Palliative Care as a Core Component of Geriatric Medicine

1
Palliative Care as a Core Component of Geriatric
Medicine

• American Geriatrics Society
• May 17, 2004
• Las Vegas
• Diane E. Meier, MD
• Professor, Departments of Geriatrics and Medicine
• Mount Sinai School of Medicine
• Director, Center to Advance Palliative Care
• in Hospitals and Health Systems
• a Robert Wood Johnson Foundation - Mount Sinai
  School of Medicine initiative
• 051704

2
Palliative Care

• Interdisciplinary care that aims to relieve
  suffering and improve quality of life for
  patients with advanced illness and their
  families.
• It is offered simultaneously with all other
  appropriate medical treatment.

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The Cure - Care Model The Old System
D E A T H
Life Prolonging Care
Palliative/ Hospice Care
Disease Progression
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Palliative Cares Place in the Course of Illness
Life Prolonging Therapy
Death
Diagnosis of serious illness
Palliative Care
Medicare Hospice Benefit
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Palliative Care
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Palliative Care and Geriatrics

• Median age of death in U.S. 78 and rising
• Chronic degenerative disease accounts for 77 of
  causes of death
• Evidence of preventable suffering across settings
  and diagnoses in elderly
• Evidence of improved clinical, functional,
  satisfaction, and utilization outcomes with
  expert symptom management/palliative care

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Palliative Care and Geriatric MedicineThe 5
Main Arguments

1. Clinical care quality
2. Patient and family preferences
3. Demographics
4. Education
5. Finances

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Why palliative care?

• 1. Clinical imperative
• The need for a better quality of care for persons
  with serious and complex illnesses

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Site of Death

• Hospitals 53
• Nursing homes 24
• Home 23
• (Teno et al, Brown Site of Death Atlas of the
  U.S www.chcr.brown.edu/dying/usa_statistic
  s.htm 1997 and
• National Mortality Followback Survey)

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Everybody with serious illness spends at least
some time in a hospital...

• 98 of Medicare decedents spent at least some
  time in a hospital in the year before death.
• 15-55 of decedents had at least one stay in an
  ICU in the 6 months before death.
• Dartmouth Atlas of Health Care 1999

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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 failure to
  understand the nature of 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 1982306639-45.

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• Serious illness and Hospitals
• What do we know about it?

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National Data on the Experience of Dying in 5
Tertiary Care Teaching Hospitals

• The SUPPORT Study
• Controlled trial to improve care of seriously ill
  patients
• Multi-center study funded by RWJ
• 9000 patients with life threatening illness, 50
  died within 6 months of entry
• JAMA 19952741591-98

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SUPPORT Phase I Results

• 46 of DNR orders were written within 2 days of
  death.
• Of patients preferring DNR, lt50 of their MDs
  were aware of their wishes.
• 38 of those who died spent gt10 days in ICU.
• Half of patients had moderate-severe pain gt50 of
  last 3 days of life.

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Pain Data from SUPPORT

• of 5176 patients reporting moderate to severe
  pain between days 8-12 of hospitalization
• colon cancer 60
• liver failure 60
• lung cancer 57
• MOSF cancer 53
• MOSF sepsis 52
• COPD 44
• CHF 43
• Desbiens Wu. JAGS 200048S183-186.

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Analgesic Prescribing For 4003 Nursing Home
Patients with Cancer and Daily Pain
Bernabei et al. JAMA 1998
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Pain, Opioids, and Delirium

• After controlling for age, education, and
  analgesic intake, only pain intensity was
  predictive of the development of post-operative
  delirium in 60 adults (age 50 - 80) undergoing
  hip surgery. (Duggleby Lander, J Pain Symptom
  Manag 1994)
• After controlling for know preoperative risk
  factors for delirium higher pain scores at rest
  were associated with an increased risk of
  delirium over the first 3 post-operative days in
  361 elderly surgical patients. (Lynch et al,
  Anesth Analg 1998)
• Type of opioid, cumulative opioid dose were not
  associated with an increase risk of delirium.

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Pain, Opioids, and Delirium

• After controlling for known risk factors for
  delirium, total opioid dose, and pattern of
  opioid use, higher pain scores at rest were
  associated with an increased risk of
  post-operative delirium in 241 cognitively intact
  hip fracture subjects.
• Opioid intake was not associated with an
  increased risk of delirium in 286 hip fracture
  subjects with dementia.

