Practicing Palliative Care by National Guidelines August 2018
Michol Negron, DO, MBA NYIT-COM Graduate 1995 Board Certified Family Medicine Board Certified in Hospice and Palliative Medicine Certified Hospice Medical Director Certified Dementia Practitioner Disclosure: I have no conflicts of interest to disclose. 2
Objectives Learner will gain understanding why hospice and palliative care access is capturing national attention Learner will be able to illustrate the 8 domains of quality palliative care Learner will be knowledgeable in four common tools of advanced care planning to incorporate into daily practice 3
Primary vs. Specialist Palliative Care Primary palliative care refers to the basic skills and competencies required of all health care professionals. Secondary palliative care refers to the specialist clinicians and organizations that provide expert consultation and/or comanagement. Tertiary palliative care refers to the academic medical centers where specialists practice, teach and conduct research. 4
National Spotlight on Palliative Care 7
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Economics of Palliative Care for Hospitalized Adults With Serious Illness A Meta-analysis Question What is the estimated association of palliative care consultation within 3 days of admission with direct hospital costs for adults with serious illness? Findings In this meta-analysis of 6 studies, hospital costs were lower for patients seen by a palliative care consultation team than for patients who not did not receive this care. The estimated association was greater for those with a primary diagnosis of cancer and those with more comorbidities compared with those with a noncancer diagnosis and those with fewer comorbidities. Meaning The estimated association of palliative care consultation with hospital costs varies according to baseline clinical factors; prioritizing current staff to patients with a high illness burden and increasing capacity may reduce hospital costs for a population with high policy importance. JAMA Intern Med. Published online April 30, 2018. doi:10.1001/jamainternmed.2018.0750 10
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HEALTH POLICY AND ADVOCACY JULY 24, 2018 PCHETA (Palliative Care and Hospice Education and Training Act) Passed by House of Representatives Senate to Act on Bill to Expand Palliative Care Workforce, Awareness, and Research PCHETA would expand opportunities for interdisciplinary education and training in palliative care, including through new education centers and career incentive awards for physicians, nurses, physician assistants, social workers and other health professionals. The bill would also implement an awareness campaign, to inform patients and healthcare providers about the benefits of palliative care and hospice and the services available to support individuals with serious illness, as well as direct funding toward palliative care research to strengthen clinical practice and healthcare delivery. 12
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AOA Certificate of Added Qualification in Hospice and Palliative Medicine Grandfathering period for board certification: 2009 2013 2014 and after, fellowship required 15
Hospice Medical Director Certification Board (HMDCB) Midcareer physician No fellowship required 16
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American Academy of Hospice and Palliative Medicine Center to Advance Palliative Care Hospice and Palliative Nurses Association National Hospice & Palliative Care Organization National Association of Social Workers National Palliative Care Research Center 18
8 Domains of Palliative Care 1. Structure and Process of CARE 2. Physical Aspects of CARE 3. Psychiatric and Psychological aspects of CARE 4. Social Aspects of CARE 5. Spiritual, Religious and Existential Aspects of CARE 6. Cultural Aspects of CARE 7. CARE of the Patient at End of Life * 8. Ethical and Legal Aspects of CARE 19
1. Structure and Process of CARE Emphasizes the interdisciplinary team approach Continuum across settings Qualifications of team members QAPI process 20
2. Physical Aspects of CARE Multimodality symptom management and validated tools to measure efficacy of interventions Pain management with evidence of safe prescribing 21
3. Psychiatric and Psychological aspects of CARE Address and treat psychological concerns and psychiatric diagnosis Bereavement newly added to the domain 22
4. Social Aspects of Care Emphasizes the role of a palliative care social worker in helping families and patients to identify their own strengths Traditional and non-traditional families 23
5. Spiritual, Religious and Existential Aspects of CARE Stresses access to spiritual care throughout the illness and trajectory This domain promotes spirituality as a tool for comfort and relief 24
6. Cultural Aspects of CARE Patient s culture can be a source of resilience Emphasis on patient s linguistic competence 25
7. Care of the Patient at End-of-Life * Emphasizes the ongoing guidance through the death process with anticipatory grief counseling and prolonged bereavement follow-up 26
8. Ethical and Legal Aspects of CARE Encourages team to engage palliative patients through the completion of documents Consider ethics committee involved in palliative care decision making when team members are not in agreement 27
Advanced Care Planning POA, MOLST or DNR, HCP and Invoked Health Care Proxy Legal Counsel Wills, Estate Planning 28
POA 29
HCP 30
Invocation of Health Care Proxy 31
MOLST 32
Conversation starters Know Your Choices https://www.mass.gov/lists/end-of-life-care Five Wishes https://agingwithdignity.org/ The Conversation Project https://theconversationproject.org/ 33
JOINCAKE.COM Mark Zhang, D.O. Co-Founder & Palliative Care Physician 34
Ethical Issues of Palliative Care Palliative Paternalism Overtreatment vs Undertreatment Withholding or Withdrawing Treatment Withholding Information Requests to Hasten death - Assisted Death - Palliative Sedation Special Populations Dementia, Court Appointed Guardians HIPAA Violations 35
Palliative Paternalism Case Study 36
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Paul and Mary 41
Paul and Mary s Health Care Journey Fall 2016 Paul was referred by town social worker for advancing urinary symptoms Paul is wheelchair-bound with MS (no physician care in 7- years) Mary had not seen a physician in 25+ Years 42
And the Journey Begins Mary sustained a hip fracture and two MI s from 9/16-12/17 43
Palliative Paternalism Molst HCP Will POA Estate Planning 44
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Mary goes on hospice End stage heart disease Respite benefit 46
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Hospice vs. Palliative Care 48
Paul goes on hospice End stage MS Both Mary and Paul get transferred to a SNF for a 5 day respite during a heat wave Paul signs out AMA Mary remains in facility 49
Why a Team? A palliative care program requires a team to comprehensively address patient and family need across the eight domains. 50
Michol Negron, DO NegronDO@gmail.com 51