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Supportive & Palliative Care Service: Professional Practice Conference. Caroline Olney, RN MSN NP October 21, 2010 San Francisco General Hospital. What we hope you will learn:. Identify the relationship between palliative care and hospice care - PowerPoint PPT Presentation
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Supportive & Palliative Care Service:
Professional Practice Conference
Caroline Olney, RN MSN NP
October 21, 2010
San Francisco General Hospital
What we hope you will learn:
• Identify the relationship between palliative care and hospice care
• Become familiar with new palliative care resources for pts/families/staff at SFGH
• Recognize where and how to document a patient’s wishes
• Identify other resources in the Bay Area
What is Palliative Care?
• “Palliative care is the medical subspecialty focused on preventing, treating and relieving the pain and other debilitating effects of serious and chronic illness.”
• “Palliative care is not dependent on prognosis and can be delivered at the same time as curative treatment. The ultimate goal: to improve quality of life for patients and families facing serious illness.”
Center to Advance Palliative Care, 2009
Palliative Care
• Patient and family as unit of care• Attention to physical, psychological, social
and spiritual needs• Interdisciplinary team approach• Education and support of patient and family• Extends across illnesses and settings• Bereavement support
http://www.nhpco.org
Traditional Approach to End-of-Life Care
Curative care
%Focus
Time
DeathTerminal phase
100
Palliative or Hospice Care
0
“Nothing more we can do”
Adapted from S Pantilat, PCLC 2005
Integrated Model forEnd-of-Life Care
Curative care%
Focus
0
100
TimeDeathTerminal phase
“Best care possible”
Bereavement
Adapted from S Pantilat, PCLC 2005
Hospice Care
Palliative Care
The Palliative Care Spectrum
Hospice
Pain Management
Life-Prolonging Therapy
Palliative Care vs. Hospice Care
Palliative Care• Eligibility does not depend
on prognosis
• Can be given at the same time as life-prolonging interventions
• Provided in hospital, SNFs, outpatient clinics, or home
Hospice Care• Usually only accessible
for pts with very limited prognosis (<6 months)
• Best for patients who choose to forego life-prolonging treatments
• Can be provided at inpatient hospice, in SNF/RCFE, or home
Both involve comprehensive management of physical, psychosocial, emotional, spiritual components of care, to enhance quality of life for patients and families
Early Palliative Care for Patients with Metastatic Non-Small-Cell Lung
Cancer
“Among patients with metastatic non small-cell lung cancer, early palliative care led to significant improvements in both quality of life and mood. As compared with patients receiving standard care, patients receiving early palliative care had less aggressive care at the end of life but longer survival”
N Engl J Med 2010; 363:733-742
New York Times Aug 19, 2010
Supportive & Palliative Care Service
• Inpatient Consult Service, launched December 2009
• An interdisciplinary team including:– Physicians:
• Anne Kinderman, MD, Medical Director• Heather Harris, MD, Associate Medical Director
– Nurse: Caroline Olney, RN MSN NP– Social Worker: Regina Epperhart, MSW– Chaplains: Eric Nefstead, MDiv and Elizabeth
Welch, MDiv
Supportive & Palliative Care Service
• Expertise in:– Communicating with patients and families
(explaining diagnoses or prognoses, establishing goals of care, and facilitating family meetings)
– Treating refractory or complex symptoms– Addressing psychosocial or spiritual concerns – Coordination of care across health care settings– Facilitating transitions from life-prolonging care
to comfort care or hospice care
SPCS: 443-5063
• Available to all patients in the hospital Monday-Friday 8am-5pm (except holidays)
• Consult requests must come directly from the inpatient primary physician– All providers (nurses, social workers,
nutritionists, etc.) are encouraged to recommend consults to the primary team
How do you request a consult?
• The best way to ensure that your patient gets a palliative care consult is to include this in your note in LCR.
• Also, contact the admitting team directly to ensure your request for a consult was received.
Which patients might benefit from a SPCS consult?
• Patients with ANY advanced or life-limiting illness and:– Unclear goals of care– Frequent ED visits or hospitalizations– Uncontrolled pain or other symptoms– Psychosocial/spiritual distress (pt/family member)– Difficult decision-making with pt/family or difficult
communication with pt/family• Patients who are transitioning to comfort-oriented care or
who may die in the hospital
SPCS: Resources for Patients and Families
• Comfort Care Suites– 2 double rooms converted into single room suites located on 5A (9 & 12)– Suites redecorated with the help of grant support from the SFGH
Foundation and Healing Environments (new flooring, furniture and art)– Occupancy triaged by 5A charge nurse and SPCS. Patients who are
imminently dying are prioritized over med/surg patients.– More room for visitors to stay with the patient; visiting hours 24/7– 5A nurses have additional training, experience with end-of-life care
• Social Work– Provide information on community resources (hospice, funeral
arrangements, bereavement support, etc.)
• Chaplaincy– Sojourn chaplaincy: 206-8500– Catholic priest: 206-8119
SPCS: Resources for Staff
• Provide education and training– Physicians & Nurses– Rehab specialists, social workers, interpreters, etc.
• Support/debrief difficult patient or family interactions, particularly regarding end-of-life issues
• Provide information on community resources (hospice, funeral arrangements, bereavement support, etc.)
Communication Toolbox
• 3 questions:– What do you know?– What do you want to know?– Who do you want with you?
• 3 techniques:– Clarify ambiguity– Talking / listening / silence– Affect vs. cognition
Communication Toolbox
• Helpful open-ended questions:– What led to your diagnosis?– What do you know about your diagnosis?– What does that mean to you?– What is life like for you now?– What concerns you the most?– What are you hoping for?– What gives you strength?
Communication Toolbox
• Other helpful questions:– Are you comfortable?– Do you feel that your treatments are causing you more harm
than good?– Do you feel like you have a good quality of life right now?– If we could do one thing other than cure your illness, what
would it be?
• Helpful phrases:– Your diagnosis is beyond our control but we can still control
your symptoms– While we are hoping for a miracle, we are preparing for the
worst
• For more information: www.caringinfo.org
Communication Toolbox
• Sit down• Active listening• Silence• Avoid medical jargon• Be respectful• Be honest• Do not be afraid to use the words death/dying
Ira Byock: The 4 Things That Matter Most
• Please forgive me
• I forgive you
• Thank you
• I love you
• (Goodbye)(Byock, 2004)
Communicating Goals of Care: Advanced Directive & POLST
• Advanced directive note in LCR• Advanced directive in LCR: can be
completed by ANY health care provider• POLST in LCR: can be printed and filled
out by any physician or nurse practitioner
• California Advance Directive: available in Spanish and Chinese
Advanced Directive: CPR/Medical Interventions tab
Advanced Directive: Agents/Health Advocate tab
Advanced Directive: Organ Donation tab
Advanced Directive: Document Location tab
Advanced Directive: Confirmation panel
Partial view of Advance Directive in LCR
Medical alert bracelet
• May indicate advanced directive and code status
• Can be linked to the medical record
Local Resources
In-home support:– Health at home– Sutter VNA
• AIM Program• Hospice
– Hospice By The Bay– Pathways Hospice
Inpatient Hospices:– Gift of Love Home– Laguna Honda Hospice– Maitri: HIV/AIDS patients– SFVA– Coming Home Hospice– Zen Hospice (Guest
House)
Questions?
Thank You
Thank you for joining us today. We appreciate your participation and helping us to develop our palliative care team. Thank you for all that you do.