Palliative Care: Helpful Information for Internal Medicine Residents

Lisa Marr, MD

Objectives

Define Palliative Care, Hospice and Comfort-only Care Palliative Care at UNM

▪ When to consult Palliative Care Surrogate Decision Makers

Specifics for New Mexico Basics of Prognostication Note Templates and Order Sets for

Palliative and End-of-Life Care

Hospice care vs. palliative care vs. “comfort only” care

Hospice: A health care benefit as well as a type of care Medicare benefit (Part A) since 1983; many

private insurances have a “hospice benefit”▪ Two MDs certify prognosis < 6 months if “disease

runs its usual course”▪ Focus is on comfort and relief of suffering, not life

prolongation Interdisciplinary team provides care It is not a place; primarily home based

▪ UNM does not have its own hospice and does not have “hospice beds”

What is Palliative Care?

Palliative Care “An approach that improves the quality of life

of patients and their families facing the problems associated with life threatening illness, through prevention of and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychological and spiritual”

WHO

Hospice care vs. Palliative Care vs. “comfort only” care

Palliative Care- team based careCan be provided in conjunction with life prolonging

treatment (i.e. no need to choose between treatment plans)Does not take the place of curative care!

No prognostic requirement; no age requirement; not limited to any specific diagnosis; not just “actively dying”

Primarily hospital based; Interdisciplinary teamThe goal is not to hasten nor prolong death

Palliative Medicine- A medical subspecialty (Hospice and Palliative Medicine)

Palliative Medicine

In September 2006, ABMS unanimously approved the creation of Hospice and Palliative Medicine (HPM) as a sub-specialty of ten participating boards: Internal Medicine, Anesthesiology, Family

Medicine, Physical Medicine and Rehabilitation, Psychiatry and Neurology, Surgery, Pediatrics, Emergency Medicine, Radiology, and Obstetrics /Gynecology▪ UNM Hospice and Palliative Medicine Fellowship since

2012▪ Fellowship Director: Dr. Marr

Palliative care vs. hospice care vs. “comfort only” care

“Comfort Only” Care: A type of care……in which the sole goal of the treatment

is to provide comfort; all treatment options are framed in terms of “does this provide comfort?”.

All hospice care is palliative care (philosophy of care)

But not all palliative care is hospice care

Conceptual Shift in Palliative Care

Medicare Hospice Benefit

Life Prolonging Care

Conceptual Shift in Palliative Care

Palliative Care

Bereavement

Hospice Care

Life Prolonging

Care

New

Palliative Care does not mean “giving up”. We are a consult service that coexists with all other care.

Who are we?

Interdisciplinary, multi-departmental team

UNMH Team Physicians Lisa Marr, MD- Internal Medicine Bridget Fahy, MD- Surgical Oncology Devon Neale, MD- Geriatrics Sarah Gebauer, MD- Anesthesia Chris Camarata, MD-Family Medicine Esme Finlay, MD- Medical Oncology

UNMH Team Advance Practice Nurses: Kim Harlow,

CNS, Samantha Marsh, ANP, Emily Antle, ANP

Social Work: April Lee, LISW Chaplain: Michelle Tatlock, MDiv Arts-in-Medicine: Patrice Repar and team Administration and Native American

education: Venita Wolfe, MS▪ HPM Fellows since 2012: 2 ED, 2 IM, 1

Psychiatry

Clinical Service

Inpatient consultation service Consult only; collaborate with primary

team Enter electronic order and call 272-

4868 Outpatient Clinic- Wednesday

afternoon 1-5 Consult only; order through EMR

▪ Require physician to refer

Who is appropriate for a palliative care consult?

Clinically: Anyone you wouldn’t be surprised will die this hospitalization or in the next year. Anyone with advanced organ failure or metastatic cancer

▪ CHF, COPD, dementia, ESLD, ESRD, etc. , particularly multiple readmissions with functional decline

ICU patient who is DNR Multiple admissions to ICU Patients/families request palliative care

Remember: Palliative Care does not mean “giving up”. Team does not have an agenda.

“Surprise” Question

Ask on rounds “Would you be surprised if this patient died during this hospitalization? within the next 6 months? the next year?” If so, this is a good palliative care consult

What are reasons for consult? Unacceptable pain or symptom distress in patients

with serious/life threatening illness We are not Ethics, Acute Pain (post op or procedure) or

Chronic Pain (patients with addiction, and/or chronic non-malignant pain), or Discharge Planners

Team/patient/family needs help with complex decision-making and determination of goals of care

Advance Care Planning- Hospice eligibility Prognostication Patient/Family support Team support (particularly family goal-setting

conferences): esp. Complex family dynamics

What are reasons for consult? Disposition assessment for seriously ill

and/or dying patients Uncontrolled psychosocial/spiritual

distress Frequent hospitalizations for the same

diagnosis with functional decline Ex. CVA, Kindred (LTAC), back with asp. PNA,

etc. Prolonged LOS/ICU stay without evidence

of progress Other?

Bottom line:

If you’re thinking about a consult, call and discuss.

Sooner better than later!