Morrison et al, 2002
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Sources of Suffering in End-Stage Dementia -
Pneumonia

• 39 cognitively intact subjects asked to rate
  symptoms associated with pneumonia
• Over 50 experienced at least one episode of
  severe dyspnea
• 50 experienced moderate to severe anxiety
• 40 experienced moderate to severe pain from
  coughing
• 20 experienced severe nausea

Morrison Siu, 2000
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Prevalence of Painful and Uncomfortable Procedures
Morrison Siu, JAMA, 2000
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Why palliative care?

• 2. Concordance with patient and family wishes
• What is the impact of serious illness on
  patients families? And what do persons with
  serious illness say they want from our healthcare
  system?

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Family CaregiversThe Numbers

• 1996 United States estimates 25 million
  caregivers deliver care at home to a seriously
  ill relative
• Mean hours caregiving per week 18
• Cost equivalent of uncompensated care 194
  billion (_at_ 8/hr)
• Levine C. Loneliness of the long-term caregiver
  N Engl J Med 19993401587-90.
• Unpaid caregivers provide gt70 of all long term
  care
• Liu et al. Home care expenses for the disabled
  elderly. H Care Fin Rev 1985751-7
• 56 of elderly have incomes under 20,000 and
  spend gt25 of it on healthcare for themselves and
  family members
• Report to Congress Medicare Payment Policy
  MedpacMarch 2003 www.medpac.gov

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Family Caregivers and the SUPPORT study

• Patient needed large amount of family caregiving
  34
• Lost most family savings 31
• Lost major source of income 29
• Major life change in family 20
• Other family illness from stress 12
• At least one of the above 55

JAMA 19952721839
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Caregiver Characteristics

• 900 family caregivers of terminally ill persons
  at 6 sites across the U.S.
• Women 72
• Close family member 96
• Over age 65 33
• In poor health 33
• Emanuel et al. N Engl J Med 1999341956.

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Caregiving Needs among Terminally Ill Persons

• Interviews with 900 caregivers of terminally ill
  persons at 6 U.S. sites
• need more help 87 of families
• transportation 62
• homemaking 55
• nursing 28
• personal care 26
• Emanuel et al. Ann Intern Med2000132451

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Caregiving Increases Mortality

• Nurses Health Study prospective study of 54,412
  nurses
• Increased risk of MI or cardiac death RR 1.8 if
  caregiving gt9 hrs/wk for ill spouse Lee et
  al. Am J Prev Med 200324113
• Population based cohort study 400 in-home
  caregivers 400 controls
• Increased risk of death RR 1.6 among caregivers
  reporting emotional strain
  Schulz et al. JAMA 19992822215.

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What Do Patients with Serious Illnesses Want?

• Pain and symptom control
• Avoid inappropriate prolongation of the dying
  process
• Achieve a sense of control
• Relieve burdens on family
• Strengthen relationships with loved ones

Singer et al. JAMA 1999281(2)163-168.
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What Do Family Caregivers Want?

• Study of 475 family members 1-2 years after
  bereavement
• Loved ones wishes honored
• Inclusion in decision processes
• Support/assistance at home
• Practical help (transportation, medicines,
  equipment)
• Personal care needs (bathing, feeding, toileting)
• Honest information
• 24/7 access
• To be listened to
• Privacy
• To be remembered and contacted after the death
• Tolle et al. Oregon report card.1999
  www.ohsu.edu/ethics

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Why palliative care?

• 3. The demographic imperative
• Hospitals need palliative care to effectively
  treat the growing number of older adults with
  serious, advanced and complex chronic illnesses.

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The Demographic ImperativeChronically Ill,
Aging Population Is Growing

• The number of people over age 85 will double to
  10 million by the year 2030.
• The 63 of Medicare patients with 2 or more
  chronic conditions account for 95 of Medicare
  spending.
• US Census Bureau, CDC, 2002.

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The Demographic Imperative Is this Patient
Terminally Ill?

• 94 y/o with moderate dementia, breast cancer,
  congestive heart failure, and recurrent
  infections. She is treated with spoon feeding,
  bisphosphonates, antipsychotic medications, an
  ACE inhibitor, a beta blocker, and judicious use
  of diuretics and antibiotics.
• Is this patient atypical?
• (slide courtesy of Joan Teno MD, Brown
  University)

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The Reality of the Last Years of Life Death Is
Not Predictable(slide courtesy of Joanne Lynn,
MD Rand Corp.)Covinsky et al. JAGS 2003 Lynn
Adamson RAND 2003.Morrison Meier N Engl J
Med 2002.
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Leading Causes of Death 77 Are Not Due to
Cancer

• Heart disease 33
• Malignant neoplasm 23
• Cerebrovascular disease 7
• COPD 5
• Accidents 4
• Pneumonia 4
• Account for 75 of all deaths
• Natl. Ctr. Health Statistics,
  CDC, 1998

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Better Care Needed From the Day of Diagnosis of
Any Serious Illness

• People need better care throughout the multi-year
  course of advanced illness.
• Medicare Hospice Benefit developed to care for
  the dying payment regulations require 6 month
  prognosis and decision to forego insurance
  coverage for life prolonging care.
• Additional approaches are needed for much larger
  numbers of persons with chronic, progressive
  illness, years to live, continued benefit from
  disease modifying therapy, and obvious palliative
  care needs.

