Emerging Challenges In Primary Care: 2015

Transcription

1 Care Se'ng Emerging Challenges In Primary Care: 2015 Transition to End of Life Care: The How and Why 1 Faculty Naresh Pathak, MD, FACP, FAAHPM Associate Clinical Professor, Nova Southeastern University, School of Medicine Voluntary Faculty, University of Miami, School of Medicine Fellow, American Academy of Hospice and Palliative Medicine Chair, Medical Economic Regulatory Committee, ACP Miami, FL 2 Disclosures Naresh Pathak, MD, FACP, FAAHPM serves as a consultant/teacher for Vitas Hospice Care. 3 1

2 Learning Objectives After participating in the proposed educational activities, clinicians should be better able to: 1. Discuss hospice care and its evolving role in end of life care 2. Describe palliative care and its evolving role in patient care 3. Identify patients eligible for hospice care 4. Discuss obstacles to better end of life care and how to overcome them 4 Learning Pearls 1. What is the difference between HOSPICE & PALLIATIVE CARE and how are they reimbursed? 2. When to call Palliative Care Consult in acute care or hospital setting? 3. How to identify patients in need of Palliative Care? 4. Can we predict which patients are in their last year of life? 5. When is feeding tube not appropriate? 5 EVALUATION Evaluation of each presentation is essential for continued improvement of the program Don t take the short cut like the airlines tried to do in past 6 2

3 Pre-Test Questions 7 Pre-test ARS Question 1 On a scale of 1 to 5, please rate how confident you feel about prognostication of end of life and talking to patients about the end of life issues: 1. Not at all confident 2. Slightly confident 3. Moderately confident 4. Pretty much confident 5. Very confident 8 Pre-test ARS Question 2 What are the obstacles clinicians face that prevent them from talking to the patient about the end of life, even when expected life span is 6-12 months: 1. Don t feel comfortable talking about death 2. Can t prognosticate 6-12 mos. of life span 3. Patients don t feel comfortable talking about death and dying 4. Patient s families don t want us to talk to patients about death 5. All of the above 9 3

4 Pre-test ARS Question 3 An elderly patient, nearing end of life, is admitted to the hospital. If he is seen by a Palliative Care Specialist early during the admission, he is likely to experience which of the following: 1. Increased satisfaction 2. Increase in Hospital Length of Stay 3. Increase chance of In-hospital death 4. Decrease chance of In-Hospital death 5. Decrease chance of admission to Hospice 10 Pre-test ARS Question 4 88 yo wf with OBS, DM II, PVD, CAD, Cardiomyopathy, CHF (class-3), CKD-4, PPS=40, FAST=7c is admitted to hospital with aspiration pneumonia. Which of the following statements are true: 1. She has 6 mos. of life span and so she is Hospice appropriate 2. PEG Tube is likely to prevent future Pneumonia 3. PEG Tube is likely to improve survival 4. PEG Tube will prevent decubiti 11 Pre-test ARS Question 5 When is the patient with end stage Dementia appropriate for Hospice: 1. When patient has 6 mos. life expectancy 2. After 3 admissions to hospital 3. When patient aspirates 4. When patient s family can not manage 5. When patient starts loosing weight 12 4

5 Definition of Death 1. The final effort of the patient to embarrass his doctor publicly 2. Ultimate state of the final common pathway that emerges subsequent to a terminal morbid event culminating in the eventual bio-cessation of animate bioprocesses 3. Death Rate in U.S.A. = 1 per person 4. We all carry the terminal Dx called BIRTH 13 (Where Are Our Priorities?) Humpty Dumpty Sat on a Wall Humpty Dumpty Had Big Fall THEN He didn t Have a Cholesterol Problem Anymore! Did he? 14 WHO Definition Of Palliative Care Pallia%ve care is an approach that improves the quality of life of pa3ents and their families facing the problems associated with life- threatening illness, through the preven%on and relief of suffering by means of early iden%fica%on and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. 15 5

