Practical Issues in Palliative and Quality-of-Life Care John E. Hennessy, MBA, CPME Beth Lown, M.D. Karin Porter-Williamson, M.D.

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Practical Issues in Palliative and
Quality-of-Life CareJohn E. Hennessy, MBA,
CPME Beth Lown, M.D. Karin Porter-Williamson,
M.D.
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Session goals

• Understand the imperative to execute on
  palliative care
• Understand barriers to execution in clinical
  settings
• Gain understanding of tools and tactics which can
  lead to successful execution

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What is palliative care?

• Hospice care?
• End of life care?
• Symptom management?
• Quality of Life care?
• .
• It is the STANDARD OF CARE
• ASCO provisional clinical opinion on palliative
  care concurrent with treatment in metastatic
  NSCLC

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Who delivers palliative care?

• Doctor?
• Midlevel practitioner?
• Infusion nurse?
• Collaborative nurse?
• Medical assistant radiation technologist
  phlebotomist
• Social workerpsychiatrist
• Pharmacist
• Dietician fitness instructor
• Receptionist

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Everybody

• Who touches the patient
• Who sees the patient
• Who talks to the patient

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So what you mean is

• Palliative care is not an office visit
• Palliative care is not a CPT code
• Palliative care is not withheld until we have
  tried everything else
• Palliative care is a way of taking care of our
  patients
• Palliative care is everyday

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If it isnt what we do every day

• It isnt desirable
• Nobody wants it
• Nobody asks for it
• Nobody mentions it
• So there must be no unmet needright?

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If I may be so boldwrong

• But chances are you have both camps in your
  officeand a bit in between
• Challenges
• How do we do it?
• Who does it?
• Is it economically sound?

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Imperative to move palliative care upstream

• 50 of all deaths annually in the United States
  happen in the hospital
• 75-90 of these after a decision to withhold or
  remove some form of artificial life support
• In repeated studies, people report that at end of
  life they would prefer
• To not be in hospital
• To not be in pain or discomfort
• To not be a burden on loved ones
• To not be sustained artificially

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Imperative to move palliative care upstream

• For success, patients and families must
• Understand their condition and treatment options
• Have time to ask questions and plan relative to
  their own values
• Have time for hard information to sink in with
  out feeling abandoned by providers
• Very hard for primary Oncology and Palliative
  Care providers to pull this off in the midst of
  crisis in the hospital setting

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Graph of Palliative Care interventions upstream
Bereavement
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Graph of Palliative Care interventions upstream
Equipment Teaching Medication Nursing
support Bath aide Volunteer Prognosis Support
Advanced Directives
Hospice Education
Code Status
Family Meeting
Symptoms pain, constipation
Spiritual Support
Goals of care
G
E
A
H
D
C
F
B
Prognostication
Bereavement
Bowel obstruction mgmt
Discharge planning
Spiritual Needs
Psychosocial support
Psychosocial Needs Legacy Building Financial
Nausea mgmt
Referrals
Referrals
Symptom mgmt Vomiting, ascites, pain, delirium
Psychosocial Needs
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Graph of Palliative Care interventions upstream
Equipment Teaching Medication Nursing
support Bath aide Volunteer Prognosis Support
G
H
F
Bereavement
Discharge planning
Psychosocial support
Referrals
Symptom mgmt Vomiting, ascites, pain, delirium
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One of many challenges

• Are there proven methods to open lines of
  communication across disciplines and teams
• To foster working relationships
• To co-create a culture that promotes
  compassionate, high quality, patient-centered
  care?

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The Schwartz Center for Compassionate Healthcare

• Dedicated to strengthening the relationships
  between patients and professional caregivers

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Schwartz Center programs

• Schwartz Center Rounds
• Schwartz Center Connections
• Safe discussion forum for high impact issues
• Build communication and relationships across
  disciplines
• Reduce lapses in communication and care that
  result in poor outcomes and suffering

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Schwartz Center Connections Key components

• Multidisciplinary cross-site teams meet
• Facilitated, case-based interactive sessions
• Connections toolbox
• Case summaries and patient/family narratives
• Facilitation guides
• Facilitator coaching
• Measures
• Communication lapse prevention scale
• Patient communication ability scale
• Quality improvements

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Example Case discussion

• The case of Jesse Smith
• Bob Smiths story
• Jesses story
• Discussion
• Key learning points
• Names and aspects of this case are
  fictionalized.

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Communication lapse prevention scale
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Average change across Communication Lapse
Prevention Scale items
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Participants changed their behavior
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Barriers to Optimal Execution Summary

• Timing of intervention late in the story and in
  the midst of crisis BAD
• Perceptual Framing of Palliative Care call the
  stop team after there are no further treatment
  options that the go team can try.
• Self fulfilling prophecy that Palliative Medicine
  hospice, inaccurate perceptions that Palliative
  care/hospice are only for the very, very end of
  life.
• Lack of shared agreement on the part of providers
  about the treatment plan.

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Barriers to Optimal Execution Summary continued

• Lack of empowerment of each member of the
  interdisciplinary team to speak and be heard
• Lack of respect for complexity of relationships
  impacting plan of care
• Between a young physician a sentinel pt in his
  career
• Between the nurses a favorite patient
• Between the father the son
• Between the father the younger physician
• Between physician partners

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Tools and Tactics to Promote Great Execution

• Teaching/Training for successful interpersonal
  and intra-professional communication
• Schwartz Center Connections excellent example to
  empower the team to communicate openly in a
  structured format
• Empowerment and education of all team members
• ELNEC training
• Palliative Care needs Identification Tool
• Shared understanding between Onc Pall Care
  about treatment planning use of the Palliative
  Care partners
• Standardized triggers for Palliative Care
  involvement

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Tools and Tactics to Promote Great Execution

• Savvy Integration of Palliative Care into the
  Interdisciplinary Oncology team
• Identify as partners all the way along
• Linked visits when Pall care is new
• Physical space planning- Pall Care physically
  embedded with Primary provider for new patients
• Close communication with primary, that pt/family
  are aware of, shows teamwork
• Integration earlier in course at defined times
• Active treatment ongoing MUST be okay
• Integration for symptom management and education
  LOWER stress than when PC introduced at time of
  crisis

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Whats the Bottom Line?

• Need to do it to provide the highest quality care
  for our patients
• Highly likely to impact the bottom line
  downstream
• Avoidance of terminal hospitalization, terminal
  ICU stay and those high associated costs
• Increase Hospice length of stay
• ? Impact offering of late line chemo when not
  thought to be beneficial
• Have Palliative Care to offer instead, to fill
  the need to offer something
• Improve patient, family satisfaction though
  dealing with advanced illness

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