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Why palliative care?

• 4. The educational imperative
• Every doctor and nurse-in-training learns in
  the hospital.

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The Educational Imperative

• Teaching hospitals are the site of training for
  most clinicians.
• Acknowledged deficits in skills/knowledge and
  attitudinal barriers abound.
• Medical school and residency curricula offer
  little to no teaching in chronic care,
  geriatrics, and palliative care.
• Meier, Morrison Cassel. Ann Intern Med
  1997127225-30.

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Deficiencies in Medical Education

• 74 of residencies in U.S. offer no training in
  end of life care.
• 83 of residencies offer no hospice rotation.
• 41 of medical students never witnessed an
  attending talking with a dying person or his
  family, and 35 never discussed the care of a
  dying patient with a teaching attending.
  Billings Block JAMA 1997278733.

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Physician Training in Pain Management

• Oncologists self-report
• 86 of their patients undermedicated
• 50 rated pain management in their own practice
  as fair to very poor
• 73 evaluated their own training in pain
  management as fair to very poor

Von Roenn et al. Ann Intern Med 1993Jul
15119(2)121-6.
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Pain Data from SUPPORT

• of 5176 patients reporting moderate to severe
  pain between days 8-12 of hospitalization
• colon cancer 60
• liver failure 60
• lung cancer 57
• MOSF cancer 53
• MOSF sepsis 52
• COPD 44
• CHF 43
• Desbiens Wu. JAGS 200048S183-186.

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The Good News Palliative Care Education Is
Improving

• Medical school LCME requirement
• Clinical instruction must include important
  aspects of end of life care. 2000
• Residency ACGME requirements for internal
  medicine and internal medicine subspecialties
  
• Each resident should receive instruction in the
  principles of palliative careit is desirable
  that residents participate in hospice and home
  careThe program must evaluate residents
  technical proficiency,communication, humanistic
  qualities, and professional attitudes and
  behavior 2000

42
Palliative Care Education in Medical Schools Is
Improving

• Annual medical school exit questionnaire
  2002-2003
• 126 LCME accredited medical schools
• 110 (87) require instructional hours in
  palliative care
• Average of hours required 12, but highly
  variable Barzansky B, Etzel SI. JAMA
  2003 2901190-6

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Why palliative care?

• 5. The fiscal imperative
• Population aging growth in numbers of patients
  in need effective new technologies antiquated
  payment system financial crisis for healthcare

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National Health Expenditure Growth 1970-2003
HCFA, Office of the Actuary, National Health
Statistics Group, 2003
45
Wall Street Journal page 1Sept. 18, 2003
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Why Palliative Care? The Fiscal Imperative

• Exponentially rising costs with effective new
  technologies, aging population
• 9.2 growth in hospital payments in 2001-2003
• 76 of 2002 Medicare budget spent on hospital
  care (198 billion)
• Under DRG system long, high-intensity hospital
  stays fiscal crisis for hospitals
• Hospital and insurer of the future will have to
  efficiently and effectively treat serious and
  complex chronic illness in order to survive

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Medical Spending in the US 1.5 trillion in
2003

• Medicare Payment Policy Report to Congress.
  Medpac 2003 www.medpac.gov

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Palliative Care aims to improve care in
3 domains

• Relieve physical and emotional suffering
• Improve patient-physician communication and
  decision-making
• Coordinate continuity of care across settings
• and in so doing
• Train future health professionals
• Meet the needs of the elderly and others with
  complex, chronic, and advanced illness and
• Coordinate and rationalize care- providing
  the right care for the right patient at the right
  time in the right place

50
Case Study What Actually Happened

• 87-year-old woman with hypertension, diabetes,
  renal failure osteoporosis, vision loss.
• Cycle of health crises- falls, fractures,
  pneumonia
• Hospitalized three times in 9 months
• Home with Medicare-Certified Home Health Agency,
  discharged from homecare after 4 weeks- new
  crisis hip fracture and repeat hospitalization
  
• In pain, symptoms not managed- long hospital
  stay, resulting in progressive deconditioning,
  weakness, functional decline
• Not ready for hospice but in need of more support
  in hospital and ongoing transition management and
  care coordination at home

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Case Study What Should Have Happened

