Home to Roost - Rural Health Association of … Phelps...Role of Hospice and Palliative Care | Dr. Greg Phelps, MD MPH FAAHPM US vs the OECD • US Healthcare is disjointed, siloed,

Role of Hospice and Palliative Care | Dr. Greg Phelps, MD MPH FAAHPM

Home to RoostRole of Hospice and Palliative Care In Helping Folks Age and Die at Home

Greg Phelps MD MPH FAAHPM

Chief Medical Officer Alleo Health/Hospice of Chattanooga

Thursday, November 21, 2019

1:45 -2:45


US vs the OECD

• US Healthcare is disjointed,

siloed, segmented with perverse

incentives

• Cost double ($10,224) average of

OECD ($5280)

• 18% of GDP

• Worst in mortality in OECD

• Worst in Maternal Mortality

• 37th over all

• 11K Baby Boomers hit 65 DAILY

• Fastest Growing population is >85

Silos of Health Care

The Issues

Source Kaiser Foundation


Endangered Species??

10 Hospitals in TN since 2012


• Readmission penalties now up to 3% of Medicare for hospitals.

Roughly 2,599 hospitals (>1/2) $566Million last year

• Readmission Penalties for SNF (73% penalized in first year)

• Readmission Penalties for Home Health which is cheaper but has

5.6% Higher rate of re-admissions than SNF.

Health Care Challenges

Jordan Rau, Medicare Eases Up on Readmissions

Penalties for Hospitals Serving the Poor;

NPR/Kaiser Health News. Sept 26th, 2018


Medicare Advantage Plans (MA)

“Medicare Advantage Plans use Significantly less PAC”

~ 40% reduction in revenues

“I’d rather take Medicaid than MA”


• Rural Americans—who make up at least 15 to 20% of the U.S.

population—face inequities that result in worse health care than that

of urban and suburban residents

• “When you don’t get your health care taken care of, you wind up

with disease presentations that are much farther along. People with

cancer show up with metastatic cancer, people with diabetes show

up with end-organ damage”

• Joseph Florence, MD, professor of family medicine and director of

rural programs at Eastern Tennessee State University Quillen

College of Medicine

Rural Health an Uphill Fight in a Headwind

https://www.ruralhealthweb.org/about-nrha/about-rural-health-care


• Older than the population as a whole

• Poorer, lower education and income

• Greater distance to health care

• More likely to have risk factors such as smoking, obesity, opioid use

• Lower rates of insurance

• Greater prevalence of top five fatal illnesses

• Higher infant mortality

• Lower access to primary care 55.1/100,00 vs 79.3/100,00 urban

• Death Rate 830.5/100,000 vs 704.3/100,000 urban

Risk Factors for People in the Rural South

Robin Warshaw, Health Disparities Affect Millions in Rural US Communities,

AAMC News Oct 31, 2017


Doing the same thing over and over and expecting different

results is the definition of Insanity

On average, patients make 29 visits to the doctor’s office in their last six months.

In their last month alone, half of Medicare patients go to an emergency department, one-

third are admitted to an I.C.U., and one-fifth will have surgery — even though 80 percent

of patients say they hope to avoid hospitalization and intensive care at the end of life.

Medicare spending for patients in the last year of life (5% of Medicare) is six times what

it is for other patients, and accounts for a quarter of the total Medicare budget — a

proportion that has remained essentially unchanged for the past three decades.

It’s not clear all that care improves how long or how well people live. Patients receiving

aggressive medical care at the end of life don’t seem to live any longer, and some work

suggests a less aggressive approach buys more time.

http://www.dartmouthatlas.org/data/table.aspx?ind=18&tf=23&ch=5,6&loc=2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52&loct=2&fmt=35

http://www.nejm.org/doi/full/10.1056/NEJMp1509664#t=article

http://www.dartmouthatlas.org/data/topic/topic.aspx?cat=18

http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/medicare/index.html?inline=nyt-classifier

http://onlinelibrary.wiley.com/doi/10.1111/j.1475-6773.2010.01082.x/full

http://www.dartmouthatlas.org/data/topic/topic.aspx?cat=18

http://www.nejm.org/doi/full/10.1056/NEJMoa1000678#t=abstract


• Palliative Care Services: Specialists in Hospice and Palliative

Medicine that focus On the “Three Cs”- Comfort, Communication and

Coordination

• Advanced Care Planning: Patients who engage in advance care

planning are less likely to die in the hospital or to receive futile

intensive care. Family members have fewer concerns and

experience less emotional trauma if they have the opportunity to talk

about their loved one’s wishes. And earlier access to palliative care

has consistently been linked to fewer symptoms, less distress, better

quality of life — and sometimes longer lives.

