11/11/2014. Deanna Speer BSN, CHPN Debbie Brand APRN, FNP-C. Describe the scope of palliative care as differentiated from hospice care.

Transcription

1 Deanna Speer BSN, CHPN Debbie Brand APRN, FNP-C Describe the scope of palliative care as differentiated from hospice care. Recognize indicators of prognosis in advanced, serious illness. Demonstrate skills in communicating with patients and families in advance care planning. Advent of new medical treatment and technologies. Medical advances have led to a culture of cure. Patients do not die.they code Still no cure for many diseases but we can prolong life with these illnesses. People now typically die after dealing with multiple chronic conditions for many years. Hospice has become brink of death care. 1

2 Disease-Modifying Treatment Hospice & End of Life Care Disease Progression New Model 2

3 It is not giving up. It is not in place of curative or lifeprolonging care. It is not based on prognosis. It is not the same as hospice. When Where Goals of Care Palliative Care Anywhere in illness trajectory Hospital, some outpatient programs Variable Hospice Prognosis < 6 months Wherever patient is (typically home, NH, inpatient facility) Comfort directed, usually avoiding hospitalization Availability Depends on program Planned visits 24/7 on-call Team Members Levels of Care How paid for Depends on program Specialty Primary/Generalist Provider billing Nurses, physicians, HHAs, SWs, chaplains, volunteers Routine, General Inpatient, Continuous Care, Respite Hospice Benefit (Medicare, Medicaid, Insurance) Non-hospice Palliative Care Hospice All hospice is palliative care.but not all palliative care is hospice. 3

4 The National Priorities Partnership, a collaborative effort of 28 major national organizations convened by the National Quality Forum (NQF) in 2008 defined six national priorities and goals to transform health care. One of those six was Palliative Care. Eight domains: Structure and processes of care Physical aspects of care Psychological and psychiatric aspects of care Social aspects of care Spiritual, religious, and existential aspects of care Cultural aspects of care Care of the imminently dying patient Ethical and legal aspects of care Dx of a serious, potentially life-limiting illness Progressive, advancing illness with multiple co-morbidities Frequent admissions to the hospital for the same illness Difficult to control symptoms (pain, anxiety, dyspnea, depression) Patient, family, or physician uncertainty regarding appropriateness of treatment options (goals of care) 4

5 Improves quality of life for both patient & family Matches treatment with patient s values & goal Improved quality at lower cost Helps to meet demands of health care reform Palliative care is growing Hospitals Prevalence of US Hospital Palliative Care Teams In hospitals, at best, only 25-50% of palliative care needs are being met Variable penetration to areas of highest need: ICUs, ED, Oncology, Neurology, Renal Between hospitals & hospice there is a large gap of palliative care needs across the continuum of health care: Outpatient services Long-term care Home care 5

6 As a provider for palliative care Hospitals Clinics Outpatient programs Primary or Specialty Care ACHPN or CHPN certification hpna.org Certification Info Patients want prognostic information Knowing what to expect gives sense of control Accurate information is necessary to make personal decisions Opportunity to get personal affairs in order prior to death Decreases anxiety, fear, and uncertainty Patients who receive prognostic information are more satisfied with their care Symptoms of recurrent heart failure at rest NYHA Class IV EF< 20% Despite optimal therapy Other factors of decreased survival Symptomatic SVT or Ventricular arrhythmia Unexplained syncope Cardiogenic brain embolism Concomitant HIV disease 6

7 Stage 4 cancer Not seeking chemotherapy or radiation Weight loss 10% in past 6 months Severity of lung disease Dyspnea at rest, bed-chair existence FEV1 <30% predicted Progressive lung disease Frequent ED visits, hospitalizations Cor Pulmonale Hypoxemia at rest on supplemental oxygen PaO2 <55 on O2 SaO2 <88% on O2 Hypercapnea, PaCO2 >50 >10% weight loss in 6 months Resting tachycardia Functional Assessment Staging Co-morbidities important Functional Assessment Staging Scale (FAST) Stage 7 <6 intelligible different words in average day/interview Cannot walk or sit upright w/o assistance Cannot smile Cannot hold up head independently Medical Complications Aspiration pneumonia, pyelonephritis, sepsis, stage 3-4 decub ulcer, recurrent fever after antibiotics Swallowing ability impaired, refusal to eat 7

8 Laboratory evidence PT > 5 sec over control Albumin <2.5 Refractory ascites despite maximal diuretics Decline in SBP Hepatorenal syndrome Elevated BUN, Cr with oliguria Hepatic encephalopathy Recurrent variceal bleeding Fast Facts 8

9 Confirm prognosis Confirm assessment findings Give statistical analysis data to support recommendations for palliative care Able to carry on normal activity and to work; no special care needed. Unable to work; able to live at home and care for most personal needs; varying amount of assistance needed. Unable to care for self; requires equivalent of institutional or hospital care; disease may be progressing rapidly. 100 Normal no complaints; no evidence of disease. Able to carry on normal activity; minor signs or 90 symptoms of disease. Normal activity with effort; some signs or symptoms 80 of disease. Cares for self; unable to carry on normal activity or 70 to do active work. Requires occasional assistance, but is able to care 60 for most of his personal needs. Requires considerable assistance and frequent 50 medical care. 40 Disabled; requires special care and assistance. Severely disabled; hospital admission is indicated 30 although death not imminent. Very sick; hospital admission necessary; active 20 supportive treatment necessary. 10 Moribund; fatal processes progressing rapidly. 0 Dead 9