• Palliative care consultation for
• Pain and symptom relief - facilitates success of
  rehabilitation, reduces hospital length of stay
• Patient/family discussions re needs/goals,
  advance care planning
• Home needs assessment
• Identification of ongoing support services at
  home
• Plan for coordination and monitoring after home
  care skilled need terminates
• Support for gradual transition to hospice if and
  when illnesses progress to terminal stage

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Role of a Palliative Care Consultation Team

• Client referring physician
• Advice and support to primary MD and team on
  symptoms, decision support and goal setting
• Support to families
• Education
• Liaison, coordination between hospital and
  hospice/home care services or other institutions
• Auditing and research
• Dunlop and Hockley 1998

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Benefits of Palliative Care The Evidence Base

• Reduction in symptom burden
• Improved patient and family satisfaction
• Reduced costs

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Palliative Care Improves Quality

• Data demonstrate that palliative care
• Relieves pain and distressing symptoms
• Supports on-going re-evaluations of goals of care
  and difficult decision-making
• Improves quality of life, satisfaction for
  patients and their families
• Eases burden on providers and caregivers
• Helps patients complete life prolonging
  treatments
• Improves transition management

Campbell et al, Heart Lung, 1991 Campbell et al,
Crit Care Med, 1997 UC Davis Health System News
2002 Carr et al, Vitas Healthcare, 1995
Franklin Health, 2001 Dartmouth Atlas, 2000
Micklethwaite, 2002 Du Pen et al, J Clin Oncol,
1999 Finn et al, ASCO, 2002 Francke, Pat Educ
Couns, 2000 Advisory Board, 2001 Portenoy,
Seminars in Oncol, 1995 Ireland Cancer Center,
2002 Von Roenn et al, Ann Intern Med, 1993 Finn
J et al ASCO abstract. 2002 Manfredi et al JPSM
2001 Schneiderman et al. JAMA 2003 Higginson et
al JPSM 2002 2003 Smith et al. JCO 2002, JPM
2003 Coyne et al. JPSM 2002 www.capc.org.
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Palliative Care A Case Example
MJ was an 85 year old women with multiple
medical problems including moderate dementia,
coronary artery disease, renal insufficiency, and
peripheral vascular disease who was admitted to
Mount Sinai with urosepsis. Her hospital course
was complicated by the development of gangrene of
her left foot resulting from her vascular
disease, candidal sepsis, multiple pressure
ulcers, and recurrent infections. She underwent 5
debridements under general anesthesia. When
asked by the primary doctor, her family
consistently said that they wanted everything
done. On day 63 of her hospitalization, a
palliative care consult was initiated to help
clarify the goals of care and to treat the
patients evident pain and discomfort. She was
persistently moaning in pain and resisting all
efforts to reposition or transfer her or to
change her dressings. The palliative care team
met with her son (her health care proxy) and her
two grandchildren. During a 90 minute
discussion, the team explored with the family
what they hoped to accomplish for the patient.
The team reviewed the hospital course and
clarified any confusion about her diagnosis and
prognosis. Possible sources of discomfort and
pain were identified. A treatment plan was
initiated which included morphine sulfate to
treat the pain associated with her necrotic foot,
discontinuing her antibiotics, withholding
hemodialysis for her acute renal failure,
treating her fevers with acetaminophen, and
transferring her to the palliative care unit.
The patient was discharged 2 days later when a
bed in a nursing home with a hospice contract
became available. The family expressed
tremendous satisfaction with the resolution of
her hospitalization and continued to visit her
daily in the nursing home where she was reported
to be interactive and comfortable until her death
2 months later.
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Palliative Care Is Cost-Saving, supports
transitions to more appropriate care settings

• Palliative care lowers costs (for hospitals and
  payers) by reducing hospital and ICU length of
  stay, and direct (such as pharmacy) costs.
• Palliative care improves continuity between
  settings and increases hospice/homecare/nursing
  home referral by supporting appropriate
  transition management.

Lilly et al, Am J Med, 2000 Dowdy et al, Crit
Care Med, 1998 Carlson et al, JAMA, 1988
Campbell et al, Heart Lung, 1991 Campbell et al,
Crit Care Med, 1997 Bruera et al, J Pall Med,
2000 Finn et al, ASCO, 2002 Goldstein et al,
Sup Care Cancer, 1996 Advisory Board 2002
Project Safe Conduct 2002, Smeenk et al Pat Educ
Couns 2000 Von Gunten JAMA 2002 Schneiderman et
al JAMA 2003 Campbell and Guzman, Chest 2003
Smith et al. JPM 2003 Smith, Hillner JCO 2002
www.capc.org.
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How Palliative Care Reduces Length of Stay and
Cost

