Palliative Care Screening

Transcription

1 Palliative Care Screening Presented by Ifey Akanuligo, BSN, RN, Sharon Naithaloor, BSN, RN, Michael Ngetich, BSN, RN, Kathy Swann, BSN, RN, and Sarah Loughary, BSN, RN

2 Objectives Define palliative care Identify difference between Palliative and Hospice care Discuss the impetus for this project Screening tool selection Implementation process Evaluation Recommendations / Future Plans

3 Kansas City Veterans Administration Medical Center Hospital is a 128 bed facility Unit breakdown: SICU: 8 beds MICU: 10 beds PCU: 12 beds 5W Med/Surg: 13 beds 8E Med/Surg/Tele: 24 beds 8W Med/Surg/Oncology/Hospice: 24 beds 10W Inpatient Psych: 9 beds Additional 28 beds for Substance/Alcohol Abuse Recovery

4 Palliative vs Hospice Care Palliative Care Can be offered at any stage of advanced and or life-threatening illness to those who desire palliation of symptoms whether it be social, physical, emotional, or spiritual Can be offered along with curative treatment Admission Criteria includes a consult to palliative team by the physician can be provided concurrent with or without a formal Hospice enrollment, and for as long as the patient lives Hospice Care Is for the terminally ill (Prognosis of 6 months or less if illness follows its natural course) Forgoes curative therapies Admission criteria includes certification by two physician that patient is terminally ill

5 Palliative Care is NOT.. Only for the imminently dying Palliative Care is NOT Only when curative treatment stops Hospice To replace care by the patient s PCP To convince patient to stop treatment

6 Why Palliative Care.

7 What is Palliative Care

8 Palliative Care Screening Process How do we decide, in a timely way, which patients need specialty-level palliative care services, and then ensure that they receive those services?

9 Palliative Care Survey for Staff Prior to Trial 1. I am comfortable with breaking the ice and talking to my patient and their family about palliative care and its benefits. How much do you agree with the above statement? 2. How much do you agree with the statement that our Veterans ought to die with dignity? 3. Do you agree that a patient(s) that you have taken care of at one point could have benefited from palliative care consult/screening? 4. Do you agree that if a palliative care screening tool were available to the nurses at the bedside it could be of benefit to our patients? 5. Our unit can benefit from a palliative care screening tool, how much do you agree with this statement? All questions rated by selecting one: ( )Strongly agree ( )Agree ( )Neutral ( )Disagree ( )Strongly disagree

10 Literature Review Center to Advance Palliative Care The National Comprehensive Cancer Network Journal of Palliative Medicine Journal of Hospice & Palliative Nursing Journal of Oncology Practice Hospitals/ other Veterans Administration Investigated during the research phase: Aspire Hospital Tomah Hospital Kansas University Medical Center Columbia Veterans Administration Denver Veterans Administration Cincinnati Veteran Administration

11 Process Steps Who will be responsible for screening the patient, what happens if a patient screens positive (e.g., daily reassessment for consultation needs during ICU rounds)? If a palliative care consult is initiated, who will make contact with the PC team to discuss the consultation question? Implementation Phase Person responsible SICU Nurses SICU Nurses. Project champions and the unit NM will be held responsible to follow through with the screening results and consult placement What are the expectations of the ICU from the palliative care consultant? Fill out the palliative care form upon admission and with and any changes Once the palliative care needs are addressed put the completed forms in the PALLIATIVE CARE ENVOLOPE by the assignment sheet. Notify PCP regarding the consult and write a comment on the palliative care form regarding plan of action Nurses keep an ongoing conversation about goal of care or plan of care during morning huddle, SBAR, and on your Kardex Notify NM about the positive screen so that they can help facilitate palliative care consult conversation with staff during morning huddles Time to complete consultation Follow-up care after initial assessment (e.g. daily follow up and verbal Discussion with (ICU team): Build in evaluation stopping points to assess and revise screening criteria and the implementation process If a palliative care consult is not initiated, what steps will occur to ensure that unmet palliative care needs are addressed, and who will be the person responsible Upon admission and with any change in status Nurses keep an ongoing conversation about goal of care or plan of care during morning huddle, SBAR, and on your Kardex Notify NM about the positive screen so that they can help facilitate palliative care consult conversation with staff during morning huddles Each trial will include a start and stop date, a post trial survey & evaluation of the finding at the end of each trial. Utilize unit specific manager and unit champions to continue to remind nurses to fill out the 2 nd palliative screening tool if there has been a change in patient condition

