Palliative Care Across the Continuum of Illness: An Introduction to Palliative Care Melissa Schepp,...
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Palliative Care Across the Continuum of Illness: An Introduction to Palliative Care Melissa Schepp, MD Director, Palliative Care St. Joseph’s Hospital,
Palliative Care Across the Continuum of Illness: An
Introduction to Palliative Care Melissa Schepp, MD Director,
Palliative Care St. Josephs Hospital, Atlanta GA
Slide 2
LEARNING OBJECTIVES Identify the principles of Palliative Care
Understand how Palliative Care applies across the spectrum of
illness
Slide 3
Definition of Palliative Care (National Quality Forum)
Palliative Care refers to patient- and family- centered care that
optimizes quality-of-life by anticipating, preventing, and treating
suffering. Palliative care throughout the continuum of illness
involves addressing physical, intellectual, emotional, social, and
spiritual needs and facilitating patient autonomy, access to
information, and choice
Slide 4
Palliative care comes from the word palliate, which means to
ease.
Slide 5
What Is Palliative Care? Specialty (ABMS 2008) Addresses
quality of life for seriously ill patients and their families
Covers a spectrum of care which encompasses Multiple disciplines
(MD, Nurse, Chaplain, SW) Alleviation of symptoms Assistance with
information sharing/decision making Coordination of resources
Slide 6
OLD VS NEW APPROACH Palliative Care Medicare Hospice Benefit
Bereavement Disease Progression Diagnosis of serious illnessDeath
Life Prolonging Care Hospice Care Life Prolonging Care Old New
Slide 7
PALLIATIVE CARE VS HOSPICE All of hospice is palliative care,
but not all of palliative care is hospice Palliative Care
Hospice
Slide 8
Palliative Care, Why? #1 Reason Medical Progress has changed
the way we live has changed the way we are sick has changed the way
we die
Slide 9
Slide 10
Slide 11
Slide 12
Modern End of Life=Protracted Course 85% of people in the US
will experience one of these trajectories at the end of life 20%
Cancer 25% Organ Failure 40% Dementia/Frailty Average American 2-4
years of disability before death
Slide 13
CURRENT NEEDS OF SERIOUSLY ILL PATIENTS and THEIR FAMILIES High
degree of unmanaged or under- managed symptoms in patients with
chronic and/or debilitating illnesses Poor to non-existent
communication regarding patient goals of care Lack of coordination
with patient and family preferences-need for advanced care
planning
Slide 14
International Comparison of Spending on Health, 19802006
Average spending on health per capita ($US PPP) Total expenditures
on health as percent of GDP Data: OECD Health Data 2008 (June
2008).
Slide 15
Inpatient Hospital Spending per Capita a b a 2003 b 2002 b a
Source: The Commonwealth Fund, calculated from OECD Health Data
2006. Adjusted for Differences in Cost of Living
Slide 16
16 High Spending: Poor Outcomes Mortality Amenable to Health
Care Deaths per 100,000 population* * Countries age-standardized
death rates before age 75; including ischemic heart disease,
diabetes, stroke, and bacterial infections. Data: E. Nolte and C.M.
McKee, "Measuring the Health of Nations: Updating an Earlier
Analysis," Health Affairs Jan.- Feb. 2008, 27(1):58-71 analysis of
World Health Organization mortality files. Source: Commonwealth
Fund National Scorecard on U.S. Health System Performance,
2008.
Slide 17
FINANCIAL IMPACT OF CURRENT MODEL OF CARE Major financial
crisis Locally Nationally
Slide 18
WHAT SERIOUSLY ILL PATIENTS WANT Appropriate treatment of pain
and other symptoms Achieve a sense of control Communication
regarding their care Coordinated care throughout the course of
illness Avoid inappropriate prolongation of the dying process
Relieve burdens on family Strengthen relationships with loved ones
Sense of safety in the healthy care system
Slide 19
Hospital-Based Palliative Care Growth (2000-2009) 658(24.5%)
168(63%)= 138% (Hospitals over 50 beds) 85% of hospitals with
>300 beds More likely in not-for-profit hospitals *Growth of
Palliative Care in US Hospitals 2011Snapshot, CAPC
Slide 20
BENEFITS TO HOSPITALS Improved patient and family satisfaction
Improved quality of care for patients and their families Meets the
needs of an aging population Assists in compliance with hospital
care quality (Joint Commission) Transition of patient to
appropriate level of care- often reducing length of stay,
especially in the ICU Decreased hospital costs and resource
utilization Improved staff satisfaction and retention
Slide 21
PALLIATIVE CARE (THIS IS THE MESSAGE!) Improve Quality of Life
(Its about the living) Goals of Care=Plan of Care Ensure patients
treatments are goal- directed NOT disease-directed NOT technology
driven
Slide 22
DO NOT ALLOW YOUR AWE FOR TECHNOLOGY AND OUR ABILITY TO KEEP A
BODY FUNCTIONING BLUR YOUR DEFINITION OF LIFE.
