2. The patient has a level of need that exceeds the resources of the primary palliative care provider.

Transcription

1 Referral Criteria fr Adult Palliative Care Services in Midland Regin Based n the Leeds Eligibility Criteria fr Specialist Palliative Care Services (Bennett, et al., 2000) Midland regin includes Bay f Plenty, Lakes, Tairawhiti and Waikat Patients must meet all five criteria belw t be eligible fr referral t Specialist Palliative Care (SPC). If there is any dubt abut eligibility, the Referrer shuld cntact the Service r Hspice t discuss further. It will be at the discretin f the Service as t whether patients wh d nt meet all f the criteria will be accepted. 1. The patient has active, prgressive and advanced disease. Patients eligible fr Specialist Palliative Care are thse with active, prgressive, advanced disease fr whm prgnsis is limited and the fcus f care is quality f life. An alternative term used is that f a life-limiting illness/cnditin. Prgnstic uncertainty (such as exists when embarking n a trial f chemtherapy fr an aggressive malignancy where the likelihd f respnse is lw) shuld nt necessarily be a barrier t referral; if there is a clinical need (criteria 2 belw) the referral is likely t be accepted. Similarly patients may be eligible fr referral t Hspital Palliative Care fllwing a sudden r traumatic event in the absence f a preexisting palliative cnditin (such as an intracranial haemrrhage r ut f hspital cardiac arrest) if the cnditin is active, prgressive and life-limiting. 2. The patient has a level f need that exceeds the resurces f the primary palliative care prvider. The Resurce and Capability Framewrk fr Integrated Adult Palliative Care Services in New Zealand (Ministry f Health Jan 2013) states that palliative care services shuld prvide direct management and e mre cmplex palliative care need exceeds the resurces f the primary palliative care prvider. The Framewrk emphasises that the level f input is needsbased rather than based n diagnsis r prgnsis. Stated anther way, referrals t SPC are apprpriate where there is an extrardinary level f need and examples f this include: uncntrlled r cmplicated symptms; specialised nursing requirements relating t mbility, functining r self-care; emtinal r behaviural difficulties related t the illness, such as uncntrlled anxiety r depressin; cncern r distress invlving children, family r carers, physical and human envirnment (including hme r hspital), finance, cmmunicatin r learning disability; unreslved issues arund self-wrth, lss f meaning and hpe, suicidal behaviurs, requests fr euthanasia and cmplex decisins ver the type f care, including its withhlding r withdrawal. 3. The patient agrees t the referral if cmpetent t d s (r an advcate agrees n their behalf). 4. The patient has New Zealand residency r has reciprcal rights, and is resident within the DHB area. (If the patient is nt a New Zealand resident and is in hspital, discuss with the Hspital SPC team. If cmmunity supprt is needed, the referral must be discussed with the Hspice team and apprval gained frm the Hspice CEO prir t the referral being made t ensure funding is authrised). 5. The patient is registered with a lcal primary healthcare prvider. (Hspital inpatients withut a GP must have this addressed prir t discharge if a Hspice r cmmunity palliative care referral is made). Criteria 4 and 5 are NOT a requirement fr referral t a Hspital Palliative Care Team Patients wh meet the abve criteria shuld be referred fr SPC Assessment; perfrmed by a SPC Care Interdisciplinary Team. The subsequent level f invlvement/interventin, treatment plan and care package will be negtiated with the patient, carer and referring team. Referral Criteria fr Adult Palliative Care Services - September