Two interventions have been show to slow the Insanity


http://jamanetwork.com/journals/jama/fullarticle/182700


https://www.ncbi.nlm.nih.gov/pubmed/24797373

http://www.nejm.org/doi/full/10.1056/NEJMra1404684#t=article


• ….patients will benefit from health care leaders who see end of life

care as part of health care rather than a failure of health care… (p

23)

• “There are powerful incentives for hospitals to define care in terms

of reimbursable treatment interventions and diagnostic testing to

prioritize quantity over quality and set lower value on …services

that are non-income generating. These incentives have a large role

in shaping the delivery of end-of-life care.” (p29)

The Hasting Center Guidelines for Decisions on Life

Sustaining Treatment and Care Near the End of Life


"To impose treatment on the

patient overmastered by disease

is to display an ignorance akin to

madness.”

Hippocrates

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjeh_iy4_vQAhUD_4MKHR2RABEQjRwIBw&url=http%3A%2F%2Fwww.pbs.org%2Fwgbh%2Fnova%2Fbody%2Fhippocratic-oath-today.html&bvm=bv.142059868,d.cGw&psig=AFQjCNGJicvFX41-I0c2jrXTMdU_RunklQ&ust=1482082879049923

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjeh_iy4_vQAhUD_4MKHR2RABEQjRwIBw&url=http%3A%2F%2Fwww.pbs.org%2Fwgbh%2Fnova%2Fbody%2Fhippocratic-oath-today.html&bvm=bv.142059868,d.cGw&psig=AFQjCNGJicvFX41-I0c2jrXTMdU_RunklQ&ust=1482082879049923


Getting to What Matters

“I learned a lot of things in

medical school but mortality

wasn’t one of them… our

textbooks had almost nothing on

aging or frailty or dying.”

Also see: “Letting Go What Medicine

Should Do When it Can’t Save Your life”

By Atul Gawande, MD

New Yorker, Aug 10th 2010


There is Never, Ever

“Nothing Else We Can Do…Ever!”

“Cure Sometimes, Treat often, Comfort Always.”

Hippocrates


• Better quality of care

• Better communication

• Less suffering

• Lower costs

• Fewer re-admissions

How Do I Sleep at Night? A True Story…..


…is specialized medical care for people with serious illnesses. This type of

care is focused on providing patients with relief from the symptoms, pain,

and stress of a serious illness – whatever the diagnosis.

The goal is to improve quality of life for both the patient and the family.

Palliative care is provided by a team of doctors, nurses, and other

specialists who work with a patient’s other doctors to provide an extra layer

of support. Palliative care is appropriate at any age and at any stage in a

serious illness, and can be provided together with curative treatment.

Palliative Care

Three Cs - Comfort, Communication, Coordination


A New Paradigm

If we keep doing what we’re doing, we’ll keep getting what we’re getting


Curative

• Primary Goal is cure

• Object of treatment is the disease

• Symptoms treated primarily as clues to

diagnosis

• Primary value placed on measurable data

such as labs and tests

• This model tends to devalue data that is

subjective, immeasurable or unverifiable

• Therapy indicated if it eradicates disease or

slows progression.

• Patient’s body differentiated from mind.

• Patient viewed as collection of parts so there

is little need to get to know the whole

person.

• Death is the ultimate failure

Palliative

• Primary Goal is relieving suffering

• Object of treatment is the patient and family

• Distressing symptoms are entities

themselves

• Subjective and measurable data valued

• This model values patient experience as an

illness

• Therapy indicated if it controls symptoms for

relieves suffering

• Patient is viewed as complex being with

physical emotional social and spiritual

dimensions

• Treatment congruent with values and beliefs

and concerns of patient and family

• Enabling a patient to live fully and

comfortably until he or she dies is a success

Curative and Palliative Models

Unipac 1: Characteristics of Curative vs Palliative Care Models

Page 8. 2003


The Difference Between Hospice and Palliative Care

HospicePalliative Care

Hospice: A 1982

Medicare benefit. For

last six months of life.

Usually home or

residential based. Used

when curative care is no

longer pursued.

