World Death Rate Holding Steady At 100 Percent - The Onion

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3 World Death Rate Holding Steady At 100 Percent - The Onion

4 Identify three interventions an out patient palliative care team could make to reduce hospital readmissions Describe challenges to pulmonary end-of-life care

5 I began to realize that coming in such close contact with my own mortality had changed both nothing and everything. Before my cancer was diagnosed, I knew that someday I would die, but I didn t know when. After the diagnosis, I knew that someday I would die, but I didn t know when. But now I knew it acutely. The problem wasn t really a scientific one. The fact of death is unsettling. Yet there is no other way to live. Paul Kalanithi, When Breath Becomes Air

6 An extra layer of support at any age, any stage of serious illness and can be provided along with curative treatment. Joe Barnes M.D. FAAFP Hospice and Palliative Care Certified Hospice Medical Director Certified CAQ Geriatrics

7 Palliative means to reduce effects or symptoms of disease without curing the disease (Greek Pallas: to shield) Balfour Mount, surgeon in Canada coined the term French term for hospice was associated with almshouses charity houses for the old and infirm. Concept introduced in the 1980s, certification since 1996 Accepted by ABMS in 2006, 70 fellowships currently 12/31/14 approximately 7000 certified physicians (297 Fellows in 2015)

8 Relatively New Specialty, ABMS 2006 Ten ABMS members recognize offer subspecialty certification Certification now requires a one year fellowship KUMC trains 3 fellows a year.

9 Simply put: All Hospice is palliative care but not all Palliative Care is hospice.

10 Caring for the sickest of the sick, the most vulnerable Based on the Hospice Interdisciplinary Team (IDT) concept The sickest 5% of us drive 50% of health care spending Value is what matters to patients and families High value intervention improves care and lowers costs

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13 Guwande said, people have other priorities in there lives aside from living longer. The goal isn t immortality; it isn t just survival at all costs. Some want to continue working as long as possible. Others want to enjoy simple pleasures and comforts. The problem is that patients and doctors are not communicating about these priorities. Harvard Gazette; 9/7/2018

14 Palliative care means patient and family centered care that optimizes quality of life throughout the continuum of illness by 1. treating suffering (physical, emotional, intellectual, social, spiritual) 2. facilitating patient autonomy 3. education 4. choice

15 Palliative Medicine Boot Camp Core Elements of Palliative Care: Symptom Management Communication Psychosocial and Spiritual Processes and Logistics of Care Infrastructure Development Serious Illness Care Planning Serious Illness Conversation Guide

16 Nursing Home residents with multiple serious illnesses, symptoms Patients and families in their homes dealing with serious illness, polypharmacy, advance directives Persons with newly diagnosed complex medical problems The Hesitant Hospice Patient/Family The Surprise Question as a screening tool

17 Cardiovascular disease Cancer Lower respiratory disease Stroke Dementia

18 Pain and symptom control A sense of control Strengthening of relationships with loved ones To relieve burdens on family Avoidance of inappropriate prolongation of the dying process

19 Pain/Symptom assessment Social/Spiritual assessment Understanding illness, prognosis and treatment options Identification of patient centered goals of care Transitions of Care from one setting to another Weissman, Archives of Internal Medicine 1997

20 Patient s Provider must request Any age, any stage of disease Can be concurrent with treatment Consult takes place where the patient is IDT may consist of local resources Payment is via Medicare, private insurance

21 What s the story? Is the patient making decisions? How can I be helpful? What do you think about the patient s prognosis? Are there family and friends involved? How long will the patient be in the hospital? Does the patient know we have been consulted? Alex Smith MD, July 18, 2018, Geri-Pal Blog

22 Being Mortal, Medicine and What Matters in the End, Atul Gawande, 2014 Metropolitan Books The Four Things that Matter Most, Ira Byock, 2004 Free Press When Breath Becomes Air, Paul Kalanithi, 2016 Random House choosingwisely.org, mypcnow.org/fast-facts palliativedoctors.org capc.org nhpco.org aahpm.org

23 mypcnow.org/fast-facts #73 Management of Respiratory Failure in ALS #27 Dyspnea at End of Life #199 Opioids for Cough #200 Non-Opioid Anti-tussives Practicalbioethics.org Caring Conversations TPOPP

24 Center for Practical Bioethics; practicalbioethics.org Advance Directive for patients approaching end-of-life Addresses 3 issues: DNR Medical Interventions Medically administered nutrition

25 Science may provide the most useful way to organize empirical, reproducible data, but its power to do so is predicated on its inability to grasp the most central aspects of human life: hope, fear, love, hate, beauty, envy, honor, weakness, striving, suffering, virtue. Paul Kalanithi, When Breath Becomes Air

26 Legal in 6 states: Oregon legal by referendum Washington legal by initiative Vermont legal by legislative action Montana not illegal by Supreme Court decision California legal by legislative action beginning 2016 Colorado Washington DC Assisting a suicide is illegal in a majority of states PAD explicitly illegal in 3 states (AR, ID, RI) No specific law permitting or prohibiting in 4 states Legislative or initiative action on PAD pending in 30 states (Ks HB2150)

