Purpose of presentation

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1 PALLIATIVE MEDICINE QUALITY OF LIFE, NOT END OF LIFE. WORKING WITH YOU TO HELP YOUR PATIENTS WITH LIFE LIMITING ILLNESS. Purpose of presentation Overview of Palliative Medicine Differentiating: Palliative Medicine and Hospice How/when to refer: inpatient and outpatient consults How Palliative Medicine can: Improve quality of life indicators Decrease hospital readmissions Improve mortality rates Symptom management Exploration of understanding about illness and prognosis Clarification of treatment goals Assessment of support and coping needs Assistance with medical decision making Coordination of care with providers Advanced Directives What is Palliative care? To Palliate: Make less severe or unpleasant without removing the cause Allay or moderate Disguise the seriousness or gravity Synonyms: alleviate, ease, relieve, soothe, assuage, moderate, temper, diminish, decrease, blunt 1

2 Definition of PC A medical and interdisciplinary subspecialty that aims to relieve suffering and improve quality of life for patients with advanced illness, and their families. Provided simultaneously with all other appropriate medical treatment ( ) Palliative care is Excellent, evidencebased interdisciplinary treatment Vigorous care of pain and symptoms throughout illness Care that patients want at the same time as efforts to cure or prolong life Not giving up on a patient Not in place of curative or lifeprolonging care Not the same as hospice Palliative care is matching treatment to patient goals providing the right care at the right time participating as neutral advisors of prognosis and goals of care, burdens and benefits of treatment improving quality of life for patients and families facing serious illness 2

3 Palliative care is helping to/with honor patient wishes 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 Palliative Care can Help support transitions to more appropriate care settings Help lower costs (for hospitals and payers) by reducing hospital and ICU length of stay, and direct costs (such as pharmacy). Palliative care improves continuity between settings and increases hospice/homecare/nursing home referral by supporting appropriate transition management. Never underestimate the power of the 3

4 Palliative Care and Hospice Palliative Care Symptom Management of Life Limiting Illness End of Life Care/Hospice Symptom Management and Comfort Care Rosenberg, M et al, Clin Geriatr Med 2013; 29:1 29 Hospice For patients who are expected to die within less than 6 months. For patients who are no longer candidates/refusing further curative therapy Palliative Care for patients who you would not be surprised if they die within the next 6-12 months. Patient does not have to forgo curative treatment or hospitalization patients requiring active symptom management, who are too tenuous to move, or are actively dying may be eligible for in-patient hospice. In these patients death is expected within 5 days. Appropriate for all patients with chronic/serious illness Differentiating PC and Hospice Care Chronic Disease Trajectories Copyright 2005 BMJ Publishing Group Ltd. 4

5 A New Vision of Palliative Care Disease Modifying Therapy Curative, or restorative intent Life Closure Diagnosis Palliative Care Hospice Death & Bereavement Appropriate Patients Patients who have a life-threatening, or lifeshortening illness Cancer, COPD, CHF, Stroke, CAD, End-Stage Renal Disease, ALS, Other (necessary criteria) and Complicated symptoms pain, dyspnea, diarrhea, constipation, anorexia, nausea, insomnia, anxiety, depression, fatigue Family, Spiritual, Social, Emotional and Physical Concerns Rabow Michael, Kvale Elizabeth, Barbour Lisa, Cassel J. Brian, Cohen Susan, Jackson Vicki, Luhrs Carol, Nguyen Vincent, Rinaldi Simone, Stevens Donna, Spragens Lynn, and Weissman David. Journal of Palliative Medicine. December 2013, 16 (12): Review of published, peer-reviewed outcomes research, including both observational studies and controlled trials of nonhospice outpatient palliative care services Assessed patient, family, caregiver, and clinician satisfaction; clinical outcomes including readmission rates, hospice use, and cost. Results: Four well designed randomized interventions as well as a growing body of nonrandomized studies indicate that outpatient palliative care services can: 1) improve patient satisfaction, 2) improve symptom control and quality of life 3) reduce health care utilization, and 4) lengthen survival in a population of lung cancer patients Conclusion Available evidence supports ongoing expansion of innovative outpatient palliative care service models throughout the care continuum to all patients with serious illness 5

6 Morrison, R. Sean, Dietrich, Jessica, Ladwif, Susan, Quill, Timothy, Sacco, Joseph, Tangeman, John, and Meier, Diane e. Palliative care consultation teams cut hospital costs for medicaid beneficiaries. Health Affairs, March 2011, vol. 30, no 3, Examination of data to determine effect on hospital costs of palliative care team consultations for patients enrolled in Medicaid at 4 New York state hospitals. On average, patients receiving palliative care incurred $6,900 less in hospital costs during a given admission than a matched group of patients who received usual care. Included $4098 in hospital costs per admission for patients discharged alive $7563 for patients who died in the hospital Palliative care recipients: Spent less time in the ICU Less likely to die in ICU More likely to receive hospice referrals than matched usual care patients Goodlin, Sarah J. MD. Palliative Care in Congestive Heart Failure Journal of the American College of Cardiology, Vol 54, #5, july 28, 2009, Palliation of symptoms (fatigue, dyspnea, compromised exertion) Interventions to address the neurohormonal alterations in HF and symptoms ACE inhibitors Beta blockers Aldosterone blockade Screening for sleep-disordered breathing Loop diuretics Dietary intervention Oral nitrates Oral opioids for dyspnea Antidepressants Antianxiety interventions Exercise Goodlin, Sarah J. MD. Palliative Care in Congestive Heart Failure Journal of the American College of Cardiology, Vol 54, #5, july 28, 2009, Communication with patients about dying and approach to care End of life care for HF patients Deactivation of ICD Management at end of life Re-evaluation of medications Hospice care for HF patients 6