Palliative Care: Can be

engaged in life threatening

illness much earlier in

acute care when curative

treatment still on-going.

Hospice is an insurance benefit, Palliative Care is a treatment philosophy


Smaller Rural Hospitals Less Likely To Have PC services

Center for the Advancement of Palliative Care- CAPC.org


Tennessee ranks B- at 61.7% of Hospitals

with Palliative Care


Grief care

Everyone is entitled to SOME Palliative Care



• Biggest concerns: Cost, Control, Communication, Choice, Cure?

– Physicians not providing all treatment options- 55%

– Doctors not sharing information with each other-55%

– Doctors not choosing best option for seriously ill- 54%

– Patient and family leave physician office not knowing what they

are supposed to do when they get home-51%

– Patient lacks control over treatment options- 51%

– Doctor doesn’t spend enough time talking and listening with

patient and family 50%

CAPC Survey of Attitudes

For Patients with Serious Illness

800 patients surveyedReleased June 28th 2011

Available at CAPC.org


California Healthcare Foundation Survey 2012

• 70-90% of patients say they would prefer to die at home (about 30% do).

• 66% say they would prefer to die a natural peaceful death.

• Only 7% desire all invasive therapeutic options deployed.


• Medical Literature Dx 37%, Tx 33%, Px 4%*

• Prognosis--The opportunity to look stupid.

• Unofficial Physician Norms

– Don’t make a prognosis

• If you have a prognosis, keep it to yourself unless asked

– Don’t be specific

– Don’t be extreme

– Be optimistic

• Doctors Err 2-5x duration to the optimistic side

*Death Foretold by Nicholas Christakis MD 1999

• A 2000 study of 343 physicians by Christakis to provide survival estimates for 468 terminally ill

patients at the time of hospice referral. Only 20% of predictions were accurate (as defined as

within 33% of actual survival).

• Overall, doctors overestimated by a factor of 5.3!

Prognosis: The Chance to Plan (We Stink)

Christakis NA, Lamont EB. Extent and Determinants of Error in Doctor’s Prognoses

in Terminally Ill Patients: Prospective Cohort Study. BMJ. 2000; 320:469-472


More Trigger Tools at CAPC.org

• The ‘‘surprise question’’: You would not be surprised if the patient died within 18

months, or before adulthood

• Six Months for hospice

• Frequent admissions: e.g., more than one admission for same condition within

several months, or coming from SNF

• Complex care requirements: e.g., functional dependency; complex home support for

ventilator/antibiotics/feedings/home O2

• Decline in function, feeding intolerance, or unintended decline in weight (e.g., failure

to thrive)

• Move to, or from ICU

• Initiation of dialysis or ventilation

• PEG tube contemplated

• Pain or symptom control

• Goals of Care/advance directives/Code status

When should you ABSOLUTELY be thinking

about having the Conversation?


What is it ALL about?

We are perfectly unprepared for

something that is totally predictable


What Do These Three Women Have in Common?

http://www.google.com/url?url=http://en.wikipedia.org/wiki/Karen_Ann_Quinlan&rct=j&frm=1&q=&esrc=s&sa=U&ei=HfCZU93ZOMy2yASLrYKoDw&ved=0CCEQ9QEwAQ&usg=AFQjCNGl2C5OhDZdw6uHvvciKB69XmC_5A

http://www.google.com/url?url=http://en.wikipedia.org/wiki/Karen_Ann_Quinlan&rct=j&frm=1&q=&esrc=s&sa=U&ei=HfCZU93ZOMy2yASLrYKoDw&ved=0CCEQ9QEwAQ&usg=AFQjCNGl2C5OhDZdw6uHvvciKB69XmC_5A


Advanced Care Planning


Honoring Choices TN

National Health Care Decisions Day


“It is always too early until it’s too late”

• The healthy and young. Express your wishes of how you would see

your life in it’s final phases.

• Over 55 or encountering serious illness

• Encountering a likely life ending or life threatening illness and

reviewing your choices and preferences.

Three Levels of Conversation or Your Life, Your Choice


Subjects terminal cancer patient, 4.4 month life expectancy

• 123 of 332 (37%) patients with terminal illness had end of life

discussions

• “Have you and your doctor discussed any particular wishes you

have about the care you would receive if you were dying?”

• These patients elected less aggressive care with fewer ICU admits

4.1% vs 12.4%, fewer ventilation episodes 1.6 vs 11%,

• More aggressive care was associated with poorer quality of life for

the patient and higher risk of major depressive disorder for bereaved

care givers. (PTSD)

• Study showed that patients did not have increased depression or

loss of hope.