12 Expectation during the trial phase Once the palliative care needs are addressed put the completed forms in the PALLIATIVE CARE ENVELOPE by the assignment sheet. Nurses keep an ongoing conversation about goals of care or plan of care during morning huddle, SBAR, and on your Kardex Fill out the palliative care form upon admission and with any changes Notify PCP regarding the consult and write a comment on the palliative care form regarding plan of action Notify NM about the positive screen so that they can help facilitate palliative care consult conversation with staff during morning huddles

13 Documentation Palliative Care Screening Palliative Care Admission Screen - Discuss Palliative Care Screening based on CAPC Tool and make recommendations to assess goals of care with patient Enter - Physician notified For patients who do not meet the Palliative Care Consult at this time, reassess as needed

14 Palliative Care 1 st Trial Start Date February13 March 13, 2017 Re-evaluate results of the second trial and review results with the team on March 13, 2017

15 Palliative Care Screening Trial #1: Patients with a score of 5 or greater should be considered for a palliative care team consult please initiate physician notification Section 1 Basic Disease Process Two (2) points per applicable item ESRD with dialysis dependence or need for CRRT Advanced COPD Progressive or metastatic malignancy Severe neurological injury including CVA, trauma, anoxic encephalopathy End stage liver disease with encephalopathy and / or severe bleeding Caner with advanced or metastatic disease Dementia CHF/CAD/cardiomyopathy 2nd readmission for same diagnosis in last 60 days Difficulty weaning off/ prolonged dependence on ventilator Multi-system failure Other life limiting or serious progressive illness Section 2 Modifiers and Situations: 1 point for each Complex situation or need for ongoing care coordination Uncontrolled or unsatisfactory symptom control of pain, nausea, delirium, etc, >24 hours Transplant or organ donation being considered PEG, tracheostomy, AICD or other long term device placement being discussed (or already in place) Unrealistic or divergent family opinions about care (including not following advanced directives) No advanced directives, spokesperson or loss of primary care giver ability to continue care Unmet psychosocial or spiritual needs Frequent Emergency Department visits in the last 60 days with the same diagnosis Prolonged stay in the ICU without evidence of progress or poor prognosis Is not a candidate for curative treatment Has a life limiting illness and has opted to not have treatment Section 3 Would you be surprised if patient died in next 12 months? (Yes=0 points; No=2 points) Functional Status of Patient - Eastern Cooperative Oncology Group (ECOG) Performance Status Scale 1 Fully active able to carry on all pre-disease activities without restriction. 2 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature (e.g. light housework, office work). 3 Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about more than 50% of waking hours. 4 Capable of only limited self-care; confined to bed or chair more than 50% of waking hours. 5 Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair. Total Points Section Total points Section Total points Section

16 1 st Post Palliative Care Assessment Survey Results Nurses Response Is the screening process working to identify the patients with the greatest needs 56% YES Do you believe our patient would benefit from palliative screening tool? 100% YES If you used the screening tool but did not contact the physician for a consult can you indicate the reason why? Do you feel comfortable screening a patient for palliative care? Is the tool user friendly? Is the tool helping you initiate palliative care conversation with the physician? 18 % N/A 81% YES 56% YES 62% YES Where would you suggest the Palliative Care Screening tool be implemented? o Admission Database 68% o Another Template 18% Would you be more apt to using this tool? If this screening tool initiated an automatic electronic alert being sent to the PCP and did not require you to talk with the physician? Did you feel like the physicians were receptive to considering a palliative care consult? 81% YES 25% Sometimes 12% YES What would you like revised about the screening tool? (Recommendations / Suggestions/ None

17 1 st Post Palliative Care Assessment Survey Results Patient Screened Total number of patient screened during the 30 day trial period 25 Total number of patient who met Palliative Care Consult criteria based on the Screening Tool 8 Total number of patient who benefited from the use of the screening tool 0 Total number of patients with positive screening tool that were left unaddressed by physician Reason: MD unable to make a decision MD did not feel patient needed a palliative consult at the time Number of patient unaccounted for? Reason: Unable to track because of no identification label on the screening tool Unable to find any documentation from nursing stand point to show screening tool was addressed with the primary team One case where the patient had an existing consult from January but no new consult during the trial phase

18 Palliative Care 2 nd trial Start Date July 12- August 12, 2017 Re-evaluate results of the second trial and review results with the team on August 21, 2017

