Palliative Care for Primary Care Providers QUYNH BUI, MD MPH DECEMBER 2015
Objectives Define palliative care and primary palliative care Describe the rationale for providing primary palliative care in primary care setting Describe core domains of primary palliative care Overview tips and pearls to building a more effective primary palliative care program
What is Palliative Care? Patient- and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering.
What is Palliative Care? Palliative care throughout the continuum of illness involves addressing: Physical needs Intellectual needs Emotional needs Social needs Spiritual needs Patient autonomy Access to information Choice
Palliative Care is not only hospice Hospice care is defined as a comprehensive set of services identified and coordinated by an interdisciplinary group to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient and/or family members, as delineated in a specific patient plan of care.
What is Primary Palliative Care? Primary Palliative Care refers to the core services and skills/competencies that are within the scope of every clinician. Representative Primary Palliative Care skills: Basic management of pain and symptoms Basic management of depression and anxiety Basic discussions about: Prognosis Goals of treatment Suffering Code status
Why Primary Palliative Care? Timely palliative care Improves quality of care and quality of life Reduces overall costs while providing care that is compatible with goals In some cases, improves survival
Why Primary Palliative Care? Demand for palliative care will outstrip supply of palliative care providers Projected shortage of 6000 to 18,000 palliative care specialists Outpatient palliative care clinics are rare 27/324 hospitals in California Most open part time. Capacity of 200-500 patients/year
Integrating Palliative Care at All Stages of Disease Stage Tasks Next Steps Pre-Disease Onset/ All Adults >50 Screen/Support AD Discuss information sharing and medical decision making Document MDPOA Disease Onset Confirm information sharing preferences Explain diagnosis and treatment options Discuss expectations/ goals Disease Management Review treatment progress Assess for symptoms/ needs Review goals/ AD Family meeting Update AD Update AD Repeat family meetings Complete POLST/MOLST Symptom management/ address needs Update treatment plan
Integrating Palliative Care at All Stages of Disease Stage Tasks Next Steps Advanced Disease Review and address symptoms/ needs Assess functional status Review and update prognosis Review and update goals of care Assess caregiver needs Connect caregiver support services Update POLST/MOLST, AD Palliative care consult prn End-Stage Disease Update prognosis and goals of care Discuss referral to palliative care/ hospice Assess patient for grief/ loss Discuss life-completion tasks Bereavement Normalize grief process Assess for depression/complicated grief Family meeting Update POLST/MOLST, AD Comprehensive symptom management Assist patient with anticipatory grief Provide follow up and monitoring for development of depression
Clinical domains of primary palliative care Screening and Identification Prognosis/ Information sharing Assessment of needs Symptom management Goals of care/ Advance care planning
Screening and Identification WHO WOULD BENEFIT FROM PRIMARY PALLIATIVE CARE
Identifying Patients for Assessment: General Indicators Decreasing activity/ functional performance Limited self-care Co-morbidity General physical decline Advanced disease Decreasing response to treatments Choice of no further active treatment Progressive weight loss (>10%) in past six months Repeated unplanned admissions/ ED visits Sentinel event
The Surprise Question Would you be surprised if the patient were to die within the next 2 years? Few months, weeks?
Prognosis and Information Sharing SETTING THE STAGE FOR GOALS OF CARE
End of Life Trajectories
10 Steps to Better Prognostication Concept 10 Steps to Better Prognostication Action Steps Disease Start with Anchor Point Obtain details/ Speak to expert Function Assess changes in performance status Use functional status tool: PPS, KPS, ECOG Foresee Science Tests Known physical signs/ labs related to prognosis Eg. Dyspnea, delirum Tools Utilize palliative or end-stage prognostic toolls PPS, PaP, PPI, SHFM, CCORT, CHESS, etc Skill Judgement Clinician prediction of survival Adjust for prognostic factors/ bias
10 Steps to Better Prognostication Concept 10 Steps to Better Prognostication Action Steps Center What is important to my patient/ the family? Who/what do they want to know? How long/what will happen? Goals/hopes Frame it Use probabilistic planning and discussion Average survival/ time blocks, ranges Foretell Art Cautions Share limitations of your prognosis Exceptions, changes Changes Review and reassess periodically Evaluate EOL trajectories Follow up Stay connected Discuss ACP Symptom control Coordinate care
Assessment of Needs
Areas of Palliative Care Requiring Regular Assessment and Documentation Area Physical Psychological Social Spiritual Examples Pain Depression/Anxiety Dyspnea Nausea/ Anorexia Caregiving burden Stress/Grief Coping Family structure/ Relationships Access/ Resources Finances Culture Spiritual beliefs/ communities Life completion tasks
Example Questions What do you understand about your illness? As you look ahead along the progress of your illness: What are your expectations? Hopes? How can we help address concerns and needs of those around you? How is our treatment working for you? What abilities are most important to you to maintain?
