Palliative Care and ESRD. Dr Douglas McGregor 12 June 2008
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1 Palliative Care and ESRD Dr Douglas McGregor 12 June 2008
2 Thanks to Sue Young, CNS, St Paul s Kidney Clinic Dr Alvin Moss Dr Sara Davison, Edmonton Dr Bev Spring Dr Neil Hilliard
3 Number of Deaths by Year (Sue Young, SPH) YEAR DEATHS (to Oct) 126 TOTAL 913 Denominator needed: i.e. deaths/ year as % of total patients registered/ year Does not account for growth in program (esp. CKD and HD) Deaths/month (05/06) 15 16
4 Deaths by age grouping Pooled data over 5 years 10 months ( )? Need deaths by age by year? Need denominator i.e. how many patients in total in each age group
5 Unadjusted Survival Probabilities (%) for Incident ESRD Patients Age 1 year 2 years 3 years 5 years
6 ESRD Patient Probability of Survival Patient Population Survival (%) 1-yr for all incident patients, unadjusted 79 1-yr for incident patients >65 yrs, unadjusted 65 2-yr for all incident patients, unadjusted 65 2-yr for all incident patients >65 yrs, unadjusted 48 5-yr for all incident patients, unadjusted 38 5-yr for incident patients >65 yrs, unadjusted yr for all incident patients, unadjusted yr for incident patients >65 yrs, unadjusted 3 USRDS, 2004 Annual Data Report
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8 Patient s Concerns Regarding End-of-Life Care Receiving adequate pain and symptom control Avoiding inappropriate prolongation of dying Achieving a sense of control Relieving burden on loved ones Strengthening relationships with loved ones Singer PA, et al. JAMA 1999; 281:
9 Regional Palliative Care Strategy (2005) Key Strategic Recommendations: 1. Regional Service Delivery Model 2. Defining And Expanding The Size Of The Target Population 3. Regional Standards For Eligibility, Access And Referral 4. Regional Leadership Structure 5. Address The Needs Of Special Populations 6. Develop Enabling Systems
10 Projections: Non-Cancer Deaths # of Deaths Actual and Projected # of Non-Cancer Deaths in VCH and Vancouver ( ) ,586 2,615 2,585 2,581 2,522 2,503 2, Actual Data Projected Data Year # of non-cancer deaths in VCH # of non-cancer deaths in Vancouver
11 Projections: Cancer Deaths 2500 Actual and Projected # of Cancer Deaths in VCH and Vancouver ( ) # of Deaths Actual Data Projected Data Year # of cancer deaths in VCH # of cancer deaths in Vancouver
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14 Model of VC Home Hospice QUALITY IMPROVEMENT& PROGRAM DEVELOPMENT COMMUNICATION & DOCUMENTATION Volunteers Specialist Physicians Spiritual Care Shift Care Nursing PT/OT Other Caregivers Client & Family Hospices Social Workers Acute Care PCU Community Health Workers BCCA Residential Care Family Physician CHN Hospice Palliative Care Consultation Team Transition Services Team EDUCATION, RESEARCH & LEADING PRACTICES Palliative On Call Service Clinical Nurse Specialists FUNDING & OPERATIONS
15 How many do we care for in VC? 1148 unique clients received VC palliative care services in 07/08 >500 palliative clients on any given day receiving services 2251 active referrals to VC professionals for palliative services in 07/08 Source: PARIS management reports
16 Who are your Team? Vancouver: SPH Dr Romayne Gallagher VGH Dr Wendy Yeomans Community Dr Bev Spring North Shore Dr Val Geddes Richmond Dr Alan Nixon
17 Incorporating Palliative Care into Your Dialysis Unit Surprise question on rounds Educational in-services on palliative care topics Advance care planning Pain & symptom assessment and treatment protocols Communication of prognosis and changes in condition Referral to hospice when terminally ill QI with review of quality of death Memorial service 17