• Palliative care
• Clarifies goals of care with patients and
  families
• Helps families to select medical treatments and
  care settings that meet their goals
• Assists with decisions to leave the hospital, or
  to withhold or withdraw death-prolonging
  treatments that dont help to meet their goals

58
Case Studies on the Clinical and Financial Impact
of Palliative Care

1. Mount Sinai Hospital, New York City
2. Kaiser Permanente, California
3. Ireland Cancer Center and Hospice of the Western
   Reserve, Cleveland
4. Virginia Commonwealth University, Richmond
5. University of Michigan and Hospice of Michigan,
   Ann Arbor

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Case 1. Mount Sinai Hospital, NYC Improvement
in Symptoms1997-2002 2219 palliative care
consult service patients
Severe
Pain
Nausea
Moderate
Dyspnea
Mild
None
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Mount Sinai Hospital Satisfaction DataPercent of
Palliative Care Families Satisfied or Very
Satisfied Following their Loved Ones Death with

• Control of pain - 95
• Control of non-pain symptoms - 92
• Support of patients quality of life - 89
• Support for family stress/anxiety - 84
• Manner in which you were told of patients
  terminal illness - 88
• Overall care provided by palliative care program-
  95

Source Post-Discharge/Death Family Satisfaction
Interviews, Mount Sinai Hospital, New York City
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Mount Sinai Hospital, 2002 Financial Analyses
in Patients who Died with and without Palliative
Care

• Medicare data Palliative Care Patients Spent 357
  Fewer Days in Mount Sinai As Compared to
  DRG-Matched Patients Not Followed by Palliative
  Care
• Cost savings from palliative care 866,806 per
  year for patients with LOS gt 21 days
• The longer the LOS, the greater the savings
• Cost per day Total cost per DRG / average LOS
  per DRG
• Cost reduction cost per day x days saved

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Mount Sinai Hospital, 2002 Length of Stay
Analyses in Medicare Patients Who Died with and
without Palliative Care

• 357 fewer days, gt866,000 total costs saved
• Additional savings from reduced LOS in patients
  discharged alive income from new admissions
  allowed by increase in bed capacity reduced
  pharmacy and ancillary costs/day
• Result hospital salary support for a doctor and
  2 nurses for the palliative care service
  
• Meier, D. Planning a hospital-based palliative
  care program A primer for institutional
  leaders. www.capc.org

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Case 2. Kaiser Permanente, CaliforniaGarfield
Memorial Fund

• Comparison trial palliative vs. usual care
• Two year study, 1999-2001
• Multivariate analysis in subgroup of deceased
  patients (n300)

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Kaiser Palliative Care Improves Satisfaction
P .01
P .6
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Kaiser Palliative Care Service Reduces Costs

• Average 6,580 (45) reduction in costs for PC
  patients
• Locus of care shifted from inpatient to home,
  result is lower costs

plt.001 F35.93
66
Case 4. Virginia Commonwealth University

• Specialist run high-volume in-patient palliative
  care unit
• Comparing 2 week periods before and after
  referral, costs and charges reduced by 66
  overall
• Compared to non-palliative care control group,
  direct and total costs reduced 57
• Smith TJ, et al. A high volume specialist
  palliative care unit and team may reduce
  in-hospital end of life care cost. J Palliat Med.
  Oct 20036(5)699-705.

67
VCU Palliative Care Reduces Cost of Treatment
for hospital cases ending in death
68
March 10, 2004
53 of Americans die in hospital Half spend time
in ICU Half have mod to severe pain
69
What Does All this Mean from the Patient
Perspective?

• For patients, palliative care is a key to
• relieve symptom distress
• navigate a complex and confusing medical system
• understand the plan of care
• help coordinate and control care options
• allow simultaneous palliation of suffering along
  with continued disease modifying and
  rehabilitative treatments (no requirement to give
  up curative care)
• provide practical and emotional support for
  exhausted family caregivers

70
The Clinician Perspective

• For clinicians, palliative care is a key tool to
• Save time by helping to handle repeated,
  intensive patient-family communications,
  coordination of care across settings,
  comprehensive discharge planning
• Bedside management of pain and distress of highly
  symptomatic and complex cases, 24/7, thus
  supporting the treatment plan of the primary
  physician
• Promote patient and family satisfaction with the
  clinicians quality of care

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The Hospital Perspective

• For hospitals, palliative care is a key tool to
• effectively treat the growing number of people
  with complex advanced illness
• provide service excellence, patient-centered care
• increase patient and family satisfaction
• improve staff satisfaction and retention
• meet JCAHO quality standards
• rationalize the use of hospital resources
• increase capacity, reduce costs

