Palliative Care, Death Panels and Rationing Resources: Medicare and End of Life Care

Transcription

1 Palliative Care, Death Panels and Rationing Resources: Medicare and End of Life Care Gobi Paramanandam MD, MHSM Arizona Palliative Home Care 1

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3 Policy Patient Self-Determination Act, 1991 Included requirements for health care facilities regarding advance directives Hospitals and SNF s must ask each patient upon admission if AD before providing treatment or care Medicare patients are not required to have an AD before they receive care American Bar Association: Division for Public Education, Law for Older Americans, accessed May 29, 2015, 3

4 No will About 4 in 10 Americans over 65 do not have AD s or written down their wishes for end-of-life treatment Hispanics and African-Americans with a lower likelihood In the absence of a terminal diagnosis or advanced serious chronic illness, they are even less likely to have completed such a document Pew Research Center, Views on End-of-Life Medical Treatments, November 2013 CMS proposes rule July 9, 2015 CMS proposes to pay physicians for advanced care planning services Values and preferences discussed and documented 4

5 Objectives Discuss the Centers for Medicare and Medicaid Services (CMS) approved payment for voluntary end-of-life counseling as part of its 2016 Physician fee schedule. Demonstrate how health care providers can effectively have these conversations with their patients. Review evidence-based data on end-of-life care and treatments. Advance Care Planning Learn about health care options available for end-of-life care Determine which types of care best fit their personal wishes Share their wishes with family, friends, and their physicians Often requires series of conversations 5

6 CMS Proposed Rule July 9, 2015 CMS proposes to pay physicians for advanced care planning services Started 1/1/2016 Values and preferences discussed and documented Physicians and other health professionals Counseling and discussing with or without completing relevant legal forms Covered in offices, hospitals, facilities Payment One or more meetings, 30 min or longer Office Pay $86 for 30 min in office Pay $75 for 30 additional min- add on Hospital Pay $80 for 30 min in hospital Pay $75 for 30 additional min- add on If a patient problem addressed can use separate E/M code 6

7 Minimum Documentation All points- first 3 required A person designated to make decisions for the patient if the patient cannot speak for him or herself The types of medical care preferred The comfort level that is preferred How the patient prefers to be treated by others What the patient wishes others to know Also document whether or not an AD or POLST has been completed Advanced Care Planning CPR Cancer Cardiovascular disease Chronic respiratory disease 7

8 Basic statistics Two literature reviews of hospitalized patients who underwent CPR in the hospital reported similar stats 1989 and % immediate survival in both 13%-14% survival to hospital discharge One in seven Basic Statistics National Registry of Cardiopulmonary Resuscitation 14,720 attempts from different hospitals Results Survival 20 minutes post CPR 44% Survival to discharge- 17% Survivors experienced overall 25% decline in function Peberdy et al. Resuscitation

9 Many complications Patients who survive cardiopulmonary arrest end up worse off clinically Spend time in an ICU with life-support measures in place, such as mechanical ventilation and vasopressors One study Determine patient knowledge about lifesustaining treatments Physician understanding of patient preferences for proxies and treatments after outpatient discussions about advance directives Fischer G, Journal of Internal Medicine

10 What is CPR? When pt asked to describe CPR 26% couldn t identify any features of CPR 37% thought ventilated pt s could talk 20% thought ventilators were oxygen tanks 20% thought people on ventilators are always comatose Patients estimated survival after CPR as 70% (reality = 14-15%) Survival after CPR Patients often overestimate their likelihood of survival after CPR This misinformation may lead them to choose to undergo resuscitation in situations in which survival is extremely unlikely 10

11 Another article The influence of the probability of survival on patients' preferences regarding cardiopulmonary resuscitation Murphy et al, N Engl J Med Feb Survival study 41 % opted for CPR before learning the probability of survival to discharge Learned probability of survival 10 % to 17 % 22 % opted for CPR Only 6 % of patients 86 years of age or older opted for CPR Murphy et al, N Engl J Med Feb 11

12 Who s at fault? Patients more willing to discuss with Family Physician/Internist Longer physician-patient relationships understood patients' preferences to forego CPR more often Discuss as inpatients Hypothesized barriers Primary Care Physicians Not trained Comfort Time and productivity constraints 15 minutes Not doing inpatient, advent of hospitalists 12

13 Hospitalists Hypothesized barriers Acute deterioration in inpatient setting encourages patient self-reflection Need to build trust and rapport quickly Time and productivity constraints Media Asked patients over 62 years of age where they obtain information about CPR from 72% from books 82% from newspapers 92% television Schonwetter, J Gen Intern Med 13

