Objectives GUIDELINES for Delivery of Q Quality Palliative Care y

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.

What Is Palliative Care?

Medical treatment that aims to relieve suffering and improve quality of life simultaneously with all other appropriate treatment for patients with advanced illness, and their families.

What is Hospice Care?

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

Palliative Care and ICU 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

Angus, Crit Care Med, 2004; 32:638; SUPPORT, JAMA 1996;274:1591

A New Vision of Palliative Care

Definition: Palliative care

Disease Modifying Therapy
Curative, or restorative intent

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

Death & Bereavement

Physical Psychological Spiritual Social

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.

The Care Unit made of:

Patient Family Caregiver g

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.

Physician offices Hospital and Emergency Rooms Home Nursing homes

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

Team members informed of patient and family needs.

Care Team

Support for the Team

Emotional support Education R Regular meetings l ti

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.

Support for the Family

Ready access to palliative care team (24/7) Help with decision making Di Discuss goals of care and advance care l f d d planning Emotional and social support

Referrals
Hospice and community resources. Specialized professionals T Transportation t ti Rehabilitation services Medications Counseling

Completion of unfinished business

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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Comments

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Palliative Care Assessment

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NURSE PRACTITIONER ASSESSMENT:

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Review of admission to unit triggers Palliative Care Screen

ICU Admission following a current hospital g p stay of at least 10 days Age>80 in presence of 2 or more lifethreatening co-morbidities Diagnosis of active Stage IV malignancy S/P cardiac arrest Intra-cerebral hemorrhage requiring ventilator

Full Consult Now Await Result of Time-limited Tria ls SIGNATURE: NP: ______________________________________________________ Date: _____________________________ PALLIATIVE CARE ATTENDING REVIEW : ________________________________________________________

SIGNATURE: Attending: ___________________________________________________ Date: ___________________________ FINAL DISPOSITION:

Trans ferred to: _____________

Died in Unit Coded Treatment Withdrawal No treatment / No code

Com m e nts :

Date: Date: Date: Date: Date:

______________________________ ______________________________ ______________________________ ______________________________ ______________________________

Palliative Care Assessment

Brief HPI Physical exam Symptoms:

Palliative Care Assessment

Patient and family support needs addressed: Yes/No Health care proxy identified Living will identified Goals of care identified End of life issues identified

Addressed: Yes/No

Pain Nausea/vomiting Dyspnea Agitation anxiety

Palliative Care Assessment

Palliative Care Assessment

Limitations set on:

No CPR DNI No Dialysis No Feeding tube No antibiotics No pressors No IV fluids

Time-Limited trials?
Ventilator Dialysis Feeding tube Antibiotics IV Fluids

Quality Measures for Palliative Care: Robert Wood Johnson Critical Care Workgroup

Quality Measures

Patient and family-centered decision making

Assessment of patient s decisional capacity patients Documentation of surrogate decision maker within 24 hrs of admission Documentation of presence and contents of advance directives Documentation of goals of care

Communication within the team and with patients and family

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

Emotional and practical support for patients and family

Open visitation Documentation that psychosocial support has been offered

Symptom management and comfort care

Documentation of pain assessment and management Documentation of respiratory distress assessment and management Protocol for analgesia/sedation in terminal withdrawal of mechanical ventilation

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.

End of life and Bereavement

Introduce hospice referral Address end of life concerns, hopes, fears P t Pastoral care to facilitate religious or l t f ilit t li i spiritual/cultural rituals. Bereavement services for at least 12 months after death.

Ethical and Legal aspects

Creating or updating wills, advance care directives. Guardianship agreements. Assist Surrogate decision makers.

Honoring patients preferences, substituted judgment and best-interest criteria.

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.

Watch our language- it drives our audience away

If our goal is to provide a patient-centered approach to improving care of seriously illthe major barrier we face is self-imposed. Many people who need palliative care are not dying. Even among the subset that are, no-one wants to die, and very few are able to accept that they are dying until death is imminent. Solution- decouple palliative care from end of life carecall it non hospice palliative 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.

Specifically: Palliative Care Is

Palliative Care in Practice

Palliative Care Is NOT Not giving up on a patient, withdrawing life support Not in place of curative or lifeprolonging care Not the same as hospice Not Comfort care

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 Nature of Suffering and the Goals of Medicine

The relief of suffering and the cure of disease must be seen as twin obligations of a medical profession that is truly dedicated to the care of the sick. Physicians f il Ph i i failure to understand the nature of t d t d th t f suffering can result in medical intervention that (though technically adequate) not only fails to relieve suffering but becomes a source of suffering itself.
Cassell, Eric NEJM 1982;306:639-45.

The demographic imperative:

Chronically ill, aging population is growing

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)

More and more physicians are providing palliative care

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)

Other Web Sites

www.palliativedrugs.com www.growthhouse.org www.stoppain.org AGS GUIDELINE Management of Persistent Pain in GUIDELINE: M t fP i t tP i i Older Persons

http://www3.interscience.wiley.com/cgibin/fulltext/122486445/PDFSTART https://cissecure.nci.nih.gov/ncipubs/detail.aspx?prodid=Q014

EPEC-O

Learn by doing!

Presentation adapted from:

www.capc.org Meier, DE. Clinical Essentials of Palliative Care, 2004 www.capc.org Care 2004. www capc org Meier, DE. Palliative Care: Making the Case, 2005. www.capc.org Meier, DE, Palliative Care Comes of Age, June 21, 2007. www.capc.org