6 Comparing Palliative Care & Hospice Care Interdisciplinary care for patients with serious life-threatening illnesses Prognosis estimated at < 6 months if disease runs its expected course Emphasizes pain and symptom management and psychosocial/spiritual support Primary goals relate to quality of life goals and symptom control Is tailored to the needs and wishes of patients and their families both Part B consultation (FFS) vs. Part A Medicare entitlement (Capita3on) Hospice Palliative Care 16 Conceptual Shift for Palliative Care Life Prolonging Care Hospice Care Old Life Prolonging Care Pallia3ve Care Hospice Care Bereavement New Dx most effective when introduced early in serious illness Death Copyright 2008 Center to Advance Palliative Care. Reproduction by permission only. 17 Pearl # 1 Is there a difference in symptom & problem clusters amongst cancer and noncancer patients in need of Palliative Care? When To Call Palliative Care Consult In Acute Care or Hospital Setting? 18 6

7 Case # 1 Mr. Bones B. Hurting, 70 yo bm, multiple myeloma Diffuse multiple pathologic fractures Failed all treatment, now with severe bone pain BP = 150/90, P = 94 R = 20 T = 98.4 F Calcium = 11.0, BUN/Creatinine = 34/1.4, WBC = 8.0. H&H = 10/30. CXR = Diffuse bony lucencies with new rib fractures 19 Case # 1 (Continued) He Is admitted & hydrated He has no Living Will Patient wants, Everything done Patient is not willing to discuss hospice care 20 Case # 1 (continued) What would you Do next? 21 7

8 Case # 1 1. Call oncologist on consult to give more chemotherapy 2. Call radiation oncologist to give more radiation 3. Increase his long-acting morphine till pain is controlled and plan transfer to rehab 4. Social service consult for placement alternatives since family can no longer take care of him 5. Call palliative care consult 6. All of the above 22 Case # 2 Mr. Ken T. Swallow, an 88 yo wm Living in a nursing home Advanced dementia with fever of 102 F Difficult to arouse, No living will Daughter in New York has not visited father for a year 23 Case # 2 (continued) BP = 90/50, P = 110 irreg. irreg., R = 24 & shallow CXR = RLL Infiltrate, WBC = 18 K with left shift BUN/Creat = 45/1.8, Albumin = 2.5 CT brain = Diffuse atrophy Admitted, Cultured & given broad spectrum Antibiotics and Hydration 24 8

9 Case # 2 (continued) What would you Do next? 25 Case # 2 1. Consult Neurologist for altered mental status 2. Consult infectious disease to help you manage the septic shock 3. Consult hospice 4. Consult palliative care 5. Consult G.I. for gastrostomy tube placement 26 Supportive Literature-1 Symptoms and Problems Clusters in Cancer and Non-cancer Patients in Specialized Palliative Care Is There a Difference? (Journal of Pain and Symptom management: Jan 10, 2014) 27 9

10 Supportive Literature 1 (continued) German Hospice and Palliative Care Evaluation Cohort ( ) 16 Item symptom-problem checklist 5 clusters identified with significant concordance (1) Nausea & Vomiting (2) Anxiety & Tension & Depression (3) Wound Deterioration & Confusion (4) Overburdening of Family (5) Weakness & Tiredness & Loss of Appetite & Need for Assistance with ADL 28 Supportive Literature-2 Effects of Initiating Palliative Care Consultation in the ER on Inpatient Stay (Journal of Palliative Medicine: Vol:16, Issue:11, November 11, 2013) 29 Supportive Literature 2 (continued) Compared In ER initiated vs. Post admission PC Consults 1453 consults over 4 year period In ER Consults were associate with significantly shorter length of stay by 3.6 days (p<0.01) 30 10

11 Supportive Literature-3 Evidence-Based Palliative Care in the Intensive Care Unit: A Systematic Review of Interventions (Journal of Palliative Medicine: February (2): ) 31 Supportive Literature 3 (continued) Systematic review of articles from last 20 years 3328 references, 37 publications detailing 30 interventions (1) ê in ICU length of stay (2) No effect on satisfaction (3) ê or No effect on mortality 32 Supportive Literature-4 Comparison of Early vs. Late Palliative Care Consultation in End-of-Life Care for the Hospitalized Elderly Patients (American Journal of Hospice and Palliative Medicine: April 8, 2014 ) Compared PC Consultations <3 days OR >3 days after the admission Retrospective review of data ( ), 531 patients, Age >65 yrs., PPS<