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15 TV Study CARDIOPULMONARY RESUSCITATION ON TELEVISION Miracles and Misinformation SUSAN J. DIEM, M.D., M.P.H., JOHN D. LANTOS, M.D., AND JAMES A. TULSKY, M.D. THE NEW ENGLAND JOURNAL OF MEDICINE They got to watch TV! Watched all the episodes of the television programs: ER and Chicago Hope during the viewing season 50 consecutive episodes of Rescue 911 broadcast over a three-month period in

16 Results 60 occurrences of CPR in the 97 television episodes 31 on ER 11 on Chicago Hope 18 on Rescue 911 Demographics In the majority of cases, cardiac arrest was caused by trauma (GSW, MVA) Only 28 % were due to primary cardiac causes 65 % of the cardiac arrests occurred in children, teenagers, or young adults 75 % of the patients survived the immediate arrest 67 % appeared to have survived to hospital discharge 16

17 Each show ER= 65 % survived the initial arrest; three of these patients died before discharge from the hospital Chicago Hope= 64 % of the patients given CPR initially survived cardiac arrest, and 36 % survived to discharge Rescue 911= the survival rate after CPR was 100 % Portrayals The outcome of CPR was portrayed as either full recovery or death One survivor of CPR on television with disability 16-year old boy who had inhaled a cleaning agent and butane Spoke with a moderate dysarthria He recovered from his cardiac arrest, completed high school, and became a motivational speaker warning about the dangers of drug abuse 17

18 CPR not benign In the real world, disability after cardiac arrest is much more common Controversy surrounds the use of CPR because the procedure can lead to Prolonged suffering Severe neurologic damage An undignified death 18

19 Bad television CPR succeeded more frequently on television than in the real world Information assymetry Like a treatment We ask people to make a decision about a difficult issue without giving them data about its effectiveness Treat the decision like any other medical condition (PNA) Don t ask but offer guidance 19

20 So when? But physicians not accurate in predicting prognosis Overemphasis on age Decision Rules Pre-Arrest Morbidity (PAM) score The Prognosis After Resuscitation (PAR) score 20

21 Decision Rules Evaluated scores for their abilities to predict the outcomes of in-hospital CPR in a racially mixed population of patients in the United States Used PAM, PAR, APACHE EBELL, MD, MS, Med Decision Making Evaluated Using the scores Immediate survival (return of spontaneous circulation with transfer to the intensive care unit) Survival to discharge 656 patients undergoing resuscitation 21

22 Results 37.6% survived the resuscitation attempt long enough to be stabilized (immediate survival) 5.3% survived to discharge None of the decision-support tools effectively discriminated between survivors and nonsurvivors for outcomes of immediate survival and survival to discharge following in-hospital CPR Positive variables Factors that increased survival included arrest due to Coronary artery disease Drug overdose/adverse reaction Location of arrest in the ICU 22

23 Negative variables Following variables were associated with failure to survive to discharge Cancer- either localized or metastatic Sepsis on the day prior to resuscitation Dementia Serum creatinine level at a cutpoint of 1.5 mg/dl Residence in a nursing home Cancer Meta-analysis reveiwed 42 studies from % cancer patients survived to discharge since

24 ESRD Dialysis patients 3 studies in 137 patients 14% survival to discharge 3% only made it to 6 months Having the conversation Comfortable setting What does the patient understand? Illness and prognosis Expectations Goals, hopes and fears 24

25 Having the conversation Discuss DNR CPR is a treatment that reverses death Terminal disease Ambiguous prognosis- If you should die in spite of all of our efforts, do you want us to use heroic measures to attempt to bring you back? Never say- do you want us to do everything? Hopes, fear, guilt Guilt- I haven t lived nearby to care for my dying mother Fear- I am afraid to make a decision that could lead to my wife s death Listen, give permission Identify underlying emotions and offer empathic comments 25

26 Not effective This particular disease/condition CPR is not an effective therapy We will treat you with medication X Not offer CPR, not effective Not withholding therapy, maximum medical therapy Certain death vs. likely death Cancer Knowledge of all options Chemotherapy Understand anticipated impact of each option on: Quantity of their remaining lives Quality of their remaining lives Radiation 26

27 Heart Failure Class III and IV disease Cardiac resynchronization therapy Biventricular Pacemaker- PM dependent? Improve symptoms and extend life Ethically appropriate Ventricular Assist Device Bridge vs destination Discontinuation related to new or worsened medical condition- sepsis, cancer, renal failure Brush et al (2010) Implantable Cardioverter Defibrillator Heart Failure Inotropic support Prognosis is challenging Understanding of reversible cardiac lesionsrevascularization, valvular repairs etc. NYHA IV, oxygen dependent Hospitalization Performance score Weight loss 27

28 Respiratory Disease Oxygen and steroid dependent Managing acute exacerbations Managing dyspnea and care plans Prognosis difficult FEV1 less 30% Hospitalization Performance score Weight loss 28