2 If the patient is in an acute hspital with n Hspital Palliative Care Team, cntact the lcal Hspice t assess their capacity/capability t give advice and supprt shuld that be required. Referral Guidance The fllwing clinical indicatrs shuld be assessed when deciding if a referral is apprpriate r nt. These general indicatrs are based n the Gld Standards Framewrk Prgnstic Indicatr Guidance (Thmas, et al., 2011). Fr patients with advanced disease r prgressive life limiting cnditins - Wuld yu be surprised if the patient were t die in the next few mnths, weeks, days? The answer t this questin shuld be an intuitive ne, pulling tgether a range f clinical, c-mrbidity, scial and ther factrs that give a whle picture f deteriratin. If yu wuld nt be surprised, then what measures might be taken t imprve the patient s quality f life nw and in preparatin fr pssible further decline? Are there increasing needs and/r general indicatrs f decline? Refer t Step 2 in Appendix A belw. Further guidance n referral criteria Fr further guidance n referral criteria fr specific diseases and cnditins, see Appendix A, which prvides infrmatin frm the Gld Standards Framewrk Prgnstic Indicatr Guidance. This Guidance aims t help health prfessinals in the earlier identificatin f adult patients nearing the end f their life wh may need additinal supprt (Thmas, K., et al., 2011). Appendix B prvides an additinal tl, the Supprtive and Palliative Care Indicatrs Tl (SPICT), which was develped as a practical, clinical tl t help multidisciplinary teams identify patients at risk f deterirating and dying in all care settings (Highet, et al., 2014). This infrmatin may be used t help determine if a referral is apprpriate, and may als be prvided t Referrers t infrm their decisin making n wh t refer and when. Nte Mst referrals t palliative care will have an expected prgnsis f less than 12 mnths. Hwever, nt uncmmnly it will either be impssible t determine prgnsis with any certainty r the clinical need will be sufficient t warrant referral in the cntext f a life-limiting illness with a mre chrnic curse. When in dubt, cntact the Service r Hspice directly. Less apprpriate referrals Specialist Palliative Care is largely inapprpriate fr: Patients with chrnic stable disease r disability with a life expectancy f several years. Patients with chrnic pain prblems nt assciated with prgressive terminal disease. Cmpetent patients wh decline referral. Patients wh are unaware f their underlying disease (unless this is a cultural preference in which case this needs t be sensitively addressed). Thse patients whse prblems are principally psychlgical and need specialist psychiatric referral, whether r nt they have declined such help. Patients can stabilise fllwing Specialist Palliative Care interventins and may n lnger require input frm that service with their nging care being managed by their primary palliative care prvider. Discharge frm Referral Criteria fr Adult Palliative Care Services - September

3 the specialist palliative care service shuld be planned in cllabratin with the primary team. Re-referral back t specialist palliative care can be made at any time shuld the need arise. Referral Criteria fr Adult Palliative Care Services - September

4 Appendix A: Prgnstic Indicatr Guidance (PIG) 4th Editin Sept 2011 The Gld Standards Framewrk Centre in End f Life Care (Thmas, et al., 2011) Step 1: The Surprise Questin Fr patients with advanced disease r prgressive life limiting cnditins - Wuld yu be surprised if the patient were t die in the next few mnths, weeks, days? The answer t this questin shuld be an intuitive ne, pulling tgether a range f clinical, c-mrbidity, scial and ther factrs that give a whle picture f deteriratin. If yu wuld nt be surprised, then what measures might be taken t imprve the patient s quality f life nw and in preparatin fr pssible further decline? Step 2: General Indicatrs Are there general indicatrs f decline and increasing needs? Decreasing activity functinal perfrmance status declining (e.g. Barthel scre, Karnfsky Perfrmance Status Scre r Palliative Perfrmance Scale), limited self-care, in bed r chair 50% f day, and increasing dependence in mst activities f daily living C-mrbidity is regarded as the biggest predictive indicatr f mrtality and mrbidity General physical decline and increasing need fr supprt Advanced disease - unstable, deterirating cmplex symptm burden Decreasing respnse t treatments, decreasing reversibility Chice f n further active treatment Prgressive weight lss (>10%) in past six mnths Repeated unplanned/crisis admissins Sentinel event e.g. serius fall, bereavement, transfer t nursing hme Serum albumin <25g/l Step 3: Specific Clinical Indicatrs A. Cancer - rapid r predictable decline Metastatic cancer Mre exact predictrs fr cancer patients are available e.g. PiPS (UK validated Prgnsis in Palliative Care Study), PPI, PPS etc. Prgnsis tls can help but shuld nt be applied blindly The single mst imprtant predictive factr in cancer is perfrmance status and functinal ability - if patients are spending mre than 50% f their time in bed/lying dwn, prgnsis is estimated t be abut 3 mnths r less B. Organ Failure - erratic decline Heart Disease At least tw f the indicatrs belw: New Yrk Heart Assciatin (NYHA) Functinal Classificatin fr Cngestive Heart Failure Stage 3 r 4 - shrtness f breath at rest n minimal exertin Patient thught t be in the last year f life by the care team - The surprise questin Repeated hspital admissins with heart failure symptms Difficult physical r psychlgical symptms despite ptimal tlerated therapy Chrnic Obstructive Pulmnary Disease (COPD) At least tw f the indicatrs belw: Disease assessed t be severe (e.g. FEV1 <30% predicted) Referral Criteria fr Adult Palliative Care Services - September