End of Life Discussions

AA Wright, B Zhang A.Ray et al, Associations Between

End of Life Discussions Patient Mental Health, Medical Care Near Death

And Caregiver Bereavement Adjustment. JAMA 1665-1673. Oct 8, 2008


Not So Much About Death as About How You Want to Live

• What are your goals?

• How do you want to live?

• Paint me a picture of how you see your life.

• What is important to you?

• What do you want for your family?

• How do you want to be remembered?

• “Begin with the end in Mind.” Stephen Covey

Advance Care Planning


The EASY Way to start a Goals of Care Discussion

S Who would speak for you if you couldn’t (Surrogate)

P Preferences - Do you have any EOL preference now?

A I’m going to Assume till you tell me otherwise you want everything done

M More- We’ll talk more later

S.P.A.M


• Pre-planning and semiotics

• Introductions

• Purpose

• Tell me about the patient

• What do you understand about the

diagnosis?

• WARNING SHOT (I wish

statements)

• Explain diagnosis

• Await reaction

• Validate emotions

• Keep the focus on the patient

• Did you (r)… ever talk/advance

directives

• What would they want (substituted

judgment)

• CPR/AND/ DNAR

• Summarize and record

“Hope for the Best/Plan for the Worst”

Success of a GOC is based on how much family and patient talk!

The Goals of Care Discussion As Done by HPM Clinicians


Providers don’t approach Advance Care Planning (ACP) for many reasons:

• I believe patients will have difficulty discussing death.• I have difficultly discussing death.• I’m not sure how to discuss or what to document.• I don’t have time• I don’t get reimbursed*

As a result many patients are never asked about their wishes. Many receive painful, expensive medical care and procedures that they never wanted and are non-beneficial.


Two new CPT advanced care planning codes (99497 and 99498) are

used to report the face-to-face service between a physician or other

qualified healthcare professional (QHP) and a patient, family member

or surrogate in counseling and discussing advance directives, with or

without completing relevant legal forms. The use of these codes

requires a face-to-face visit, however, the patient may not be present.

99497

First 30 min of the conversation (must be at least 16 minutes)

wRVU 1.50-Proposed reimbursement $80.16

In addition to problem visit with modifier 25

In addition to wellness visit with modifier 33

99498

Additional 30 min

wRVU 1.40-Proposed reimbursement $75.11

In addition to problem visit with modifier 25

In addition to wellness visit with modifier 33


Minimum documentation requirements for advance

care planning discussions should include all of the

following:

• Time in and time out- minimum 16 minutes

• The person designated to make decisions for the patient if the

patient cannot speak for him or herself (HCR)

• Who participated in conversation (HCR, patient, family)

• What was discussed (preferences for treatment)

• What documentation was or was not completed


Unless You’re a Plant,

Walking, eating and activity are Essential to Life


Six Month Mortality %

• PPS Score 10-20%....96%

• PPS Scare 30-40%....89%

• PPS Score 40-50%...80%

Survival in Days average

Median 1 Median 2

• PPS 10% 1.88 6

• PPS 20% 2.62 6

• PPS 30% 6.7 41

• 40% 10.3 41

• 50% 13.9 41

Mortality PPS Score


Honest Conversation about Prognosis and Goals of

Care Can Reduce “Do everything!”


• COPD

• Solid Cancers

• Heart Failure

• End Stage Renal Disease- Dialysis

Illnesses with ~ 50% Mortality at Five Years


ECOG PERFORMANCE STATUS*

Grade ECOG

0. Fully active, able to carry on all pre-disease performance without

restriction

1. Restricted in physically strenuous activity but ambulatory and able to carry

out work of a light or sedentary nature, e.g., light house work, office work

2. Ambulatory and capable of all self care but unable to carry out any work

activities. Up and about more than 50% of waking hours

3. Capable of only limited self care, confined to bed or chair more than 50%

of waking hours. (estimated survival < 6 months)

4. Completely disabled. Cannot carry on any self care. Totally confined to

bed or chair (estimated survival < 3 months)

5. Dead

Most clinical trials require ECOG status of 0-1

Eastern Co-operative Oncology Group ECOG (1982)


• Palliative Care sample had life expectancy closer to one year

(control 9 months)

• Patients in Palliative Care arm of study had less pain, less

depression, and less anxiety

• JS Temel, JA Greer, A Muzikansky. Early Palliative Care for

Metastatic Non-Small Cell Lung Cancer. NEJM Aug 19, 2010

733-742

• “Survival times may also have improved as patients were helped to

avoid preventable hospitalizations and fruitless chemotherapy”

(Diane Meier MD)

Metastatic Non-Small Cell Lung Cancer 151 Patients


• Malignant hypercalcemia (>11.2): 8 weeks, except newly diagnosed breast

cancer or myeloma (see Fast Fact #151) 50% mortality at 30 days

• Multiple brain metastases: 1-2 months without radiation; 3-6 months with

radiation.