19 Palliative Care Screening Tool Criteria for a Palliative Care Assessment at the Time of Admission Primary Criteria A _ The surprise question : You would not be surprised if the patient died within 12 months or before adulthood _ Frequent admissions (e.g., more than one admission for same condition within several months) _ Admission prompted by difficult-to-control physical or psychological symptoms (e.g., moderate-to-severe symptom intensity for more than hours) _ Complex care requirements (e.g., functional dependency; complex home support for ventilator/antibiotics/feedings) _ Decline in function, feeding intolerance, or unintended decline in weight (e.g., failure to thrive) Secondary Criteria B _ Admission from long-term care facility or medical foster home _ Elderly patient, cognitively impaired, with acute hip fracture _ Metastatic or locally advanced incurable cancer _ Chronic home oxygen use _ Out-of-hospital cardiac arrest _ Current or past hospice program enrollee _ Limited social support (e.g., family stress, chronic mental illness) _ No history of completing an advance care planning discussion/document Patient would be considered to have a positive screen if he or she has a positive response to 3 or more question Patient Sticker: RN initial: Physician notified: Time: Date: Comments:

20 Palliative Care Screening Tool Criteria for Palliative Care Assessment during Each Hospital Day as needs change Primary Criteria A _ The surprise question : You would not be surprised if the patient died within 12 months or did not live to adulthood _ Difficult-to-control physical or psychological symptoms (e.g., more than one admission for same condition within several months) _ Intensive Care Unit length of stay _7 days _ Lack of Goals of Care clarity and documentation _ Disagreements or uncertainty among the patient, staff, and/or family concerning (e.g.; major medical treatment decisions, resuscitation preferences, use of nonoral feeding or hydration) Secondary Criteria B _ Awaiting, or deemed ineligible for, solid-organ transplantation _ Patient/family/surrogate emotional, spiritual, or relational distress _ Patient/family/surrogate request for palliative care/hospice services _ Patient is considered a potential candidate, or medical team is considering seeking consultation, for: (e.g.; feeding tube placement, tracheostomy, initiation of renal replacement therapy, ethics concerns, LVAD or AICD placement, LTAC hospital or medical foster home disposition, bone marrow transplantation (high-risk patients) Patient Sticker: RN Initial: Physician notified: Time: Date: Comments

21 2nd Post Palliative Care Assessment Survey Results Total number of patients screened during the trial phase between July 12 th 2017 August 12 th 2017 Total number of patient with positive screen during the trial phase 5 Total number of patient with a positive screen who received evaluation by a palliative care member 43 5 Is the screening process working to identify the patient with the greatest Do you believe our patient benefited from the palliative screening tool Do you feel comfortable screening for palliative care Is the tool friendly Is tool helping you initiate palliative care consult with the physician sometimes teams aren t always receptive Do you feel you need more resources to enable you to complete your screening tool effectively What would you like revised about the screening tool? (Recommendation, suggestions, comments, questions) 16/18 said yes. Other two haven t used the tool enough 16/18 one not sure, the other two felt like patient would benefit if physician would follow through 16/18 yes, one mostly, and one not comfortable 100 % yes. A request for electronic version 100 % yes! 1 not sure None.

22 Current Progress Presented to Clinical Practice Committee in November Presented to Executive Council of Nursing Staff in December Approved to roll out practice to SICU, MICU, PCU, and 8W Started February 1st

23 Sustainability / Future Plans Future Plans Recommendations Help generate more champions in other units, educate staff nurses and physicians in other areas, generate increased awareness through education, be available when needed to answer questions Help spread the practice to other areas to improve quality of life and reduce our SMR scores

24 Moral Distress Defined When one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action Jameton Repeated and unaddressed situations lead to moral residue 3 categories of root causes Clinical situations Internal factors External factors

25 Source: "Moral Distress in ICU Nurses." Intensive Care Medicine, vol. 42, no. 10, Oct. 2016, pp EBSCOhost, doi: /s Contributing Factors to Moral Distress Internal Constraints Lack of Self-Confidence Fear Maladaptive Coping Religious/Spiritual Conflicts Futile Treatment Inappropriate Care Inadequate Pain Relief Incompetent Coworkers Hastening Dying False Hope Clinical Situations External Constraints Lack of Collegiality Hierarchical Structure Poor Communication Inadequate Staffing Restrictive Policies

26 Problems Stemming from Moral Distress Short-Term Consequences Feelings of Powerlessness Withdrawal from morally charged situations Impaired patient care Long-Term Consequences Emotional Withdrawal Emotional Exhaustion Depersonalization Burnout syndrome

27 Moral Distress Scale-Revised Survey used to identify moral distress Designed for critical care nurses 32 items that deal with clinical situations Moral Distress Scale-Revised (MDS-R) 21 items 6 parallel versions for nurses, physicians, and other healthcare professionals 0-4 Likert scale for both frequency and level of disturbance