Slide 23
THIS IS A SKILLLets put ourselves out of business Palliative
Care teams must provide education and support to hospital staff
regarding symptom management communication issues ethical dilemmas
family conference/goal setting resource utilization
Slide 24
TOOL #1 Maslows Hierarchy
Slide 25
ANXIETY/INSOMNIA DYSPNEA DEPRESSION NAUSEA/DIARRHEA
FEAR/AGITATION COUGH FATIGUE/WEAKNESS COMMON SYMPTOMS
Slide 26
TOOL #2 Patient Centered Interview F = FEELINGS related to the
illness, especially fears What are you most concerned about? Do you
have any specific fears or worries right now? I imagine you have
had many different feelings as you have coped with this illness.
Sometimes people have fears that they keep to themselves and dont
tell their doctor. I = IDEAS and explanations of the cause of a
symptom or illness What do you think might be going on? What do you
think this pain means? Do you have ideas about what might have
caused this illness? F = FUNCTIONING, the illness impact on daily
life How has your illness affected you day to day? What have you
had to give up because of your illness? What goals do you have now
in your life? How has your illness affected your goals? How does
this illness affect important people in your life? E = EXPECTATIONS
of the doctor & the illness What do you expect or hope I can do
for you today? Do you have expectations about how doctors can help?
What do you hope this treatment will do for you? What are your
expectations about what might happen with this illness?
Slide 27
TOOL #3 Family Meeting Multidisciplinary Format (templates
available CAPC) Team data demonstrates 80% rate of
multidisciplinary family conferences by Day 2 of consult Tangible
outcomes Treatment goals Resolution of conflicts Advance Directives
Documented in the chart!
Slide 28
DIFFICULT DECISIONS Are we preserving life or prolonging death?
When is chemo or radiation therapy palliative in nature and when is
it curative? PEG tube placement? Do I want to be a DNR-what is a
DNR? IVFs? Hemodialysis? What is quality of life? Our job as
palliative care providers is to gently help patients reach
conclusions that are in line with their goals, then do our best to
help them achieve those goals.
Slide 29
OLD VS NEW APPROACH Palliative Care Medicare Hospice Benefit
Bereavement Disease Progression Diagnosis of serious illnessDeath
Life Prolonging Care Hospice Care Life Prolonging Care Old New
Slide 30
Concurrent Care Early Palliative Care of Patients with
Metastatic Non-Small-Cell Lung Cancer Temel, J, NEJM 363;8 151
patients with new diagnosis metastatic NSC Lung Cancer Randomized
to Onc Care OR Onc Care + Palliative Care
Slide 31
Results Onc + Palliative Care group Reported better QOL Less
depression Chose less aggressive care at EOL Lived Longer (11.6
months vs. 8.9 months)
Slide 32
Non-hospice Palliative Care Allocate resources by need, not
prognosis (hospice) Inpatient (ICU!! IPAL-ICU) Outpatient
Palliative Care Programs Hospital-Based Hospice/HH Based Long-term
Care Facilities 25% of Americans die in NH By 2030 NH population
expected to double from 1.5 million to 3 million
Slide 33
When a patient is severely ill, he is often treated like a
person with no right to an opinion. It is often someone else who
makes the decision if and when and where a patient should be
hospitalized. It would take so little to remember that the sick
person too has feelings, has wishes and opinions, and has-most
important of all-the right to be heard. Elisabeth Kubler-Ross,
MD
Slide 34
Recommended Reading Living Long in Fragile Health: The New
Demographics Shape End of Life Care, Joanne Lynn, MD (Hastings
Center Report) Letting Go. What Should Medicine Do When it Can Not
Save Your Life?, Atul Gawande (New Yorker Article) Handbook for
Mortals, Joanne Lynn, MD Hard Choices for Loving People Hank Dunn
(Patient-Friendly Pamphlet) Palliative Care; Transforming the Care
of Serious Illness, Diane Meier, et al
Slide 35
Other Resources Center to Advance Palliative Care (capc.org)
American Academy of Hospice and Palliative Medicine (AAHPM.org)
Education in Palliative and End of Life Education (www.epec.net)
ELNEC (www.aacn.nche.edu/elnec) EPERC
(www.eperc.mcw.edu)www.eperc.mcw.edu) Fast Facts
Slide 36
REFERENCES Kubler-Ross, E. (1969). On death and dying. New
York, NY: Scribner. Center to Advance Palliative Care (CAPC).
(2008). Palliative care and hospice care across the continuum.
http://www.capc.org/palliative- care-across-the-continuum.
End-of-Life Nursing Education Consortium (ELNEC) (2007). Promoting
palliative care nursing. ELNEC-Core Training Program. City of Hope
and American Association of Colleges of Nursing. National Consensus
Project (NCP) for Quality Palliative Care (2004). National
consensus project for quality palliative care: Clinical practice
guidelines for quality palliative care, executive summary. Journal
of Palliative Medicine, 7(5), 611-627. National Quality Forum.
(2006). A national framework and preferred practices for palliative
and hospice care: A consensus report. Washington DC.