• Malignant ascites (see Fast Fact #176), malignant pleural effusion (#209),

or malignant bowel obstruction: < 6 months.

• For any patient with advanced solid tumor, KPS <60% or ECOG score >2

has median survival of 6 months or less.

• Systematic Review of Cancer Presentations with a Median Survival of Six

Months or Less. Salpeter s, Malter DS, Luo EJ et all; Journal of Palliative

Medicine

• Feb 2012 175-185

Prognosis in Advanced Cancer

www.eperc.mcw.edu/fastFactff_13htm

http://www.eperc.mcw.edu/FileLibrary/User/jrehm/fastfactpdfs/Concept151.pdf




• British Columbia Cohort of 4,374 patients hospitalized for HF

• Mortality significantly increased after each HF hospitalization.

Number of HF hospitalizations was a strong predictor of all-cause

death.

• Median survival after the first, second, third, and fourth

hospitalization was 2.4, 1.4, 1.0, and 0.6 years.

• Am Heart J. 2007 Aug;154(2):260-6.

Oddly enough hospice confers an 81 day longer survival benefit!!

CHF re-hospitalization as Marker for Mortality

Slide 23

Connor SR et al. J Pain Symptom Manage. 2007;33(3):238-46


• Poor response to optimal treatment with diuretics and vasodilators

• NYHA Class IV, (symptoms at rest)

• Ejection fraction under 20% (not required)

• History of refractory arrhythmias, cardiac arrest and resuscitation

• Patients should not be candidates for re-vascularization, or

transplant, LVAD or resynchronization therapy

6 Months- CHF (any)


End-stage Renal Disease

All of first three plus one from 4

1. Not seeking dialysis or transplant

2. Creatinine clearance <10 (15 with DM)

3. Elevated BUN/Creatinine (>8 or >6 with DM)

4. cachexia, massive edema, confusion/obtunded, intractable

nausea/vomiting, generalized pruritus, oliguria (400cc/d) intractable

hyperkalemia (K>7 not responsive to medical treatment) uremic

pericarditis, hepato- renal syndrome, intractable fluid overload.

6 month ESRD


• Prognosis in lung disease is difficult to predict but the lung disease should be

severe and progressive as documented by:

• Homebound/chair-bound/ oxygen dependent. Hypoxemia </+ 88% on room air

• Increased hospitalizations (1)/ED (4) visits in last year.

• Prior mechanical ventilation with exacerbation.

• Cyanosis fingertips or lips

• FEV1 < 30%

• Dyspnea /hypoxemia at rest on oxygen

• Unintentional weight loss >10% last six months

• Resting tachycardia (>100 bpm)

• Dec line in performance scores.

• Patients with BODE Score 7 or higher had 80% Risk of mortality in 52 months

www.copd.about.com/od/copdbasics/a/BODEIndex.html

6 month-COPD


FAST (Functional Assessment Staging) Scale Items:

Stage #1: No difficulty, either subjectively or

objectively

Stage #2: Complains of forgetting location of

objects; subjective work difficulties

Stage #3: Decreased job functioning evident to

coworkers; difficulty in traveling to new locations

Stage #4: Decreased ability to perform complex

tasks (e.g., planning dinner for guests; handling

finances)

Stage #5: Requires assistance in choosing proper

clothing

FAST (Functional Assessment Staging) Scale Items:

Stage #6: Decreased ability to dress, bathe, and

toilet independently:

· Sub-stage 6a: Difficulty putting clothing on properly

· Sub-stage 6b: Unable to bath properly; may

develop fear of bathing

· Sub-stage 6c: Inability to handle mechanics of

toileting (i.e., forgets to flush, does not wipe

properly)

· Sub-stage 6d: Urinary incontinence

· Sub-stage 6e: Fecal incontinence

Stage #7: Loss of speech, locomotion, and

consciousness:

· Sub-stage 7a: Ability to speak limited (1 to 5 words

a day)

· Sub-stage 7b: All intelligible vocabulary lost

· Sub-stage 7c: Non-ambulatory

· Sub-stage 7d: Unable to sit up independently

· Sub-stage 7e: Unable to smile

FAST Criteria For Dementia Functional Assessment Staging

Dementia is hospice qualified 7A-7C


Non-Hospice Patients

• Elderly patients avg. age 83

• 75% visit ER in final 6 months

(40% more than once)

• >50% visit ER final month

• Of those in ER, 75% admitted

• 39% admitted to ICU

• 68% admitted died in hospital

Hospice Patients

• Hospice Patients

• Less than 10% seen in ER

• Vast majority die at home

Smith AK, McCarthy E, Weber E et al; Half

Of Older Americans Seen In Emergency

Department In Last Month Of Life; Most

Admitted To Hospital, And Many Die

There. Health Affairs. June 2012

31:61277-1285

So What Happens to the Elderly (Survey 4158 Seniors)


JAMA Oct 26th, 2011 Covinsky KE, Pierluissi E., Johnston CB

• Loss of ADLs during acute hospitalization

• Occurs in 1/3 hospitalized patients > 70

• > 50% of patients > 85 leave hospital with new disability

• 1/3 of hospitalized elderly have delirium (more commonly hypoactive

delirium)

• 41% of elderly who developed HAD DIED! In under one year,

another 29% still disabled at one year

Hospital Associated Disability


• Major Quality Enhancer NHF, IHI etc.

• 27 states (including TN) have laws to promote palliative care as of

2018 with Ohio, Kentucky and NJ joining this year.

• 71% of patients have never heard of palliative care.

Palliative Care

Hospice News-5/30/2019-Jim Parker


• Twenty-five per cent of all Medicare spending is for the five per cent of

patients who are in their final year of life, and most of that money goes for

care in their last couple of months which is of little apparent benefit.

• Spending on a disease like cancer tends to follow a particular pattern. There

are high initial costs as the cancer is treated, and then, if all goes well, these

costs taper off. Medical spending for a breast-cancer survivor, for instance,

averaged an estimated fifty-four thousand dollars in 2003, the vast majority

of it for the initial diagnostic testing, surgery, and, where necessary,

radiation and chemotherapy. For a patient with a fatal version of the

disease, though, the cost curve is U-shaped, rising again toward the end—

to an average of sixty-three thousand dollars during the last six months of

life with an incurable breast cancer

Atul Gawande: Letting Go, What Should Medicine Do when It Can’t Save Your Life,

The New Yorker Aug 2, 2010

Palliative Care and Costs


Morrison, R. S. et al. Arch Intern Med 2008;168:1783-1790.

Mean direct costs per day for patients who died and who received palliative care consultation on hospital days 7, 10, and 15 compared with mean direct costs for usual

care patients matched by propensity score

Sooner is Better!

Why Hospital Administrators LOVE Palliative Care


Headline: “Jindal to Poor: ‘Drop

Dead’”January: Jidal rescinds order.

Why?

• It was pointed out that many of

those people dying at home in

hospice would soon be dying in

much more expensive hospitals

• Savings to Medicare by hospice

and LOS to death:

• 1-7 days……… $2,651.00

• 8-14 days……. $5040.00

• 15-30 days..... $6,430.00

Jindal drops Hospice for Medicaid Patients

Health Affairs, 3/6/2013

Citing possible 8.3 million dollar savings, Gov. Bobby Jindal of Louisiana

drops hospice for Medicaid Patients (Dec 2012)


• “..unnecessary care often crowds out necessary care, particularly

when the necessary care is less remunerative.”

• “In just a single year,…25-42% of Medicare patients received at

lease one of twenty six useless tests and treatments.”

• “Millions of people are receiving drugs that aren’t helping them,

operations that aren’t going to make them better and scans and

tests that do nothing beneficial.”