Symptom Management
Pain
Pain: Short acting opiates Good for dose titration and breakthrough pain Initial Routine Dosing: Opioid naïve: (severe pain): Oral morphine liquid 10-20 mg IR q 4 hr/ 5 mg in elderly/frail Opioid tolerant: May need to increase dose by 50-100% Consider opioid rotation
Pain: Breakthrough Pain Use IR preparation of same opioid used for baseline dosing When baseline opioid is methadone or transdermal fentanyl, use alternative IR form like morphine or hydromorphone Each breakthrough dose is about 10% of total 24 hr dose
Pain: Opioid Titration With short acting opioids, best pain control achieved within 24 hours If pain is uncontrolled: Increase by amount equal to total dose of breakthrough medication Increase by 25-50% for mild to moderate pain, 50-100% if severe pain
Pain: Convert to ER Preparation Calculate total morphine dose required Calculate equianalgesic 24 hour dose and correct for cross-tolerance Divide dosing according to pharmacokinetics Recalculate breakthrough dose
Pain: Opioid choice Opioids 90-95% eliminated by the kidney Dehydration or acute renal failure will impair clearance Increase dosing interval or decrease dose size Consider stopping scheduled dosing and go to prn only Hydromorphone has fewer active metabolites than morphine or oxycodone Fentanyl is metabolized only by liver Avoid meperidine, propoxyphene, agonistsantagonists
Pain: Opioid side effects Sedation, constipation, nausea, confusion Treat adverse effects Opioid rotation Adjuvant pain therapy
Pain: Other pain medications Acetaminphen/ NSAIDs Gabapentin, anticonvulsants TCAs Corticosteroids Topical lidocaine
Opioids: Side effects: Nausea/ Vomiting: Dopamine- acting antiemetics (metoclopramide, haloperidol) Ondansetron or benzodiazepines if refractory Constipation: Stimulant laxatives (senna, bisacodyl)rather than stool softeners Osmotic agents (MOM, lactulose, sorbitol), enemas Sedation: Dosing or opioid change, psychostimulant Delirium: Work up, dosing or opioid change, Haldol, donepezil
Depression SSRIs/ SNRIs Duloxetine and venlafaxine can be used for adjuvant pain treatment TCAs Atypical antidepressants Psychostimulants Start dosing low and titrate slowly
Depression: Psychostimulants Methylphenidate 5mg qam and q 12 noon, max 40 mg/day Modafinil 100 mg qam, max 200 mg/ day Dextroamphetamine 5 mg qam and a 12 noon, max 40 mg/ day
Dyspnea Treat underlying cause Symptomatic management: Oxygen Opioids Anxiolytics Cool air across patient s face
Dyspnea: Opioids Hydrocodone: 5 mg q 4 hr, q 2 hr prn Morphine IR: 5-15 mg po q 4 hr Oxycodone: 5-10 mg po q 4 hr Hydromorphone: 0.5-2 mg p q 4 hr Tolerance not usually a problem Keep to low doses, dosing guidelines.
Advance Care Planning/ Goals of Care
Potential Goals of Care Cure of disease Avoidance of premature death Maintenance/ improvement of function Prolongation of life Relief of suffering Optimized quality of life Maintenance of control A good death Support for families and loved ones BUMC PROCEEDINGS 2001;14:134 137
7 Steps in Negotiating Goals of Care 1. Create the right setting 2. Determine what the patient and family knows 3. Explore what they are expecting or hoping for the future 4. Suggest realistic goals 5. Respond empathetically 6. Make a plan an follow through 7. Review and revise periodically as appropriate BUMC PROCEEDINGS 2001;14:134 137
Language about palliative care that has negative connotations Do you want us to do everything possible? Will you agree to discontinue care? It s time we talk about pulling back. I think we should stop aggressive therapy I m going to make it so he won t suffer BUMC PROCEEDINGS 2001;14:134 137
Language about palliative care with more positive connotations We will concentrate on improving the quality of your child s life I ll do everything I can to help you maintain your independence. I want to ensure that your father receives the kind of treatment he wants. I will focus my efforts on treating your symptoms. Let s discuss what we can do to fulfill your wish to stay at home. BUMC PROCEEDINGS 2001;14:134 137
Advance Medical Directives http://www.iha4health.org/our-services/advance-directive/
Medicare Billing for Advance Care Planning 99497: Initial 30 minute advance care planning consultation (wrvu 1.5) 99498: Add-on code for additional 30 minute time blocks needed for advance care planning (wrvu 1.4)
Summary Primary palliative care is complementary of disease-modifying care Primary care has unique capabilities and responsibilities in providing primary palliative care Primary palliative care should be provided throughout the continuum of serious illness Domains of physical, psychological, social and spiritual needs should be assessed and addressed on an ongoing basis Goals of care are dynamic