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Summary Making the Case

• Universal human experience and universal health
  professional obligation.
• Palliative care improves quality of care for our
  sickest and most vulnerable patients and
  families.
• Palliative care is an integral part of geriatric
  medicine, contributes to goals of both functional
  recovery and best possible quality of life

73
How Do You Use this Information to Integrate
Palliative and Geriatric Medicine?

• The next 2 presentations will help you
• Tailor the case made here to your practice
  setting
• Create compelling business marketing plans
• Design and launch a program
• Measure your success

74
Although the world is full of suffering, it
is also full of the overcoming of it.

• Helen Keller
• Optimism 1903

75
Appendix
76
More and more physicians are providing
palliative care

• Number of hospital-based palliative care programs
  has doubled in recent years to more than 950
• 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
77
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

78
Palliative Care Operational Resources

• Go to www.capc.org
• Palliative Care Leadership Centers six premier
  palliative care programs hosting site visits and
  providing ongoing mentoring
• Web site Comprehensive tools for starting and
  sustaining palliative care services billing for
  palliative care services, clinical models,
  criteria for referral, clinical forms and
  procedures, technical assistance publications and
  presentations
• CAPC seminars on building palliative care programs

79
CAPC Products

• Management and Training Seminars- next in Miami,
  March 2005
• www.capc.org
• Palliative Care Leadership Centers
• Publications
• A Guide to Establishing a Hospital-Based
  Palliative Care Program
• Hospice-Hospital Partnerships
• The Case for Hospital Based Palliative Care

80
Palliative Care Leadership Centers

• Six exemplary programs for 2.5 d. site visits,
  hands-on learning, 1 yr. distance mentoring.
  Only available til Spring 2006 and filling up
  fast! Consistent curriculum, different hospital
  settings, and locations.
• The site visit program made all the difference.
  Because of what our staff learned, our palliative
  care program has more patients, a larger budget,
  and much more legitimacy throughout the hospital.
  It really helped to have a leader in the field
  behind our efforts.
• Erin Rhatigan, RN, HPNC/ Community Hospital of
  the Monterey Peninsula

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Palliative Care Leadership Centers

• Fairview Health System- Minneapolis
• Mt. Carmel Health System- Columbus, OH
• Medical College Wisconsin- Milwaukee
• Palliative Care Center of the Bluegrass-
  Lexington, KY
• UCSF- San Francisco
• Virginia Commonwealth University- Richmond

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CAPC Resources Palliative Care Program Nuts and
Bolts

• Leadership
• Strengths and weaknesses of clinical models
• How to choose
• Resources www.capc.org

83
Leadership

• Physician
• Nurse
• Social Work, Care Management
• Chaplain
• Pharmacist
• Critical care
• Hospitalist
• Ethics
• Oncology
• Geriatrics
• Nursing Department

• Rank and authority in institution
• Opinion leadership
• Respect of others
• Competence

84
Outline

• Leadership of models
• Strengths and weaknesses of clinical models
• How to choose

85
STRENGTH WEAKNESS
Inpatient Consultation Flexible, broad educational impact Influence on outcomes may be minimal
Inpatient Unit Control over clinical care, outcomes, and utilization Isolation from hospital culture, less educational impact


86
Outline

• Leadership of models
• Strengths and weaknesses
• How to choose

87
How to choose (where to start)

• What is needed?
• What is possible?
• Who wants to do this?
• Who has the skills to do it?
• Who can make the commitment to do this?
• Who is most likely to be able to make the case
  and gain support?
• What is easy?
• Where and with whom does support lie?

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Bed Availability
Beds are not available All beds occupied Patients
cant get in
Beds are available Closed units
Consult Service easier
Inpatient Unit Possible
89
Hospital Size
Small Hospital
Large Hospital
Consult Service easier
Inpatient Unit Possible
90
Physicians
Private Practice
Staff Model-HMO, capitated care
Consultation Etiquette Open inpatient unit
Primary CareClosed inpatient unit
91
Local Culture
Private Practice Traditional
Collaborative Patterns
Physician-led
Nurse-Led
92
Hospice
Present
Absent
Collaborate
Home visits
93
Health Care Funding
Fee-for-Service
Global Budget
Justify Services Based on Revenues, Cost avoidance
Justify Services Based on Utilization, Cost
avoidance
94
How models chosen

• Administrator interest
• Clinician interest
• Loci of support
• Community pressure
• Serendipity (loss)
• Opportunity

95
Summary Assessing Needs and Choosing a Model

• Many variables influence program development
• Several leadership models
• Several models
• Strengths and weaknesses
• Select the structure that is best for you
• No one right way

96
Where can you learn more palliative medicine
content?
97
Domains of Palliative Care

• Communication, help with medical decision-making
• Expert symptom assessment and treatment
• Psychosocial and practical support, care
  coordination, and bereavement services

98
Communication

• Essential to practice of palliative medicine
  decreases anxiety, improves well-being,
  satisfaction with providers and health care, and
  outcomes
• Good communication honesty, willingness to talk
  about dying, sensitive delivery of bad news,
  listening, and encouraging questions.
• MD role Articulating choices, likely benefits
  and burdens, and helping patient/family to make
  medically appropriate decisions in keeping with
  their goals.