10 Considers location (community, home) ADL s Age Comorbids Predict mortality 10

11 Refers to a change in health status over time as patient approaches death Helpful to understand patterns of advanced illness and dying for different disease processes 11

12 Sudden death is beyond the care of the physician Hallmark is lack of preparation Intense bereavement needs for survivors Cancer has a relatively predictable trajectory Pts with advanced cancer who have taken to bed without a correctable cause will usually die within weeks CHF, COPD, CVD, Dementia follow a unique pattern Overall health status is low 6-24 months prior to death Acute exacerbations occur intermittently Approx. 3 admissions in the year prior to death Difficult to predict death within weeksmonths 12

13 Patient/Family meeting an opportunity for shared decision-making to establish goals near the end of life. Skill set necessary for successful outcome Group facilitation skills Counseling/emotional reactivity skills Knowledge of medical and prognostic information Willingness to provide leadership in decision-making Who are you talking with? What is most important to that person? Listening can earn you the right to tell the truth. Communication has nothing to do with what you say and everything to do with what the other person hears. Anon Establish what they know. Use open-ended questions. Medical review give the big picture. Allow time to react use silence. Respond to emotions. 13

14 Work in the framework of their priorities and needs. People want to know what you recommend. Present the best care possible. Help weigh the benefits and burdens. Will this intervention improve function, quality, or time? Conflict surrounding care decisions, as patients near the end of life, are very common. This is a time of emotional turmoil, uncertainty, and fear among both the patient/family and the health care team. Not every conflict will be recognized by visible anger. Naming the problem, out loud, is an effective means of starting a meaningful dialog among the conflicted parties. It seems like you are very angry, can you talk about what is making you angry? Plan A, Plan B, etc. Clarify Does this make sense to you? Define everything. Use time as an ally. 14

15 There s nothing more we can do. Do you want us to do everything possible? Do you want to stop treatment? Initiate goals of care discussions without assessing readiness. Assume a person has to accept a limited prognosis in order to relieve suffering. Label a patient/family as being in denial. Debate with patient/family over the medical reality of the prognosis. Medical Power of Attorney Living Will DNR/AND 15

16 TPOPP Form Section A: Resuscitation Status -- For Full Blown cardiac arrest * Attempt Resuscitation * Do Not Attempt Resuscitation Section B: Medical Intervention -- Still with pulse and breathing but with rapid health deterioration * Comfort Measures Only * Limited Additional Interventions * Full Treatment Section C: Medically Administered Nutrition Section D: Signatures This document moves with the patient across health care continuum Ascension Health. (2014). Palliative Care. Retrieved from t&view=article&id=346&itemid=283 Byock, I. (2012). The Best Care Possible. New York, NY: Penguin Group. Capasso, J., Kim, R., & Perret, D. (2013). Hospice for the Terminally Ill and End-of-Life Care. In N. Vadivelu, A. D. Kaye & J. M. Berger (Eds.), Essentials of Palliative Care (pp ): Springer New York Center to Advance Palliative Care. (2009). The Case for Hospital Palliative Care: Improving Quality, Reducing Cost. New York, NY: Center to Advance Palliative Care. Choosing wisely: Five things physicians and patients should question in hospice and palliative medicine (2014). American Academy of Hospice and Palliative medicine. Fast Facts and Concepts. At Ford, D. W., Koch, K. A., Ray, D. E., & Selecky, P. A. (2013). Palliative and end-of-life care in lung cancer: Diagnosis and management of lung cancer, 3rd ed: american college of chest physicians evidence-based clinical practice guidelines. Chest, 143(5) Hallenbeck, J., (2010) Palliative Care Perspectives. Oxford University Press; Heffner, R., & Meier, D. (2014, February 8). Bringing palliative care into mainstream American medicine. Retrieved May 1, 2014, from Hospice and Palliative Nurses Association. (2014). National Board for Certification of Hospice and Palliative Nurses. Retrieved September 30, 2014, from hpna.org: Preparation Jones, J. A., Lutz, S. T., Chow, E., & Johnstone, P. A. (2014). Palliative radiotherapy at the end of life: A critical review. CA: A Cancer Journal for Clinicians, 64(5), doi: /caac Medicare benefit policy manual. Meier, D. (2011). Increased access to palliative care and hospice services: opportunities to improve value in health care. The Milbank Quarterly, 89 (3),

17 Metzger, M., Norton, S. A., Quinn, J. R., & Gramling, R. (2013). Patient and family members' perceptions of palliative care in heart failure. Heart & lung : the journal of critical care, 42(2), National Hospice and Palliative Care Organization, Hospice Care A Physician s Guide, 2012 National Consensus Project. (2013). Clinical practice guidelines for quality palliative care, 3rd edition. Pittsburgh, PA. Retrieved from TPOPP Wichita. (2014). Retrieved from tpoppwichita.com: Weissman, D. (2004). Decision making at a time of crisis: near the end of life. JAMA, 292(14), Yourman, L. C., Lee, S. J., Schonberg, M. A., Widera, E. W., & Smith, A. K. (2012). Prognostic indices for older adults: A systematic review. JAMA, 307(2),