How to introduce Palliative Care consult

“This is a team of doctors, nurses, social worker, chaplain who can help with ______.” (ex. Your pain, your breathing problems, ideas for what we can do for you after this hospital stay, etc.)“This is a team of people who help patients and their

families facing serious or life threatening illness.”

How not to introduce palliative care:“This is a team of people who help you die.”“This is a team of doctors who see you when there is

nothing else to do.”“This is the hospice team”

Surrogacy

New Mexico: Surrogacy for Decision Making If a patient is decisional, make

decisions with the patient Who makes decisions for non-decisional

patients in New Mexico?

Surrogacy for decision making Guardian, POAHC (Look in “Urgent

Clinical Documents for Advance Directives) What if there is no guardian or POAHC?

▪ New Mexico Uniform Health Care Decisions Act▪ http://law.justia.com/newmexico/codes/nmrc/jd_ch24art

7a-acff.html

Uniform Health Care Decisions Act

24-7A-5. Decisions by surrogate. A.     A surrogate may make a health-care decision for a patient who is an adult or emancipated minor if the patient has been determined according to the provisions of Section 24-7A-11 NMSA 1978 to lack capacity and no agent or guardian has been appointed or the agent or guardian is not reasonably available.    B.     An adult or emancipated minor, while having capacity, may designate any individual to act as surrogate by personally informing the supervising health-care provider. In the absence of a designation or if the designee is not reasonably available, any member of the following classes of the patient's family who is reasonably available, in descending order of priority, may act as surrogate:   

(1)     the spouse, unless legally separated or unless there is a pending petition for annulment, divorce, dissolution of marriage or legal separation;    (2)     an individual in a long-term relationship of indefinite duration with the patient in which the individual has demonstrated an actual commitment to the patient similar to the commitment of a spouse and in which the individual and the patient consider themselves to be responsible for each other's well-being;    (3)     an adult child;    (4)     a parent;    (5)     an adult brother or sister; or    (6)     a grandparent.    (7) a “concerned” person

Basics of Prognostication

Why prognosticate? Patients want and need prognostic

information▪ “Doc, how long do I have?”▪ Patients who understand their prognosis

make different decisions▪ CPR – Murphy et al. NEJM. 1994.▪ Oncology treatments – Weeks et al. JAMA. 1998.

▪ Patients can’t complete end-of-life planning if they don’t know they are dying

Why prognosticate? Clinical decision making should occur in

the context of prognosis Should we do a transplant work up or not? Should we refer to rad onc or not? Should we start coumadin / antibiotics /

TPN / xxx or not? Care planning requires prognostication

Hospice referral requires documentation of <6 mo prognosis

How do you determine prognosis? Best studied in advanced cancer Use general data (e.g. median survival)

and modify with patient specific factors Factors influencing prognosis

Disease related Patient related Environmental / Psychosocial

Glare and Sinclair, Palliative Medicine Review, JPM, 2008. 11(1). 84-94

Methods / Tools for Prognostication Clinical Predictions of Survival (CPS) Functional decline Surprise question Karnofsky Performance Status (KPS) and

Eastern Cooperative Oncology Group (ECOG) Score

Palliative Performance Scale (PPS)

Karnofsky Performance Status 100 = normal activity 50 = requires considerable assistance

and frequent medical care 0 = dead

ECOG Performance Status 0 = asymptomatic 3 = confined to bed or chair >50%,

limited self care 5 = dead

Clinical Prediction of Survival (CPS) Physicians overestimate survival

▪ Only 20% estimates were accurate ▪ Average MD overestimates survival by a

factor of 5.3x! Christakis, Lamont. BMJ 2000.

Factors that impact accuracy▪ Length of clinician - patient relationship; age;

training▪ ASK a colleague for a prognostic estimate

Despite these factors, CPS correlates with survival

Functional Status is an important determinant of prognosis

Functional decline atthe end of lifeLunney, J et al, JAMA 2003, 289: 2387-2392

Where does your patient fall on these curves?

Talking About Prognosis:

Change in clinical status is an opportunity for prognostic disclosure Repeat hospitalizations Worsening O2 requirement Maximizing meds for chronic conditions Tumor progression requiring new chemo

Note Templates and Order Sets

Documentation Assistance Orders:

Pain Order Set▪ Adult Pain

Comfort Order Set- for patients on comfort only care

Note Templates: Anyone can use these In “Urgent Clinical Documents”:

▪ Code Status Note- required for every admitted patient▪ Surrogate Decision Maker Note- make sure to ask at time

of admission, and document, if patient does not have an Advance Directive. This is good for this admission.

Family Conference Note- in “progress note” section

PCA documentation

Question: Where do you find PCA data in the electronic record? Hint: It is not on the MAR, and it is not

intuitive

PCA documentation

Answer: “All Results” Flowsheet

▪ Note: PCA cartridges are usually cleared every nursing shift (7AM-7PM, and 7PM-7AM)▪ Data is documented incrementally over the shift▪ Determine amount used by going from documented

usage at one time, minus documented dosage at another time Example: used 0.2mg at 2100 and 3.2mg by 0600.

Therefore, used 3.0 mg in 9 hours

Thank you!

Questions?