PALLIATIVE CARE IN GERIATRIC TRAUMA

Transcription

1 PALLIATIVE CARE IN GERIATRIC TRAUMA Kathleen O Connell MD, MPH Assistant Professor of Surgery Director of Surgical Palliative Care Harborview Medical Center katmo@uw.edu DISCLOSURES NONE LEARNING OBJECTIVES > Identify the primary competencies of primary palliative care > Outline the basic components of a palliative care assessment > Identify special considerations for the delivery of primary palliative care to geriatric trauma patients 1

2 OUTLINE 1. Benefits of palliative care Recent literature review 2. Primary vs. secondary palliative care Integrative vs. consultative models 3. Delivery of primary palliative care to trauma patients Basic palliative care assessment 4. Palliative care in geriatric trauma Frailty screening 5. Resources: Building your palliative care skill set WHY PALLIATIVE CARE IN TRAUMA? PC is delivered in parallel with life-sustaining trauma care The higher number of severely injured elderly survivors has created an imperative to better integrate palliative care into every trauma program EPIDEMIOLOGY OF GERIATRIC TRAUMA National Trauma Data Bank 2016 Annual Report 2

3 BENEFITS OF PC IN TRAUMA Literature Review Decreased Increased Length of stay Costs Non-beneficial EOL Quality of care Pain & symptom management Hospice utilization Long-term care bed use Nursing-lead intervention with pathway for scheduled meetings Improved quality of communication, patient & familycenteredness of care, decreased length of stay White DB. et al. NEJM2018 3

4 Inpatient PC associated with lower intensity EOL care PRIMARY VS. SECONDARY PALLIATIVE CARE Learning objective #1 Identify the primary competencies of primary palliative care > Integrative vs. consultative models PRIMARY VS. SECONDARY PALLIATIVE CARE Learning objective #1 Primary PC Health care proxy Advance care planning Prognostication & GOC Secondary PC Complex pain & symptom management Difficult communication & end of life decision making Complicated grief & bereavement Pain & symptom management Emotional support End-of-life care Who: all nurses and physicians Who: PC team 4

5 PRIMARY VS. SECONDARY PALLIATIVE CARE Integrative vs. Consultative Palliative Care Embedded within ICU care: primary PC Specialized PC providers: secondary PC DELIVERY OF PRIMARY PALLIATIVE CARE TO TRAUMA PATIENTS Learning objective #2 Outline the basic components of a palliative care assessment Identification of pre-existing advance directives Identification of surrogate decision-maker Family meeting within 72 hours DELIVERY OF PRIMARY PALLIATIVE CARE TO TRAUMA PATIENTS 2017 Guidelines 5

6 PALLIATIVE CARE ASSESSMENT Learning objective #2 Pre-existing advance directives Living will POLST Durable power of attorney DNR Surrogate Statutory authorization for surrogate decision-making WA state Family meeting 72 hours Prognostication Advance care planning PRE-EXISTING ADVANCE DIRECTIVES Living will Records end-of-life wishes Life-sustaining treatment POLST DPOA DNR Physician order for lifesustaining treatment OUTPATIENT orders Remainsin effect when not able to make decisions Allow Natural Death (AND) SURROGATE DECISION-MAKER Statutory authorization for surrogate decision-making WA state Appointed guardian Durable power of attorney Spouse / State registered domestic partner Children (>18 yo) Parents Adult siblings 6

7 FAMILY MEETING WITHIN 72 HOURS Family meetings every 3-5 days thereafter Prognostication Geriatric Trauma Outcome Score Advance care planning Goals of care Shared decision-making PROGNOSTICATING: GERIATRIC TRAUMA OUTCOMES SCORE Forecasting in-hospital mortality (age, ISS, PRBC transfusion) ADVANCE CARE PLANNING Shared Decision-Making Schrager S. et al. Fam Pract Manag

8 ADVANCE CARE PLANNING Best Case/Worst Case Framework Taylor LJ. et al. JAMA Surg 2017 PALLIATIVE CARE IN GERIATRIC TRAUMA Learning Objective #3 Identify special considerations for the delivery of primary palliative care to geriatric trauma patients Frailty FRAILTY SCREENING Predictor of poor functional status & mortality Frailty: increased vulnerability to adverse outcomes after exposure to a stressful event Trigger for palliative care consultation 8

9 1. CLINICAL FRAILTY SCALE Canadian Study on Health & Aging K. Rockwood et al. CMAJ 2005 CFS predicts adverse discharge disposition 2. FRAIL SCALE 3 = frail 1-2 = pre-frail 0 = not frail Morley JE et al. J Nutr Health Aging

10 2. FRAIL SCALE 5-item FRAIL scale predicts 1-year functional status and mortality RESOURCES: BUILDING YOUR PALLIATIVE CARE SKILL SET > VITALtalks > PCNOW Fast Facts > GeriPal Podcast & Blog > UW Graduate Certificate in Palliative Care VITALtalk 10

11 VITALtalk App VITALtalk Courses > Delivering serious news (online) > Mastering tough conversations (in-person) > Faculty development (in-person) PALLIATIVE CARE FAST FACTS 11

12 PALLIATIVE CARE FAST FACTS App

13 9/14/2018 SUMMARY PC is delivered in parallel with life-sustaining trauma care Primary palliative care is delivered by all nurses and physicians Palliative care assessment includes Identification pre-existing advance directives Identification of surrogate decision-maker Family meeting within 72 hours (prognostication & ACP) Frailty assessment useful as a trigger for palliative care consultation THANK YOU WWAMI TRAUMA CONFERENCE! My personal palliative care provider 13