28 Table 1. Moral Distress Scale-Revised Scores Professional group (n) Mean score, range Profession Nurses (38) 91.66, Setting Medical Intensive Care Unit (20) 86.65, Progressive Care Unit (8) 114, Medical/Surgical/Oncology/Hospice Unit (10) 83.3,

29 Mean Scores 10 Average Score of Moral Distress (frequency x intensity) per Survey Item, Combined Scores MDS-R Survey Item Number

30 Table 2. Root Causes of Moral Distress Following family s wishes for life support when not in best interest of patient MDS-R Mean (SD) Rank 9.5 (5.42) 1 Initiating life-saving actions to only prolong death 8 (5.26) 2 Providing care that doesn t relieve patient s suffering because physician fears dose will result in death 8.21 (6.09) 3 Carrying out orders that are considered unnecessary 7.42 (5.08) 4 Working with unsafe staffing levels 6.71 (5.08) 5 Witnessing diminished care due to poor communication 6.55 (2.94) 6 Working with incompetent providers 5.05 (5.03) 7 Witnessing providers giving false hope 5.02 (4.62) 8 Range for item scores MDS-R = Moral Distress Scale-Revised

31 Table 3. Intention to Leave a Position n (%) Never considered leaving 19 (50.0) Considered but did not leave 15 (39.5) Left job 1 (2.6) Not considering leaving now 22 (57.9) Considering leaving now 11 (28.9)

32 Possible Interventions Ethics Education Ethics Committees Multidisciplinary Ethics Rounds Formal Debriefings End-of-life/futile care policies

33 Consider the Future of Palliative Care American hospitals are filling rapidly with seriously ill and frail adults. By 2030, the number of people in the United States over the age of 85 is expected to double to 8.5 million Most people facing serious illness will end up in the hospital at some point in their illness

34 Hallmarks of A Vital New Trend: Time, Communication, Expertise, Quality, Coordination and Support Provide specialty-level assistance to the attending physician for difficultto-treat pain and other symptoms, including nausea, shortness of breath, fatigue, constipation and depression. Palliative care responds to the episodic and long-term nature of serious and chronic illnesses. These are the pillars of palliative care. Improve quality and lower costs of hospital care. Support patients and families struggling with complex decisions. Coordinate care for patients and families dealing with multiple doctors and a fragmented medical system. Handle time-intensive patient/family/physician meetings. Improve quality of life for patients and families struggling with serious illnesses they might live with for years, including heart and lung disease, diabetes, cancer and Alzheimer s disease.

35 Palliative Care Cost On average, palliative care consultation is associated with reductions of $1,700 per admission for live discharges and reductions of $4,900 per admission for patients who died in the hospital. This means savings of more than $1.3 million for a 300- bed community hospital and more than $2.5 million for the average academic medical center.

36 Available Resources Palliative Care Team: (Dr. Kallenbaugh; Kelly Artis, Social Worker; Cheryl Buntz, SICU Nurse Manager; Palliative Care Team Champions) Palliative Care Hand-out and Book will remain available for in-patient and nurses in the SICU

37 References Lapp, E., I., & L. (2015, December). Examination of a Palliative Care Screening Tool in Intensive Care Unit Patients. Retrieved November 9, 2017, from Hamric, Ann Baile, et al. "Development and Testing of an Instrument to Measure Moral Distress in Healthcare Professionals." AJOB Primary Research, vol. 3, no. 2, Apr-Jun2012, pp EBSCOhost, doi: / Mealer, Meredith and Marc Moss. "Moral Distress in ICU Nurses." Intensive Care Medicine, vol. 42, no. 10, Oct. 2016, pp EBSCOhost, doi: /s Nelson Je et al. Models for structuring a clinical initiative to enhance palliative care in the intensive care unit: a report from the IPAL-ICU Project. Crit Care Med Sep;38(9): doi: /CCM.0b013e3181e8ad23. Available at: Nelson Je et al. Choosing and using screening criteria for palliative care consultation in the ICU. Crit Care Med (in press). Nelson Je et al. Organizing an ICU Palliative Care Initiative: A Technical Assistance Monograph from The IPAL-ICU Project. Center to Advance Palliative Care; 2010; Palliative Care Serious Illness Get Palliative Care Weissman DE, Meier DE. Identifying patients in need of a palliative care assessment in the hospital setting: a consensus report from the Center to Advance Palliative Care. J Palliat Med Jan;14(1): doi: /jpm Whitehead, P.B., Herbertson, R. K., Hamric, A. B., Epstein, E. G., and Fisher, J. M. Moral Distress Among Healthcare Professionals: Report of an Institution-Wide Survey. Journal of Nursing Scholarship, p

38 Palliative Care Questions, concerns, or comments?