12 Supportive Literature 4 (continued) Results (1) ê # of days from consult to discharge (2) é patients admitted to Hospice (3) é live discharges to home (4) é live transfers to rehab (5) ê in-hospital death 34 Survival Over Time For Early Palliative Care vs. Standard Care 35 Bottom Line 1- There is no difference in Symptom-Problem Clusters between cancer & non-cancer patients in need for Palliative Care. 2- Early Palliative Care Consultation in acute care hospital setting is better than Late. ER is the earliest place to intervene

13 Pearl # 2 Can we predict which patients are in their last year of life? 37 Case # 3 69 yo wf 100 pack year smoker NSCLC, Liver metastases Progressive dyspnea on exertion Fatigue and Decline in function. 38 Case # 4 84 yowm, (+)MI, Cardiomyopathy, CKD-4, CHF, DM Recurrent hospitalizations for CHF Progressive increase in SOB, Fatigue, Poor appetite Needs more diuretics, Blood pressure dropping Did not tolerate rehab last time Urinating less with more and more diuretics 39 13

14 Case # 5 99 yobf, COPD, CHF, DJD, Osteoporosis Alzheimer's disease, CKD-3 Living in nursing home, Declining Eating less, Keeps food in the mouth Non-ambulatory, Incontinent of stool and urine Rolled out of bed twice Two episodes of UTI in past one month 40 Cases # 3, 4, 5 1 Can you predict when these three patients will die? 2 Can you reduce the symptom burden? 3 Are they appropriate for hospice care in spite of not having cancer diagnosis or other terminal diagnosis? 4 Can you, as their primary care provider, be involved in their care and still get paid if you refer them to hospice? 5 What care can they receive and what treatment will stop once they join hospice? 41 Supportive Literature -1 Can We Predict Which Hospitalized Patients are in Their Last Year of Life? A Prospective Cross- Sectional Study of the Gold Standards Framework Prognostic Indictor Guidance as a screening tool in the Acute Care Hospital Setting European Association for Palliative Care (EAPC) (Palliative Medicine: May 22, 2014) 42 14

15 Supportive Literature -1 Prospective, Cross Sectional Study, 551 patients In New Zealand Tertiary Care Teaching Hospital Screening done using Gold Standard Framework Prognostic Indicator Guidance 99 patients identified (with at least 1 trigger indicator) 6 Month Mortality = 56% vs. 5% 12 Month Mortality = 67% vs. 10% At 1 Year -- Sensitivity = 62%, Specificity = 91%, Positive Predictive Value = 67%, Negative Predictive Value = 90% 43 The GSF Prognostic Indicator Guidance 3 Triggers That Suggest That Patients are NEARING END OF LIFE 1. The Surprise Question: Would you be surprised if this patient were to die in the next few months, weeks, days? 2. General Indicators of Decline: Deterioration, increase in need or choice for no further active care 3. Specific clinical indicators related to certain conditions 44 Guideline for Estimating Length of Survival in Palliative Patients A. Diagnosis with a poor prognosis Pancreatic Cancer, Biliary cancer, Metastatic cancer with Unknown Primary 45 15

16 Guideline for Estimating Length of Survival in Palliative Patients B. Circumstances with a very poor prognosis Cancer: Multiple metastasis, bone marrow failure, bleeding from tumor, refractory hypercalcimia CHF: Need for inotropic support, progressive renal failure, repeated admissions COPD: Respiratory failure Renal Failure: Discontinuation of dialysis, refractory Hypokalemia without Tx Misc.: Coma, Shock, major CVA, Hypoxic encephalopathy, frail & bed bound stat 46 Karnofsky Performance Scale 100 Normal; no complaints; no evidence of disease 90 Able to carry out normal activity; minor signs or symptoms of disease 80 Normal activity with effort; some signs or symptoms of disease 70 Cares for self; unable to carry on normal activity or do active work 60 Requires occasional assistance, but is able to care for most of his/her needs 47 Karnofsky Performance Scale (continued) 50 Requires considerable assistance and frequent medical care 40 Disabled; requires special care and assistance 30 Severely disabled; hospitalization is indicated although death not imminent 20 Very sick; hospitalization necessary, active supportive treatment necessary 10 Moribund; fatal processes progressing rapidly 0 Dead 48 16