99
How to Communicate

• Establish realistic, attainable goals of care
• Help patients and families understand scope of
  illness and likely progression
• Identify relevant values and goals
• Define acceptable and unacceptable quality of
  life
• Define choices to be made and their benefits and
  burdens
• Help with decision-making
• Develop care plans that maximize chances that
  goals will be achieved

100
Communication Protocol
Establishing Goals of Medical Care
Communicating Bad News
Withholding/Withdrawing Treatment
 
Get started and create the right setting Plan
what to say, create a conducive setting, allow
adequate time, and determine who else should be
present
Establish what the patient knows Clarify the
situation and context in which the discussion
about goals is occurring
Establish what the patient knows What is known,
access ability to comprehend, reschedule if
unprepared  
Establish and review the goals of care
Explore both what patients are expecting and
hoping to accomplish Help identify realistic and
non realistic goals
Establish how much the patient wants to know?
Recognize and support different preferences.
People handle information differently
Establish the context of the current discussion
What has changed to precipitate the discussion?
Suggest realistic goals Explore how goals can be
achieved and work through unreasonable/
nonrealistic expectations
Share the Information Say it then stop (avoid
jargon, pause frequently, check for
understanding, use silence), dont minimize the
information
Discuss specific treatment(s) in context of goals
of care Will continuation or initiation of the
treatment meet the goals of care?
101
Protocol, continued
Discuss alternatives to the proposed treatment
and what will happen if the patient decides not
to have the treatment
Respond empathetically to feelings Be prepared
for strong emotions and allow time for response,
listen, encourage description of feelings. Allow
silence
Make a plan and follow through What treatments
will be undertaken to meet goals. What
treatments will not be utilized. Establish a
concrete plan for follow-up Review and revise
periodically as needed
Planning/Follow up Plan for next steps, discuss
potential sources of support, give contact
information, assess patient safety and supports,
repeat news at future visits
Document, disseminate (i.e., to family, other
healthcare team members), and implement plan for
withdrawal of treatment
102
Symptom Assessment and Treatment

• 3 items necessary for good pain and symptom
  management
• Routine and repeated assessment
• Skill in prescribing
• Treatment of side effects

103
Symptom Assessment and Treatment

• Pain management
• Pain meds administered on standing or regular
  basis
• PRN or rescue doses available for breakthrough
  pain or pain not controlled by regimen
• All patients on opioids should be started on a
  bowel regimen
• WHO analgesic ladder should be used as a guide
  for most pain syndromes

104
WHO Analgesic Ladder

• Mild Pain (1-3/10 on a 10 point scale) Begin
  acetaminophen or a non-steroidal antiinflammatory
  agent (consider opioids instead in older adults)
• Moderate Pain (4-7/10) Begin an opioid
  combination product (acetaminophen codeine,
  acetaminophen oxycodone, acetaminophen
  hydrocodone) and dose based upon opioid half life
  (3-4 hours) not acetaminophen half life (6-8
  hours).
• Severe Pain (8-10/10) Begin a strong standing
  opioid (hydromorphone, morphine sulfate,
  oxycodone) and titrate until pain relief is
  obtained or intolerable side effects develop.
  Long acting opioids (sustained release
  morphine/oxycodone, transdermal fentanyl) should
  be started after pain is well controlled and
  steady state is achieved.

105
Symptom Assessment and Treatment Pain

• Rescue doses employing immediate release opioids,
  dose should be 10 of the 24 hour total opioid
  dose and given every hour (oral) and every 15 -
  30 minutes (parenteral) as needed. Methadone
  should only be used by clinicians experienced in
  its use.
• Adjuvant agents (corticosteroids,
  anticonvulsants, tricyclic antidepressants,
  bisphosphonates) should be employed for specific
  pain syndromes when applicable (e.g., neuropathic
  pain).