27 Terminal Illness ( death expected within 6 months) Decisionally capable adult Resident of the state of Oregon Required consultation by independent physician Two oral requests and one written request separated by 15 days Psychiatric or psychological consult if prescribing physician questions decision making capacity Physician must inform patient the request may be withdrawn at any time

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30 PalliativeDoctors.org Choosingwisely.org Practicalbiioethics.org Aahpm.org Capc.org/fast-facts

31 Being Mortal, Medicine and What Matters in the End, Atul Gawande; 2014 Metropolitan Books The Four Things That Matter Most, Ira Byock; 2004 Free Press When Breath Becomes Air, Paul Kalanithi; 2016 Random House

32 11/29/2017 What if it s me? What if it s my family?

33 8 y/o child with a metabolic disease since birth Pediatric ICU 3 hours away, no local provider Recurrent seizures made worse by sunlight 2 other older children, healthy Child sleeps with parents in order for parents to be alerted to seizures Parents fear accusations of poor care if child dies at home Mom would like support system in place to manage illnesses

34 80 y/o female with weakness, confusion, unsure if she can live alone DPOA-HC and finances is son Presents to hospital with bruising to face and abdomen from fall Presents to hospital with bruising and ruptured spleen from fall While preparing for placement discover bank account empty and land sold

35 35 y/o married female with 3 children, 8,12,16 Kidney cancer spread to spine; operation on kidney and spine Pain 8 on scale of 10 Husband has new job (health insurance). Family moves to small town in NW Ks. Primary care doctor 2 hours away; cancer doctor 4 hours away Her goal is to be a wife and mother.

36 Communication Goals of Care Advance Directives

37 8 y/o child with a metabolic disease since birth Pediatric ICU 3 hours away, no local provider Recurrent seizures made worse by sunlight 2 other older children, healthy Child sleeps with parents in order for parents to be alerted to seizures Parents fear accusations of poor care if child dies at home Mom would like support system in place to manage illnesses

38 First level Second level Third level Fourth level Fifth level

39 93 y/o female resident of an assisted living facility Multiple recurrent trips to ER with Chest pain Daughters live out of state Assisted living staff unsure of what to do so call ambulance Medical staff has obligation to rule out serious problems Multiple admissions to hospital

40 80 y/o female with weakness, confusion, unsure if she can live alone DPOA-HC is son Presents to hospital with bruising to face and abdomen from fall Presents to hospital with bruising and ruptured spleen from fall While preparing for placement discover bank account empty and land sold

41 Who is patient s advocate? Where does patient go? Wants to return home. Is this patient suffering? Physical, emotional What s the plan for her care? Who pays?

42 80 y/o male with dementia enters nursing home from home where spouse has cared for him for > 5 years Wonders constantly, swings at staff, non-verbal Since admit has been to 2 Geriatric Psych centers for treatment Spouse being told she needs to move him somewhere else Spouse having financial troubles Only child lives out of state, cannot help time or $

43 35 y/o married female with 3 children, 8,12,16 Kidney cancer spread to spine; operation on kidney and spine Pain 8 on scale of 10 Husband has new job (health insurance). Family moves to small town in NW Ks. Primary care doctor 2 hours away; cancer doctor 4 hours away Her goal is to be a wife and mother.

44 Suffering? Physical, emotional, socially Symptom control Support for herself, children, husband Education Goals of care, prognosis Communication: family, school, caregiver, insurance company, disability carrier, physicians

45 Who has the problem here? Who needs the help? How do we help the patient, family, nursing home staff Goals for this patient? Is this patient suffering? Advance directives?

46 93 y/o female resident of an assisted living facility Multiple recurrent trips to ER with Chest pain Daughters live out of state Assisted living staff unsure of what to do so call ambulance Medical staff has obligation to rule out serious problems Multiple admissions to hospital

47 Goals of care Different at age 93 vs 35 Support system Family Suffering Cost enter in?

48 Terminating life-sustaining treatments i.e. respirator, artificial nutrition Double effect of opioids for treatment of pain or dyspnea Physician assisted death (also called physician assisted suicide), physician provides at patient s request Voluntary active euthanasia, intentionally administered to cause patient s death with full informed consent

49 80 y/o male with dementia enters nursing home from home where spouse has cared for him for > 5 years Wonders constantly, swings at staff, non-verbal Since admit has been to 2 Geriatric Psych centers for treatment Spouse being told she needs to move him somewhere else Spouse having financial troubles Only child lives out of state, cannot help time or $

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51 CATEGORY 1 CATEGORY 2 CATEGORY 3 CATEGORY 4 Series 1 Series 2 Series 3

52 Group A Group B Class Class First bullet point here Second bullet point here Third bullet point here Class

53 First bullet point here Second bullet point here Third bullet point here Group A Task 1 Task 2 Group B Task 1 Task 2 Group C Task 1