5 Recurrent hspital admissins (at least 3 in last 12 mnths due t COPD) Fulfils lng term xygen therapy criteria MRC grade 4/5 shrtness f breath after 100 metres n the level f cnfined t huse Signs and symptms f right heart failure Cmbinatin f ther factrs i.e. anrexia, previus ITU/NIV resistant rganisms Mre than 6 weeks f systemic sterids fr COPD in preceding 6 mnths Renal Disease Stage 4 r 5 Chrnic Kidney Disease (CKD) whse cnditin is deterirating with at least 2 f the indicatrs belw: Patient fr whm the surprise questin is applicable Patients chsing the n dialysis ptin, discntinuing dialysis r nt pting fr dialysis if their transplant has failed Patients with difficult physical symptms r psychlgical symptms despite ptimal tlerated renal replacement therapy Symptmatic Renal Failure nausea and vmiting, anrexia, pruritus, reduced functinal status, intractable fluid verlad Liver Disease Ascites despite maximum diuretics: spntaneus peritnitis Jaundice; Hepat-renal syndrme PTT> 5 secnds abve cntrl Encephalpathy Recurrent variceal bleeding if further interventin inapprpriate General Neurlgical Diseases Prgressive deteriratin in physical and/ r cgnitive functin despite ptimal therapy Symptms which are cmplex and t difficult t cntrl Swallwing prblems (dysphagia) leading t recurrent aspiratin pneumnia, sepsis, breathlessness r respiratry failure Speech prblems: increasing difficulty in cmmunicatins and prgressive dysphasia. Plus the fllwing: Mtr Neurne Disease Marked rapid decline in physical status First episde f aspiratinal pneumnia Increased cgnitive difficulties Weight Lss Significant cmplex symptms and medical cmplicatins Lw vital capacity (belw 70% f predicted using standard spirmetry) Dyskinesia, mbility prblems and falls Cmmunicatin difficulties Parkinsn s Disease Drug treatment less effective r increasingly cmplex regime f drug treatments Reduced independence, needs ADL help The cnditin is less well cntrlled with increasing ff perids Dyskinesias, mbility prblems and falls Psychiatric signs (depressin, anxiety, hallucinatins, psychsis) Similar pattern t frailty- see belw Multiple Sclersis Significant cmplex symptms and medical cmplicatins Dysphagia + pr nutritinal status Cmmunicatin difficulties e.g. Dysarthria + fatigue Cgnitive impairment ntably the nset f dementia Referral Criteria fr Adult Palliative Care Services - September

6 C. Frailty / Dementia / Cerebral Vascular Accident (CVA) - gradual decline Any persn wh fits within this categry f diseases shuld already have had a referral t, and assessment by, a District Health Bard funded Needs Assessment Service. This will ensure that bth the patient and their family/carers have access t DHB funded supprtive care prgrammes and funding apprpriate t the patient s disease and identified needs. Specialist Palliative Care Services are nt equipped t prvide all f the service cmpnents necessary t care fr thse with frailty, dementia r the cnsequences f a severe cerebral vascular accident. Frailty Individuals wh present with Multiple c mrbidities with significant impairment in day t day living and: Deterirating functinal scre e.g. perfrmance status Barthel/ECOG/Karnfksy Cmbinatin f at least three f the fllwing symptms: weakness slw walking speed significant weight lss exhaustin lw physical activity depressin Cerebral Vascular Accident (CVA/Strke) Persistent vegetative r minimal cnscius state r dense paralysis Medical cmplicatins Lack f imprvement within 3 mnths f nset Cgnitive impairment / Pst-strke dementia Dementia There are many underlying cnditins which may lead t degrees f dementia and these shuld be taken int accunt. Triggers t cnsider that indicate that smene is entering a later stage are: Unable t walk withut assistance and Urinary and faecal incntinence, and N cnsistently meaningful cnversatin and Unable t d Activities f Daily Living (ADL) Barthel scre <3 Plus any f the fllwing: Weight lss Urinary tract Infectin Severe pressures sres stage three r fur Recurrent fever Reduced ral intake Aspiratin pneumnia It is vital that discussins with individuals living with dementia are started at an early t ensure that whilst they have mental capacity they can discuss hw they wuld like the later stages managed. Referral Criteria fr Adult Palliative Care Services - September

7 Appendix B: Supprtive and Palliative Care Indicatrs Tl (SPICT) (Highet, et al., 2014) Referral Criteria ria fr Adult Palliative Care Services es - September embe

8 References Bennett, M., Adam, J., Alisn, D., Hicks, F. & Stcktn, M. (2000). Leeds eligibility criteria fr specialist palliative care services. Palliative Medicine, 14, Highet, G., Crawfrd, D., Murray, S.A. & Byd, K. (2014) Develpment and evaluatin f the Supprtive and Palliative Care Indicatrs Tl (SPICT): a mixed-methds study. BMJ Supprtive and Palliative Care, 4(3): Ministry f Health (2013). Resurce and capability framewrk fr integrated adult palliative care services in New Zealand. Wellingtn, Ministry f Health. Thmas, K., et al. (2011). The GSF prgnstic indicatr guidance. (4th Edn).Available frm: Referral Criteria fr Adult Palliative Care Services - September