7 Rebecca Aslakson, MD, PhD, Jennifer Cheng, MD, Daniela Vollenweider, MD, Dragos Galusca, MD, Thomas J. Smith, MD and Peter J. Pronovost, MD, PhD. Evidence-Based Palliaive Care in the Intensive Care Unit: A Systematic Review of Interventions. Journal of Palliative Medicine. February 2014, Vol. 17, No. 2: Literature search from 8/12/12 forward using the terms palliative care and intensive care unit references, 37 publications included, with 30 unique interventions Focus on outcomes of patient and family satisfaction, mortality, and ICU and hospital length of stay Results Heterogeneity of interventions made comparison of ICU based palliative care interventions difficult Existing evidence suggests proactive palliative care in the ICU using either consultive or integrated palliative care interventions decrease hospital and ICU LOS, do not affect satisfaction and either decrease or do not affect mortality Gaertner, J, Siemens, W, Meerpoho, JJ, Antes, G, Meffert, C, Xander, C, Stock, S, Mueller, D, Schwarzer, G, Becker, G. Effect of specialist palliative care services on quality of life in adults with advanced incurable illness in hospital, hospice, or community settings: systematic review and meta-analysis. BMJ, 2017 Jul 4;357. Objective: to assess the effect of specialist palliative care on quality of life and additional outcomes relevant to patients in those with advanced illness. Meta analysis of randomised controlled trials with adult inpatients or outpatients treated in hospital, hospice or community settings with advanced illness. Results Of 3967 publications, 12 were included 10 randomised controlled trials with 2454 patients randomised, of whom 72% (n=1766) had cancer Conclusion Specialist palliative care was associated with a small effct on quality of life and might have most pronounced effects for patient with cancer who received such care early It could be most effective if it is provided early and if it identifies through screening those patients with unmet needs NCI Staff, Study confirms benefits of early palliative care for advanced cancer. National cancer institute. October 5, Randomized clinical trial shows patients who received palliative care along with standard treatment for advanced cancer reported having better quality of life and mood than patients who did not receive early palliative care. Patients receiving early palliative care also scored better on assessment of their ability to cope with their disease and were more likely to discuss end-of-life care preferences with their health care team. Joseph A. Greer, PhD of Massachusetts General Hospital Enrolled 350 patients with gastrointestinal cancers as well as lung cancers. Randomly assigned to receive palliative care along with standard treatment or standard treatment alone 7

8 Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8): nonblinded, randomized, controlled trial of early palliative care integrated with standard oncologic care, as compared with standard oncologic care alone early palliative care met with a member of the palliative care team, which consisted of board-certified palliative care physicians and advanced-practice nurses, within 3 weeks after enrollment and at least monthly thereafter in the outpatient setting until death. Additional visits with the palliative care service were scheduled at the discretion of the patient, oncologist, or palliative care provider 151 patients were enrolled in the study 8

9 Ambulatory Consults Referral Sources Seen in hospital, follow up outpatient From specialist: oncologist, cardiologist, pulmonologist From PCP Self-referral/family or friend suggestion Setting Clinic office ECF/Assisted living facility Home visit Inpatient consults Referral from: Hospitalists Critical Care Intensivists Specialists Cardiology Oncology Pulmonology Surgeons Most frequent issues Goals of care Code status Dysphagia/failed swallow study Treatment options/end points Pain/symptom management End of life care/transition to hospice Family meetings When to refer Consultive service: we manage along with you Refer as soon as you think of it. Don t wait until the end Referral at diagnosis of life limiting illness Never too early to start the conversation 9

10 Palliative Care Team Physicians Completion of primary residency Palliative medicine fellowship trained 1 year fellowship Some physicians practicing longer have been grandfathered, don t need fellowship Board certification Advanced practice providers APRN s PA s Social work Chaplain Pharmacist RN Child life Office Coordinator Carle Palliative Medicine M-F Service, day shift, with weekend/holiday coverage Mostly Inpatient Consults, expanding ambulatory service Extensive consults for goals of care, advance directives Providers rotate between inpatient and ambulatory Imbedded providers in oncology clinic and heart failure clinic Case Study 10

11 Closing THANK YOU! References Lilly et al, Am J Med, 2000; Dowdy et al, Crit Care Med, 1998;Carlson et al, JAMA, 1988; Campbell et al, Heart Lung, 1991; Campbell et al, Crit Care Med, 1997; Bruera et al, J Pall Med, 2000; Finn et al, ASCO, 2002; Goldstein et al, Sup Care Cancer, 1996; Advisory Board 2002; Project Safe Conduct 2002, Smeenk et al Pat Educ Couns 2000; Von Gunten JAMA 2002; Schneiderman et al JAMA 2003; Campbell and Guzman, Chest 2003; Smith et al. JPM 2003; Smith, Hillner JCO 2002; Steinhauser, et al. Ann Intern Med 2000; 132: Singer et al, JAMA Murray, S. A et al. BMJ 2005;330: Rosenberg, M et al, Clin Geriatr Med 2013; 29:1 29 Resources Vitaltalk.org Communication skills for serious illness Globalrph.com Drug/opioid calculations HPNA.advancingexpertcare.org Hospice & Palliative Nurses Association CAPC.org Centers to Advance Palliative Care Great modules on symptom management with CE s AAHPM.org American Academy of Hospice and Palliative Medicine Many position statements: Artificial nutrition/hydration at EOL Palliative research Palliative sedation Physician assisted dying Withholding and withdrawing non-beneficial medical interventions 11