Communication and Shared Decision-Making in the Absence of Terminal Disease

Transcription

1 Communication and Shared Decision-Making in the Absence of Terminal Disease Prema R. Menon, MD, PhD Assistant Professor of Medicine Pulmonary and Critical Care Division University of Vermont

2 Outline Introduction: Patient population Shared Decision-Making (Collaborative) Outcomes of Interest/Data What should we be talking about? When should we talk about this? Conclusion 2

3 Introduction Complex Medical Needs/Care Require coordinated response to deliver care Multidisciplinary Multiagency support Non-acute basis Complex Medical Problems Life threatening Frequent monitoring Multiple organ systems Risk of serious complications Conditions may be serious and complex for SOME patients at SOME points during the course of disease/disability 3

4 Introduction Natural history of patients with complex medical problems/needs As individual issues progress New medical issues New medical needs With each new issue/need level of complexity increases Need to continually discuss changes in management Acute issues arise Patients get closer to death 4

5 Shared Decision Making (SDM) Collaborative process Patients (support members) Providers Health care decisions Together It takes into account: Best clinical evidence Patient values Patient preferences 5

6 What s happening now? Primary care medical home Patient-centered Comprehensive care Coordinated care Access to care Systems-based approach to quality and safety But what is really happening? Can you provide comprehensive and coordinated care to patients with complex medical needs? AHRQ 2011 Peikes, D. JAMA 2009;301(6);

7 What should we be talking about Patient Values Patient Preferences Quality of life What is considered burdensome? How much burden is the patient willing to take? How much burden is the surrogate willing to take? Who do we ask about treatments? 7

8 When do we make decisions? When the patient falls extremely ill Patients Surrogate decision-makers Why is this the wrong time? Patients Delirium Severity of illness Surrogates Acuity of illness Increased anxiety, PTSD, burden of illness TYRANNY OF THE URGENT!!! Azoulay, E. Am J Resp Crit Care Med 2005;171(9); Siegel, K. Cancer 1991;68(5):

9 Some problems are so complex that you have to be highly intelligent and well-informed just to be undecided about them -Laurence J. Peter 9

10 Case #1 A 65 yo Caucasian male with history of: Heart disease COPD DM Kidney disease MO/immobility Presents to hospital with chest pain

11 Case#1 Cardiac catheterization at his local hospital Transferred to TCC for further testing Has another catheterization Complications: Unable to manage medically, needs surgery Worsening renal failure

12 Next steps? Surgery vs Medical management? Initiate dialysis?

13 What should we be talking about? Dialysis data? Cardiac surgery data? Both? General discussion? TYRANNY OF THE URGENT!!

14 So let s talk data

15 More data. People with ESRD do equally well as those who do not have Renal disease IF they make it to discharge Increased immediate mortality rates compared to controls. TYRANNY OF THE URGENT!!

16 Discussion Case#1

17 Case#2 75 yo male with history of: CHF COPD DM Frailty CKD Develops severe pneumonia, fails outpatient management and develops respiratory failure

18 Next steps? Mechanical Ventilation TYRANNY OF THE URGENT!!

19 Let s talk data again Esteban A et al., JAMA 2002

20 Tracheostomy Survival 30% survive to 1 year Increased risk of death COPD, older than 70 years Average LOS in the hospital: 45 days Discharge destination 90% discharge to NH or rehab facility Kojici MRespir Care, 2011 ; 56(11)

21 Feeding Tube Mortality 1 year mortality: 62% Risk factors Age Pre-placement nutritional status Comorbidities Mental status Survival Cowen ME., J Gen Inern Med 1997;12(2);

22 Cardiopulmonary resuscitation (CPR) Outcome of interest: return of spontaneous circulation (ROSC) In-hospital: 24% ROSC Survival to discharge? 18.3% Where do you go? 30% home, 30% another hospital, 20% nursing home, 10-15% hospice CPR Stapleton, RD CHEST 2014;146(5): Ehlenbach, WJ NEJM 2009;361:

23 CPR What if you have COPD? 17% survival Discharged home If you survive what does it look like? Long-term survival 5 months (compared to 12 months) Increased likelihood to be hospitalized during those 5 months What if you have CKD? Metastatic cancer? 14%, 11%; LTS: 3 months Likely to be discharged elsewhere Stapleton, RD CHEST 2014;146(5): Ehlenbach, WJ NEJM 2009;361:

24 What do I do? ICU Physician Director of the UVM MC Interstitial Lung Disease Clinic Idiopathic Pulmonary Fibrosis

25 IPF course is variable King TE, et al. Lancet

26 Idiopathic Pulmonary Fibrosis Richeldi L, et al. Lancet 2017

27 Shared Decision-Making Physician provides Treatment options Risks and benefits Mutually acceptable decision Patient provides Personal preferences Values and concerns Discuss the efficacy and safety of FDA-approved therapies Listen to patient s preferences and concerns Focus on symptom control and management of comorbidities Look at the option of lung transplantation Set treatment expectations 27

28 Conclusions 28

29 Questions/Discussion Thank you 89 Beaumont Ave Given D 208D Burlington, VT