New Yorker May 11th 2015, p 42-53

• See-Less Medicine/More Health- H Gilbert Welch MD

• TheNNT.com

Atul Gawande, MD: Overkill


• Pain: 50% of all cancer patients suffer pain and >70% of terminal

cancer patients suffer pain

• 40-70 % suffer unnecessary pain

• Fatigue 70-95%

• Shortness of Air: 21-78%

• Delirium 28-83%

• Constipation/Bowel Obstruction 5-28%

• Nausea/ vomiting 15-40%

• Dry mouth/mouth sores

• Depression

• Spiritual angst

Symptoms, Total Suffering


“We have two public health crises going on at the same time: One is the under treatment of

pain and the other is prescription drug abuse.” Dr Scott Fishman JAMA

• 1994- Agency for Heath Care Policy and Research

disseminates guidelines for Cancer Pain then Non-

chronic pain 1996

• 1997 Expert Panel of American Pain Academy of

Pain Medicine, American Society of

Anesthesiologists and American Pain Society

promulgate guidelines for pain treatment

• 2001 JCAHO establishes “Pain as the Fifth Vital

Sign” campaign

• 2001 Bergman v Chin 1.5 million dollar judgment

against Dr. Chin for allowing patient to die in pain

(10/10)

• And then the pendulum swings back

• New focus on overdose deaths, doctor shopping

criminal penalties

• Average 390 “for cause” surrenders of DEA

licensure annually

And Then

• June 2011, IOM releases study on cost of pain and

it’s under-treatment

The Pendulum Swings Both Ways


• The hospice motto: “What ever it takes”

• No functional ceiling to pain meds but!

• TN Opioid laws carve out for hospice and palliative care

• Rule of “Double Effect”

• Pain is NOT a Pressor Agent!

Pain at the End


The Gold Standard and Conversions

Morphine Hydromorphone

Oral Med 30 mg 7.5

IV/Sub Q Med 10 mg 1.5

Hydrocodone </= oral morphine </= oxycodone

Oral morphine daily dose is double fentanyl patch dose

IE: 50 mcg/h patch equals 100 mg daily oral morphine.

Oxymorphone is slightly more that twice the potency of morphine

So 40 mg Opana = about 100 mg oral morphine

Codeine is 1/6th as potent as morphine, i.e. 30 mg of

Codeine = 5 mg of morphine

Demerol 100 mg IV = 10 mg Morphine IV

ALWAYS REDUCE DOSE IN CONVERSION 25-50% FOR INCOMPLETE CROSS TOLERANCE

Scientists have identified 9 different forms of mu opioid receptors

All conversion tables are, at best, rough equivalencies

Oral Morphine Equivalents (OME)


• Onset to peak: IV 6-15 minutes, Sub Q 30 minutes, PO one hour-

short acting 3-4 hours long acting. Fentanyl patches up to 12-16

hours.

• Duration three to four hours for most short acting medications (a

little less for demerol, fentanyl)

• So meds should be should be scheduled accordingly--- regularly

and routinely

• If an IV med hasn’t worked in 15 minutes, it won’t. If a PO short

acting med hasn’t worked in an hour, waiting four hours just

ensures an effective dose is never reached.

Timing Pain Meds


1. Long acting: MS Contin, Oxycontin, Fentanyl patches, Opana ER, Synalgous, Methadone

2. Short acting: MS IR, oxycodone, hydrocodone, dilausid

3. Bowel regimen

– The Opioid Naïve Patient: Set scheduled Q 4 h short acting. hydrocodone/oxycodone/morphine 5-10 mg) PRN’s much more frequent-q 1.

– Tally all meds, scheduled and PRN and create new scheduled dose using long acting medication with breakthrough dose about 10-15% of total daily long acting dose given q one hour PRN!

Pain Meds: Three Prescriptions


• Patients will rarely notice a dose change of less than 25%

• Mild to moderate pain, pain level of 4-6 increase dose 25-50%

• Moderate to severe pain, pain level 7-10 adjust dose 50-100%

• PRN Dose should be about 10-15% of daily long acting dose.

• Use of more than 3 rescue/breakthrough doses should trigger

possible increase in long acting medication.

• In the hospital tally up total doses both scheduled and prns and then

factor in current pain level to come up with new dose.

Adjusting the Dose


• Hyperactive (13-46%)-restless, agitated,

confused, hallucinations, “climbing over the

bedrails”

• 52-88% of terminally ill patients develop

delirium

• Hypoactive (up to 86%) reduced awareness,

psycho motor retardation, lethargy. (Higher

mortality than hyperactive)

• 42% of advanced cancer patients have

delirium on admission and 88% at the end of

life.