17 Palliative Performance Scale (PPS) Version 2 Similar to Karnofsky Performance Scale Looks at Ambulation, Activity & Evidence of Dz, Self-Care, Intake & Consciousness Level 100% - Fully conscious, normal function 50% - Sit & lie, Extensive Dz, Confused 10% - Bed bound, Total care, Drowsy 0% - Death 49 TRAJECTORIES OF DYING In Acute Hospital Setting JAMA 2003;289: TRAJECTORIES OF DYING With Terminal Illness (Case # 3) JAMA 2003;289:

18 TRAJECTORIES OF DYING With Organ Failure (Case # 4) JAMA 2003;289: TRAJECTORIES OF DYING With Frailty (Case # 5) JAMA 2003;289: Supportive Literature # 2 & 3 #2- Prognostication in Hospice Care: Can the Palliative Performance Scale (PPS) Help? (Journal of Palliative Medicine: Vol. 8, No. 3, 2005) 54 18

19 Can PPS Score help with Prognostication? Retrospective chart review of 502 patients PPS Score (Risk Ratio for Death; Median Survival in Days) (p<0.0001) 60% (17%; 44), 50% (20%; 43), 40% (30%; 29), 30% (40%; 20), 20% (?; 9) PPS Scores are associated with patient length of survival in a hospice program and can be used in evaluating hospice appropriateness 55 Prognostication (continued) #3- Time to Death and Re-enrollment After Live Discharge From Hospice: A Retrospective Look (American Journal of Hospice and Palliative Medicine: May 20,2014) 35% of the patients dis-enrolled from hospice die in 6 months (1491 pts.) Those who chose aggressive Tx and self dis-enrolled had higher mortality 56 Bottom Line (Cases # 3, 4, 5) 1 Can you predict when these three patients will die? -- Yes 2 Can you reduce the symptom burden? --Yes 3 Are they appropriate for hospice care in spite of not having cancer diagnosis or other terminal diagnosis? -- Yes 4 Can you, as their primary care provider, be involved in their care and still get paid if you refer them to hospice? -- Yes 5 What care can they receive and what treatment will stop once they join hospice? Hospice Diagnosis related care is covered by Hospice 57 19

20 Pearl # 3 When is Feeding Tube Not Appropriate? 58 Case # 6 90 yowf, Advanced OBS, No cancer Recurrent aspirations, Now in ER with Pneumonia Needs assistance with all ADL Non-ambulatory, sits all day in wheelchair Speech limited to single word, Oriented to self Poor oral intake, Lost 10% of body wt. in 6 mo. 59 Feeding Tube? BP=100/60, P=110 reg., R=28, T=101 F. RA Pulse Ox=88% Lungs - Rt basal Crackles, Skin - Poor turgor Sacral decubitus, Confused and Agitated WBC=13K with Lt shift, BUN/Cr=52/1.8, Albumin=3.0 Condition improves with Tx. Speech Therapist recommends, alternate means of nutrition for safety When feeding tube was discussed, family was worried about, starving mom to death Should a feeding tube be placed in this patient? 60 20

21 Case # 6 Patient is DYING from complications of dementia Demented pts in hospital for acute illness = 4x increase in 6 mo. Mortality Patient has FAST=7c (6 mo. mortality appropriate for hospice) Feeding Tube does not reduce risk of aspiration Feeding Tube does not extend life 61 Functional Assessment Staging (FAST) Stage 1: No difficulty, either subjectively or objectively Stage 2: Complains of forgetting location of objects; subjective work difficulties Stage 7: Loss of speech, locomotion and consciousness 7c: Non-ambulatory 7d: Unable to sit up independently 7e: Unable to smile 7f: Unable to hold head up 62 Bottom Line 1- Dementia is a terminal illness. 2- Feeding tubes, including PEG tubes, have not been shown to decrease the risk of recurrent aspiration pneumonia or to improve nutritional parameters in advanced dementia 63 21