18 General Practice Issues: Changing job satisfaction/ lifestyle Low recruitment Everyone is downloading splintering
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20 CANCER MANAGEMENT FLOW SHEET (Noncurative Intent) BCCA# Patient Name: DOB: dd-mm-yyyy Allergies: Cancer Site: Cancer Type: Dx date: Metastases: Liver Bone Lung Skin Other Recurrence date: Co-morbid Conditions: Diabetes CHF COPD Renal Hepatic Arthritis Depression EtOH/Drug Abuse Complications of Disease/Rx: Medical Oncologist: Radiation Oncologist: Palliative Care Contact: Patient Encounters, Diagnostic/Clinical Data/Prognostic Data, by Date: Enter Review Date: Baseline: Date: Date: Date: Date: Review: dd-mm-yyyy Prognostic WEIGHT PERFORMANCE STATUS - ECOG (0-5) / PPS (0-100) Dyspnea (0-10) Cognitive Impairment/Confusion lbs kg lbs kg lbs kg lbs kg lbs kg Pain 1: location: type: (0-10) Symptoms (VAS 0-10) Pain 2: location: type: (0-10) Pain 3: location: type: (0-10) Nausea (0-10) Constipation Other 1 (ie: fatigue) Other 2 (ie: disease specific Sx - dysphagia) Lungs Liver Signs Spine/Bone CNS Nodes Skin /Edema Lab (use for tumour marker, Hb, INR, etc.) Systemic: Medications Anticancer Rx Symptom Control Biological: Hormonal: Radiation Other: (bisphosphonate, etc.) Opioid SR: Opioid IR: Antiemetic: (eg: metoclopramide) Bowel Protocol: Adjuvant 1: (?neuropathic pain) Adjuvant 2: (?dexamethasone) Care Plan DNR Home DNR form: Discussion: Palliative Care Benefits Form: Discussion: Program Referral Home care: Advance Directive Discussion: Proxy: Phone: Copyright 2006 Family Practice Oncology Network, BCCA
21 Stage 1 Renal Patient Name: DOB: dd-mm-yyyy Allergies: Kidney Disease: Biopsy: Dx date: Complications: Heart BP Bone CVS Other Referral date: Co-morbid Conditions: Diabetes CHF COPD Hepatic Arthritis Depression EtOH/Drug Abuse Other Complications of Disease/Rx: Nephrologist: Urologist/Surgeon: Palliative Care Contact: Review: Enter Review Date: dd-mm-yyyy Baseline: Date: Date: Date: Date: Prognostic WEIGHT PERFORMANCE STATUS - ECOG (0-5) / PPS (0-100) Dyspnea (0-10) Cognitive Impairment/Confusion lbs kg lbs kg lbs kg lbs kg lbs kg Pain 1: location: type: (0-10) Symptoms (VAS 0-10) Pain 2: location: type: (0-10) Nausea (0-10) Constipation Other 1 (ie: fatigue) Other 2 (ie: disease specific Sx - dysphagia) BP Urinalysis Signs edema CNS Skin irritation tachypneoa Lab egfr etc Medications Symptom Control Reanl specific Rx Systemic: Biological: Hormonal: Surgical Other: Opioid SR: Opioid IR: Antiemetic: (eg: metoclopramide) Bowel Protocol: Adjuvant 1: (?neuropathic pain) Adjuvant 2: (?dexamethasone) Care Plan DNR Home DNR form: Discussion: Palliative Care Benefits Form: Discussion: Program Referral Home care: Advance Directive Discussion: Proxy: Phone:
22 General Practice Major emphasis by Ministry to support and reverse trends PSP Billing Codes Complex Care Fees = $315 pa Follow up = $15 Community Conf = $40/ 15 min Facility Conf = $40/ 15min
23 General Practice Primary Care Charter Integrated Health Networks Divisions of General Practice end of life care a priority Provincial Framework for EOL Care Action Plan being formulated
24 Advance Directives New legislation in BC The Conversation not the Form Context relational not hierarchical Regional / provincial approach
25 The Way Ahead Shared Care Models GP champions Combined rounds
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