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Francis A. Komara, D.O. Michigan State University College of Osteopathic Medicine Define Palliative Care. Identify indications for palliative care services. services Describe Guidelines for delivery of palliative care and quality outcomes. Identify types of palliative care services and their utilization.
Support and care for persons in the last phase of an incurable disease so that they may live as fully and comfortably as possible. NHPCO Hospice is a program designed to care for the dying and their special needs:
Control of pain and other symptoms Psychosocial support for patient and family Medical services with needs of patient Interdisciplinary Team approach AAFP
Critical Care
Critical care is the sophisticated, state-ofthe-art and technologically-oriented medical and nursing care provided to patients facing life-threatening illness or injury with the goal of reversing illness or injury and restoring health
Greater than half of hospital deaths in U.S. occur in ICU. 20% of Americans receive ICU care near the end of life. 10-20% of ICU patients will die. 70 - 90% of ICU deaths occur in the context of withholding or withdrawing life support. Many ICU patients Live with significant reduction in quality of life after the ICU Return to the ICU
Life Closure
Serves patients of all ages with chronic illness or injury that affects daily functioning or reduces life expectancy. Care given by Interdisciplinary team
Diagnosis
Palliative Care
Hospice
NHWG; Adapted from work of the Canadian Palliative Care Association & Frank Ferris, MD
Definition
Definition
Begins when condition is diagnosed and continues through cure or until death or family bereavement. Provided in multiple settings.
Should be Integrated into daily clinical practice (Not just specialty care). Primary Care Physician expected to provide basic palliative care. May require PC Specialists in Complex situations Can be main focus of care or given with life-prolonging treatment.
Goals of Care
Care Team
Prevent and relieve suffering. Enable the best quality of life. Address physical, psychological and psychiatric, spiritual and social issues. Promote communication and continuity of care across settings. Prepare patient and family of dying process and death, explore hospice option. Bereavement
Communication
Determine Goals and Preferences of patient and family. Assist in Medical Decision Making
Care Team
Specialist-level skills in physical, psychological, social, spiritual and legal aspects. Symptom control skills y p Assessment of Social and Practical needs. Psychiatric need awareness: Depression, anxiety, delirium, co-morbidities of serious illness. Medical Decision Making: Advance care planning, directives, surrogate decision makers.
Referrals
Hospice and community resources. Specialized professionals T Transportation t ti Rehabilitation services Medications Counseling
Communication
Care Plan
Identify goals of patient and family Review regularly!! A Assessment T l t Tools Care plan changes as patient and family needs evolve. Benefit vs Burden Need for higher intensity care near death.
TIME-LIMITED TRIALS:
Currently Receiving: Ventilator: Dialysis Feeding Tube Antibiotics IV Fluids Other: Other: Re-Evaluation Date:
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Full Consult Now Await Result of Time-limited Tria ls SIGNATURE: NP: ______________________________________________________ Date: _____________________________ PALLIATIVE CARE ATTENDING REVIEW : ________________________________________________________
Addressed: Yes/No
Time-Limited trials?
Ventilator Dialysis Feeding tube Antibiotics IV Fluids
Quality Measures for Palliative Care: Robert Wood Johnson Critical Care Workgroup
Quality Measures
Documentation of timely physician communication with family and interdisciplinary clinician-family conference Transmission of key information with transfer of patient out of ICU
Continuity of care
Quality Measures
Quality Measures
Quality Measures
Documentation that spiritual support was offered Emotional and organizational support for clinicians
Care Plan
Identify Alternative settings and treatment. Communicate regularly. C ll b Collaborate between palliative and hospice t b t lli ti dh i programs and community providers to assure continuity of care.
Treatment
Care Setting
By patient and family preference. Address safety Fl ibl visiting hours Flexible i iti h Space for families Privacy
According to goals of care. Assessment of Risk vs Benefit. Pain and Symptom management. management
Timely reduction of pain and symptoms that is acceptable to the patient. Pharmacologic, non-pharmacologic, complementary therapies. Barriers: Fear of addiction, side-effects, respiratory depression.
Creating or updating wills, advance care directives. Guardianship agreements. Assist Surrogate decision makers.
Advance care planning. Withholding and withdrawing treatments Do not resuscitate orders
Ethical Aspects
Beneficience Self-determination C Capacity assessment it t Informed consent
Quality Improvement
Be attentive to: Safety Error reduction Timeliness Patient preferences Benefit and effectiveness Equity of access Efficiency
Quality Improvement
Collaborative Regular assessment I Input from patients, families, health tf ti t f ili h lth professionals Focus on meeting needs of those receiving the care.
Language matters
Communicate who we are and what we do to patients, families, and colleagues using language that focuses on the needs of the audience as they perceive them- for patients+families: relief, practical help. For referring docs: time and assistance. For hospitals: quality and efficiency. efficiency Use of end of life, dying, and bereavement language renders our services immediately irrelevant to 95% of our audience. If we want to reach the patients and families who need us we cannot force them to 1st agree that they are dying.
Definitions
CAPC: Palliative care is an Interdisciplinary specialty that aims to relieve suffering and improve quality of life for patients with advanced illness, and their families. It is provided simultaneously with all other appropriate medical treatment. NCP: The goal of palliative care is to prevent and relieve suffering and support
the best th b t possible quality of life for patients of all ages and their families. ibl lit f lif f ti t f ll d th i f ili Palliative care is a both a philosophy of care and an organized program for delivering care to persons of all ages with life threatening conditions. This care focuses on enhancing quality of life for patient and family, optimizing function, helping with decision-making, and providing opportunities for personal growth. As such, it can be delivered concurrently with life prolonging care or as the main focus of care.
Use the language of the National Consensus Project for Quality Palliative Care, National Quality Forum, and CAPC.
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.
Excellent, evidencebased medical treatment Vigorous care of pain and symptoms throughout illness Care that patients want at the same time as efforts to cure or prolong life
Expert control of pain and symptoms Uses the crisis of the hospitalization to facilitate communication and decision-making about goals of care with patient and family Coordinates care and transitions across fragmented medical system Provides practical support for family and other caregivers Cultural competency
The 63% of Medicare patients with 2 or more chronic conditions account for 95% of Medicare spending (CDC)
The number of people over age 85 will double to 9 million by the year 2030 (CDC)
But
Number of palliative care programs, specialists not sufficient to meet patient need In absence of comprehensive palliative care programs and PC specialists, physicians need basic PC clinical skills
Number of hospital-based palliative care programs has doubled in recent years to more than 800 One in five hospitals now offers palliative care US News & World Report includes palliative care in its criteria for Americas Best Hospitals ABHPM certifying more and more physicians Referral rates at established programs are growing each year
Billings JA et al J Pall Med. 2001, AHA Survey 2002, Pan CX et al J Pall Med. 2001
References
Smith L. Guidelines for Delivering Quality Palliative Care. American Family Physician, Physician March 15 2006;73 15, 2006;73. Mularski RA, et al. Proposed quality measures for palliative care in the critically ill: A consensus from the Robert Wood Johnson Critical Care Workgroup. Critical Care Medicine 2006 Vol 34, No. 11 (Suppl)
http://www3.interscience.wiley.com/cgibin/fulltext/122486445/PDFSTART https://cissecure.nci.nih.gov/ncipubs/detail.aspx?prodid=Q014
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