Top 3 Tips in Decision Making

Transcription

1 Top 3 Tips in Decision Making Jeanie Youngwerth, MD, FAAHPM University of Colorado School of Medicine Assistant Professor of Medicine, Hospitalist Associate Program Director, Colorado Palliative Medicine Fellowship Director, UCH Palliative Care Consult Service Objectives Discuss the importance of prognostication Describe the value-based approach to weighing options Explore the role of advance care planning IOM: September 2013.

2 Case Study 43 y/o M with metastatic RCC s/p surgery; chemotherapy Told 3 months ago that cancer shrinking Past 2-3 weeks: increasing weakness, fatigue, anorexia, weight loss, pain Case Study Admitted to the hospital - 3rd time in the past year Acute pain crisis Albumin 2.4 Work up - rapidly worsening disease tumor invading lumbar paraspinal areaabscess? Case Study What is his prognosis? Hours-days Days-weeks Weeks-months Years

3 Top Tip #1 Offer to discuss prognosis Prognostication: Want to Know Patients want at least some information on prognosis Steinhauser: JAMA 2000; Johnson: BMC Palliat Care; Hagerty: J Clin Oncol 2005; Maltoni: J Clin Oncol 2005; Parker: JPSM 2007; Innes: Palliat Med 2009; Smith: Oncology 2010; Campbell: Cancer J 2010; Ahalt: JGIM 2011; Wachterman: JAMA IM Prognostication: Disclosure Physicians referring patients to hospice 37% frank estimate 23% no estimate 40% knowingly inaccurate estimate 70% overoptimistic Lamont: Annals IM 2001.

4 Prognostication: Impact on Patients Awareness of prognosis Improved coping anxiety control trust satisfaction with care Provided hope Innes: Palliat Med Prognostication: Impact on Decisions and Outcomes Patients with advanced cancer who thought they would live > 6 months More likely to favor life extending therapy 1.6 x more likely to have a hospital readmission, attempted resuscitation, or death on the ventilator No difference in 6 month survival Weeks: JAMA Prognostication: Impact on Decisions and Outcomes Patients with advanced cancer aware of prognosis Less likely to choose aggressive medical interventions Less likely to receive ICU care at EOL More likely to enroll in hospice earlier Finlay: CA Cancer J Clin 2009.

5 Prognostication: Delivering Patient and caregiver prognostic preferences diverge as the illness progresses Caregivers need more Patients need less Parker: JPSM Prognostication: Delivering Individualized approach Negotiate content and extent Clarify what/how much they want to know Clayton: JPSM 2005; Parker: JPSM 2007; Innes: Palliat Med 2009; Back: Mastering Communication with Seriously Ill Patients Prognostication: Delivering Ask-Tell-Ask "Has anyone talked to you about what to expect? Check-in Tell me more Do you have a sense? I hope/wish and let s prepare for in case that doesn t happen Present in a time range Hours-days; days-weeks; weeks-months; months-year; years+ Back: Mastering Communication with Seriously Ill Patients 2010.

6 Prognostication: Performance Status Rapid decline in functional status predicts shorter survival Head: JPM 2005; Finlay: CA Cancer J Clin Illness Trajectory Cancer Functional Status Organ Failure Dementia/Frailty Death Time Clinician Estimates of Survival in End-Stage Cancer Glare: BMJ Glare P et al. BMJ 2003;327: by British Medical Journal Publishing Group

7 Prognostication: Clinician Estimates Improved when combined with Clinical signs and symptoms Performance status Prediction tools Knaus: Annals IM 1995; Glare: BMJ 2003; Glare: JPM 2008; Lau: JPSM 2009; Finlay: CA Cancer J Clin 2009; Casarett: JPM Prognostication: The Surprise Question Would I be surprised if this patient died in the next year? Pattison: JPM 2001; Johnson: BMC Palliat Care 2003; Moss: Clin J Am Soc Nephrol 2008; ICSI Health Care Guideline: Palliative Care 2009; Cohen: Clin J Am Soc Nephrol 2010; Moss: JPM No, not surprised Cancer patients/oncologists 7x greater hazard of death 75% sensitivity and 90% specificity More likely to have ADs, POLST, DNAR status Pattison: JPM 2001; Moss: JPM 2010.

8 Case Study Prognosis: weeks months Option of further chemo? Difficult Decision Making Match therapies to patient goals Top priority was living as long as possible 96% physicians 59% breast cancer patients Patients may choose different options after they become better informed Mulley: BMJ 2012; Lee: Ann Plastic Surg 2010; Zafar: Cancer Top Tip #2 Value-based decision making Mulley: BMJ 2012; IOM: September 2014.

9 Values- Goals of Care Tell me about life before your diagnosis? How has the cancer affected this? How do you feel about your treatments? Do you think they have been helping you or not? What has been most difficult for you about this illness? What worries you most about your illness? What do you hope for most looking forward? Case Study Goals Work as long as possible Control pain (enjoy time with wife and friends) Die at home Risks-Benefits-Burdens Weigh the options based on values/goals Risks- worsen infection; fatigue Benefits- may decrease pain Burdens- less time at work/home Mulley: BMJ 2012.

10 Case Study Recommended hospice Pursue chemo Discontinue after next complication or hospitalization Back-up plan would be hospice Top Tip #3 Facilitate ongoing advance care planning discussions Advance Care Planning 80% of people say that if seriously ill, they would want to talk to their doctor about end-of-life care 7% report having the conversation 82% of people say it s important to put their wishes in writing 23% have actually done it Institute for Healthcare Improvement:

11 Advance Care Planning Allow a patient s voice to be heard even when they lack capacity 70% of patients lack capacity at EOL More likely end-of-life wishes will be honored Silveira: NEJM 2010; IOM: September Advance Care Planning Facilitating the discussions There s an app for that: ACP Tools Abba: BMC Pall Care 2013; Butler: Annals IM

12 Sudore: JPSM 2014; Volandes: Cancer Advance Care Planning Discuss/document MDPOA Medical living will MOST form CO CPR Directive Messinger-Rapport: Clev Clinic 2009.

13 Take-Home Top Tips Offer to discuss prognosis Negotiated on patient s terms Value-based decision making Discuss risks/benefits/burdens Facilitate ongoing advance care planning discussions Sssssssssssss Ssssssssssssssssssssssssssssssssssssssssssssssss