22 Bottom Line 3- Mortality in this population is high and may be higher after a feeding tube is placed. The mortality rate is 24% at 1 mo., 37% at 2 mo. And 70% at I year after tube placement. 4- Patients with advanced dementia who stop eating apparently do not suffer from hunger and thirst. 5- Patients with advanced dementia who develop difficulties eating should be offered slow handfeeding and nurturing care which is consistent with a palliative focus. 64 Post-Test Questions 65 Post-test ARS Question 1 What are the obstacles clinicians face that prevent them from talking to the patient about the end of life, even when expected life span is 6-12 months: 1. Don t feel comfortable talking about death 2. Can t prognosticate 6-12 mos. of life span 3. Patients don t feel comfortable talking about death and dying 4. Patient s families don t want us to talk to patients about death 5. All of the above 66 22

23 Post-test ARS Question 2 An elderly patient, nearing end of life, is admitted to the hospital. If he is seen by a Palliative Care Specialist early during the admission, he is likely to experience which of the following: 1. Increased satisfaction 2. Increase in Hospital Length of Stay 3. Increase chance of In-hospital death 4. Decrease chance of In-Hospital death 5. Decrease chance of admission to Hospice 67 Post-test ARS Question 3 88 yo wf with OBS, DM II, PVD, CAD, Cardiomyopathy, CHF (class-3), CKD-4, PPS=40, FAST=7c is admitted to hospital with aspiration pneumonia. Which of the following statements are true: 1. She has 6 mos. of life span and so she is Hospice appropriate 2. PEG Tube is likely to prevent future Pneumonia 3. PEG Tube is likely to improve survival 4. PEG Tube will prevent decubiti 68 Post-test ARS Question 4 When is the patient with end stage Dementia appropriate for Hospice: 1. When patient has 6 mos. life expectancy 2. After 3 admissions to hospital 3. When patient aspirates 4. When patient s family can not manage 5. When patient starts loosing weight 69 23

24 Post-test ARS Question 5 On a scale of 1 to 5, please rate how confident you feel about prognostication of end of life and talking to patients about the end of life issues: 1. Not at all confident 2. Slightly confident 3. Moderately confident 4. Pretty much confident 5. Very confident 70 Post-test ARS Question 6 Which of the statements below describes your approach to counseling patients on end of life issues and managing their care: 1. I do not counsel patients on end of life issues or manage their care, nor do I plan to this year. 2. I did not counsel patients on end of life issues or manage their care before this course, but as a result of attending this course I m thinking of doing this now. 3. I do counsel patients on end of life issues and manage their care. As a result of attending this course, I plan to change my treatment methods. 4. I do counsel patients on end of life issues and manage their care and this course confirmed that I don t need to change my methods. 71 Final Words Never say to the patient, There is nothing I can do for you. You can always be there for them as an active listener Just because you can not treat the disease, does not mean you can not treat the patient You may not control the QUANTITY of life but you can certainly influence the QUALITY of it 72 24

25 Final Words REMEMBER Ultimately We Are All Biodegradable 73 REFERENCES 1. Billings JA: Comfort measures for the terminally ill is dehydration painful? J Am Geriatr Soc 1985:33: Grant M. Rudberg M, Jacobs 13: Gastrostomy placement and mortality among hospitalized Medicare beneficiaries. JAMA 1998;279: Mitchell S, Kicly D. Lipitz. L: Does artificial nutrition prolong the survival of institutionalized elders with chewing and swallowing problems? J Gcrontoi 1998:53A:M207-M Finucane T. Christmas C. Travis K: Tube feeding in patients with advanced dementia a review of the evidence. JAMA 1999:282: Gillick M: Rethinking thc,1" of tube feeding in patients with advanced dementia. N Engl J Mcd 2000:342: Callahan C. Haag K. Nisitct, et al: Outcomes of percutaneous endoscopic eastrostomy among older adults in a community setting.) Am Geriatr SuE 2000:48: Morrison RS. Siu AL- Survival in end-stage dementia following acute illness, JAMA 2000:284: My Contact jaima310@gmail.com