6 Importance of Palliative Care Longevity is not compromised (266 days with palliative care vs. 227 days without palliative care) Fewer futile interventions with better adherence to patient preferences When to Consult Terminal diagnosis or advanced chronic disease Symptom management is becoming difficult Standard medical care is increasingly viewed as futile or not desired (redefining goals of care) Hospital readmission seems likely Readmissions Within 30 Days Beginning in 2012 hospitals will not receive reimbursement for patients with coronary artery disease, heart failure, or pneumonia who come back to the hospital within 30 days of hospital discharge 6

7 COPD 46 million smokers in the U.S. 4th most common cause of death in the U.S. with costs of $32 billion / year Dementia 5.5 million patients with this in the U.S. 45% of patients > 85 y/o have this Deaths occur within 3-10 years of diagnosis Significant problems with pain, behavioral disturbances, infections, and decubiti Heart Failure 4-5 million pts. in U.S.; $38 billion / year 900,000 admissions per year 300,000 deaths per year NYHA class IV 30-75% annual mortality This is a fatal incurable disease!!! (20% die within one year of diagnosis) 7

8 Heart Failure Symptom Burden Similar to advanced cancer -- MUST ASK!! Symptoms present in final weeks: - fatigue (80%) - depression (25-48%) - dyspnea (55-80%) - cough (44%) - pain (50-78%) - insomnia (45%) - anorexia (37%) - cognit. impair.(29%) - constipation (32%) CASE STUDY Palliative care outpatient support structure for a patient with CHF Symptomatic High risk for hospital readmission The Patient 74 year old, obese man with combined systolic and diastolic right-sided heart failure, EF 35% 4 hospitalizations in the last year for decompensated HF During the most recent hospitalization he was diuresed with IV Lasix 8

9 Past Medical History COPD, A fib, hypercholesterolemia, obesity, OA, BPH, GERD, anxiety Past Surgical History Carotid stent placed (2004) Medication List Aspirin 81 mg daily Avapro 150 mg daily Avodart 0.5mg daily Cardizem 120mg daily Flovent 1 puff BID Lasix 40 mg daily Lipitor 20 mg at HS Prilosec 20 mg daily Synthroid 150 mcg daily Tylenol 1000mg BID Vitamin D 50,000units q month Zoloft 50 mg daily Albuterol 1 puff q 4 hrs PRN Xanax 0.25 mg at HS PRN Percocet 5/325 1 tab q 6 hrs PRN Ibuprofen 400 mg daily PRN Social History Living Environment only bathroom in the home is on the second floor. His wife is dying of lung cancer. Son just returned from prison and is living in the home and has 3 children that visit every other weekend. Large Italian family. Hx of smoking -- only during WW II. EtOH use socially but not since wife s diagnosis. 9

10 Continued Social History Never had home healthcare arranged after first 3 hospitalizations. There was a larger gap between the 3 rd and the 4 th hospitalization with implementation of home care visits during that time. Physical Exam BP 165/70 Coarse breath sounds SOB at rest 4+ edema bilaterally Loud systolic murmur at apex Tachycardic and dyspneic with ambulation No oxygen in the home PAIN-AD 6 with ambulation Impression/Plan Well enough to go home although still volume overloaded Not far off from a subsequent rehospitalization Plan to stabilize him at home palliative care to help Plan to improve his health state with frequent follow-up to monitor HF and other comorbidities. Patient goal remain at home with fewer trips to the ER or hospital 10

11 Palliative Care Involvement Education given on medications and dosages. Ordered a spacer for his inhalers Pt was using ICS MDI prn and not scheduled dosing. Implemented daily weights record. Assessed family environment and developed relationship with DPOA-HC. Targeted most effective family members for preventative care teaching. Continued to see pt through wife s death (hospice care involved) monitoring depression. Continued Palliative Care Involvement Teaching done on diet modifications, exercise, medication management. Pt lost 19 lbs. Changed his diet dramatically. It has been 5 months and no hospitalizations. Increased Lasix (with physician approval) twice over the past 5 months for volume overload. Arthritic pain managed with Tylenol and prn Percocet Palliative Care Referral Augments home health care. In conjunction with PT/ OT/ ST if needed. Care provided in the home environment See patients not only for cardiac disease but also for OA pain, COPD, cancer, etc. On call services 24/7 for symptom management 11

12 Role of the Palliative Care Consultant Advice and support to primary MD and team on symptoms, decision-making and goal setting Support to families Education Liaison, coordination between hospital and hospice/home care services or other institutions Dunlop and Hockley 1998 Is Palliative Medicine Different from Standard Medicine? Expert use of opioids for pain, dyspnea and other symptoms Focus on goals of care (patient-specific) Focus on symptom management Benefits of Palliative Care: The Evidence Base Improved patient and family satisfaction with appropriate goals of care Reduced costs Probable decreased hospital readmissions hospitals will need this 12

13 Palliative Care: Is There a Problem with Concurrent Billing? Attending Physician: Uses diagnosis code Palliative Care: Uses a symptom code Hospice / Palliative Care Myth My physician will know what I want and what to do when that time comes Importance of advance directives palliative care can help The essential task of palliative care is helping patients make the difficult transition from being seriously ill and fighting death, to being terminally ill and seeking peace. Dr. Robert Twycross 13