• In cancer patients who develop delirium, 30

day mortality 83%

• 74% of patients can recall “being confused”

in episode of delirium and over 80% said it

was distressing

Delirium


• Drugs (opioids, anticholinergics)

• Eyes (sensory deficit-sundowning)

• Low O2 I, CVA, PE,

• Infection UTI, Pneumonia

• Retention urine/stool

• Ictal (seizures)

• Under nourished, under hydrated

• Metabolic DM, calcium, Sodium

• Subdural

DELIRIUMS


• Minimize catheters, IV’s restraints

• Avoid immobility

• Monitor nutrition/hydration

• Monitor stool and urine output

• Control pain

• Review medications

• Minimize noise and interventions/promote sleep

• Orientation Board and familiar family

• Reorient/redirect communication with patient

Treatment, Non-Pharmacologic First


• Haldol, haldol haldol……..Haldol

• Few anti-cholinergic effects, minimal cardiovascular effects, lack of

active metabolites, versatility of routes of administration. (liquid

2mg/ml, tabs 1, 2 and 5 mg, injectable solutions 5mg/ml

• Maximum doses between 20-100 mg orally

• Parenteral dose about ½ PO dose

• Usual starting dose 0.5-1 mg Q 6.

• May be given hourly until effective

Treatment


• Vestibular- meclizine (newer anti-histamines do not cross blood

brain barrier as well)

• Mind: anticipatory nausea –benzodiazepines

• Infection/Inflammation- may respond to anti-

cholinergics/antihistamines

• Dysmotility/Gut- 5HT-4 (metoclopramide) bind receptors that that

then release acetylcholine to increase motility (anti-cholinergics

antagonize this)

• Chemoreceptor Zone: Affected by toxins, chemotherapy and some

medications such as opioids (CRZ) mediated via D2 receptor

blockers (Haldol etc) and 5HT3 receptors (Ondansetron etc)

Sources of Nausea and Treatments


• Why am I here?

• Does my life have meaning?

• Are we part of something larger?

• Is there a God and what is my relationship?

• Why do I suffer?

• Does my suffering have meaning/ causes/fault?

• Does death have meaning?

• What happens after death?

•

Universal Spiritual Concerns


• Some patients (or their families) refuse to engage insisting that “God

will cure them,” that as a good and faithful person, God will not let

them die. (“Magical thinking” combination of denial and bargaining)

• And if they die does that mean their faith was not strong enough or

God doesn’t answer prayers?

• Miracles are called such because they are rare to the point they

appear to violate laws of biology and physics.

• Can always hope for the best while preparing for the worst.

• Death comes to us all. At what age is death a just outcome?

The Problem with Miracles


• Forgive me

• I forgive you

• I love you

• Thank you

• Goodbye, I wish you peace

From Ira Byock’s “Four Things That Matter Most”

What Do I (Patient and Family) Say


4 things that need to be done to assure better care for frail older persons

1. Honest discussion: We should stop deluding the public with the message that late

life frailty is a preventable problem. Of course good health habits should be

encouraged. But most who do all the right things will still have a period of disability

when they reach advanced age. Let's stop telling the public that exercising and

eating blueberries will avoid this problem. Let's instead talk about how to maintain

good quality of life in elders with late life disability.

2. Better advance care planning based on each elders goals that targets care and

services based on each elders individual needs. (Maybe we can call these "life

panels")

3. Care delivery in the elder's home. For disabled elders, just making it to a doctors

office can be an insurmountable hurdle.

4. A care system that embraces long term supportive services and medical care as

equal partners. "food, transportation, and direct personal services are often more

important than diabetes management…."

So What Do We Do With Failing Patients?

Lynn J. Reliable and Sustainable Comprehensive Care for Frail Elderly People

JAMA Nov 13th, 2013 1935-36

http://www.ncbi.nlm.nih.gov/pubmed/23231944


• Blogs: Pallimed Geripal, Medicalfutilty (great for keeping up)

• Fast Facts: https://www.mypcnow.org/fast-facts

• American Academy of Hospice and Palliative Medicine-

AAHPM.org

• www.theconversationproject.org

• Hospice and Palliative Nurses Association www.hpna.org

• National Hospice and Palliative Care Organization -NHPCO.org

• Center for the Advancement of Palliative Care- CAPC.org

• Greg Phelps MD [email protected]

Resources

Documents

Home to Roost - Rural Health Association of … Phelps...Role of Hospice and Palliative Care | Dr. Greg Phelps, MD MPH FAAHPM US vs the OECD • US Healthcare is disjointed, siloed,