Palliative Care and Hospice Silver Linings: Reflecting on Our Past & Transitioning into our Future
Objectives: 1. What is Palliative Care? What is Hospice? What is the difference? 2. What are the trending models for today s medicine and Palliative Care Medicine? 3. What is the value in Community Based Palliative Care Medicine?
NPR kirk siegler 7/16/17 doctor shortage in rural Arizona sparks another crisis in forgotten America. Telemedicine Mid levels Increase incentive to doctors Stop using ER for normal health needs
End of Life Care = Define Palliative and Hospice Medicine
END OF Life Care: Palliative and Hospice Medicine Goal relief of suffering and distressing symptoms To enable the patient to live fully and comfortably until he/she dies is a success.
Palliative care Medicine versus Hospice medicine Life expectancy: Palliative Medicine less than 1 year Hospice Medicine less than 6 months Insurance: Palliative Medicine - Medicare B (medical svc) Hospice - Medicare A (hospital svc)
Other names for palliative/hospice medicine = End of Life Care = Supportive Care = Advanced Illness Services = Progressive Life Limiting Illness Care
Trending Model of Today s Medicine
Traditional (thru the 20 th century) Medicine Focus: Diagnosis Therapeutics Prognosis (very little)
Modern (~2010) Medicine Focus: Chronic Disease Care Prognosis Palliative Care
Other factors affecting death rates Sedentary lifestyle Unhealthy diet Tobacco use Drinking too much alcohol
By 2030 nearly half (49.2%) of the population will be affected by chronic disease
Chronic disease: Leading Cause of Death and Disability in U.S. Only10% deaths are sudden Most pts gradually accumulate serious chronic diseases i.e. heart trouble, emphysema, strokes, dementia, cancer, renal failure, liver failure These conditions eventually cause disruption in daily life, and eventually worsen to cause death.
It s going to take a village
Trending Models of Today s Palliative Care Medicine
diagnosis death Palliative Care Old Model Palliative Care time
SNF/NH Palliative Care Hospital Palliative Care Home Palliative Care Hospice/End of Life
Value in Palliative Care in the Rural Community
Site of Death: sites of care at EOL Site of death: 1989 to 2009 Site 1989 1997 2009 Hospital 62.3% 51.7% 24.6% Nursing Home Unit 19.2% 23.0% 27.6% Home 15.9% 22.9% 33.5%
Palliative Care Philosophy Prevent and relieve suffering Enhance quality of life Optimize functioning Help with Decision Making Provide opportunities for personal growth
When to call for Palliative Care... Would you be surprised if the patient died in the next year? General prognostication: decline in months, prognosis months; multiple hospital admissions for exacerbation of disease.
Other indicators for Palliative Care ICU stay > 7 days Difficult to control physical or psychological symptoms Lack of clarity and documentation of treatment goals Decline in function, feeding intolerance, or unintended decline in weight Disagreement or uncertainty among pt/family/staff (Weissman,Meier.2011) Admit from LTC facility Metastatic cancer Pt/family, emotional, spiritual, or relationship distress Chronic home oxygen use Limited social support No history of advanced care documentation Ethics concerns Elderly patient with cognitive impairment
Chronic Diseases suited for End of Life Care Discussion
General Debility with ANY diagnosis Life-limiting disease Decline in functional status in last 3 months -Decreasing ADL (dependent on > 2 ADL) -Decreasing mobility -Decreasing intake -Decreasing mentation Weight loss Frequent hospitalizations/er visits Often dysphagia, postural hypotension
Dementia Bedfast Speaks 6 words or less Incontinence Infection, decubiti, weight loss, hip fracture
Guidelines that encourage Palliative Care and Hospice ACC/AHA American College Cardiology/American Heart Association 2013: NYHA class III-IV/C- D GOLD (Global initiative in Chronic Obstructive lung disease) criteria 2016: COPD class C/D
Chronic CHF Frequent ER and hospitalizations ACC/AHA pts need repeat exposure to education CHF pts worried about future, about having MI and dying ACC/AHA recommend pt have a plan for sudden decompensation and advanced directives Duke study showed CHF pts lived average 81 days longer with hospice
Chronic COPD Average 3-4 hospitalizations/year Quality of life is inversely proportional to exacerbation frequency Patients report health status worse than death Patients report a desire for education, how to manage their breathlessness COPD patients have high level emotional issues contributing to breathlessness cycle COPD patients worse px received if no palliative care
And other accepted non-malignant chronic debilitating diseases when. Chronic renal disease - no dialysis or txplnt planned, cr clear < 15cc/min Chronic liver disease - INR > 1.5 & serum albumin <2.5 Debilitating Stroke - acute or chronic Debilitating Neuromuscular diseases: ALS, advanced MS, Parkinson s HIV/AIDS
Benefits Community Based Palliative Care Medicine Decreased hospitalization Initiation of discussion w/better transition to hospice care Better pain and symptom management Help with decision making Improved Quality of Life: physical, emotional, social, spiritual
Additional Benefits of Palliative Care Medicine Better support for caregivers Better grief support
CDC Guidelines for Prescribing Opioids for Chronic Pain United States, 2016 Nonopioid therapy is preferred for treatment of chronic pain. Opioids are now recommended to be reserved for certain specialties such as pain clinic and hospice or palliative care.
Discussion of why EOL care use live longer 1. people in palliative/hospice care may forego certain aggressive cure directed therapies, that carry a higher mortality rate 2. may improve monitoring and treatments patients receive (telemedicine) 3. several studies have shown psychosocial support tends to prolong life
This extra time is crucial to patients and their families as time for resolution, closure, and PEACE...