106
50 of pain management side effect management

• Constipation
• Nausea
• Confusion, sedation

107
Constipation

• Does not resolve!
• Morbidity obstruction, nausea, delirium,
  perforation, death
• Prevention monitoring check for and treat
  impaction
• Rx softeners, polyethylene glycol powder
  Miralax, senna, bisacodyl tabs or suppositories,
  sorbitol, mg citrate, enemas

108
Nausea

• CTZ- area postrema of medulla vestibular
  delayed gastric emptying
• Tolerance develops Usually resolves after 3 5
  days
• If persistent nausea evaluate for other causes
• Metoclopramide, haloperidol, diphenhydramine (DA,
  5HT, histamine)

109
Sedation

• Side effect versus need to catch up on sleep
  after pain resolves
• Tolerance develops rapidly (hours)
• Sedation always predates respiratory depression
• If RR lt 8 and patient unarousable, use 101
  dilution of naloxone, tirate to arousal, and
  monitor closely
• Naloxone half life minutes
• Persistent sedation usually multifactorial
• Rx- identify and treat underlying contributors,
  opiate dose adjustment, opiate rotation,
  antipsychotics, psychostimulants,

110
If you dont ask you wont know. Routine
assessment is prerequisite to good symptom
management.

• Pain
• Weakness
• Fatigue
• Anorexia/cachexia
• Constipation
• Dyspnea
• Nausea
• Constipation

• Anxiety
• Depression
• Delirium
• Sleep
• Energy
• Hopes and fears
• Biggest concern
• Tools at www.promotingexcellence.org

111
Practical Support and Care CoordinationMobiliz
ing Community Resources

• 95 of the illness and the care occurs at home
• Families provide gt70 of long term care
• Most patient/family needs cannot be met in
  physician offices and hospitals
• Physicians can help by coordinating array of
  community services for patients and families
  Home safety and needs evaluation, PACE, visiting
  RN/home care services, case management, hospice,
  financial planning resources, Medicaid
  eligibility, family support groups.

112
Other Resources

1. Communication and decision-making
2. Pain and symptom management
3. Care coordination, commmunity resources for
   patients and families

113
Communication

• 1. Buckman R. How to Break Bad News A Guide
  for Health Care Professionals. Baltimore Johns
  Hopkins University Press, 1992 - The definitive
  guide for communicating bad news.
• 2. Meier DE, Back AL, Morrison RS. The inner life
  of physicians and care of the seriously ill. JAMA
  2001 2863007-14. - Practical approaches to self
  care for physicians caring for seriously ill
  patients
• 3. EPEC - A continuing medical education program
  providing detailed protocols for major
  communication topics (www.epec.net)
• 4. The Center for Palliative Care of Harvard
  University Medical School - Continuing medical
  education programs in communication skills for
  practicing clinicians (http//www.hms.harvard.edu/
  cdi/pallcare/)

114
Symptom Assessment and Treatment

• 1. Doyle D, Hanks G, MacDonald N. Oxford Textbook
  of Palliative Medicine Second Edition. Oxford
  Oxford University Press, 1998. Comprehensive
  textbook of palliative care.
• 2. Morrison RS, Meier DE. Geriatric Palliative
  Care. New York Oxford University Press, 2003.
  Comprehensive textbook of palliative care focused
  specifically on older adults.
• 3. Education for Physicians in End of Life Care
  www.epec.net - A continuing medical education
  program providing practical advice for managing
  pain and other symptoms
• Fast Facts and Concepts on End of Life Care-
  Concise evidence based summaries on treatment of
  common symptoms www.mcw.edu/pallmed/html/about1.
  html
• palliativedrugs.com growthhouse.org
  stoppain.org

115
Psycho-Social Support and Care Coordination

• Elderweb- A comprehensive listing of services for
  older adults including resources for personal
  care needs, care coordination, and home care
  www.elderweb.com
• EPEC - Contains modules on psycho-social support
  and grief and bereavement www.epec.net
• National Agency for Home Care and Hospice
  www.nahch.org and National Hospice and Palliative
  Care Organization www.nhpco.org - Trade
  organizations whose web sites provide
  comprehensive lists of member home care agencies
  and hospices searchable by city and zip code.
• Growthhouse - Grief and Bereavement Resources
  www.growthhouse.org
• Bereavement and Hospice Support Netline An
  online directory of bereavement and hospice
  bereavement programs in the U.S
  www.ubalt.edu/www/bereavement
• Centers for Medicare and Medicaid Services (CMS)
  - Information about Medicare coverage and
  Medicaid eligibility. Information about PACE
  programs (including their location) and Medicare
  Choice Programs (which may include case
  management) can also be obtained at www.cms.gov.
  

116
Education is Not Optional

• Training opportunities
• ELNEC www.aacn.nche.edu/elnec
• EPEC www.epec.net
• DELeTCC www.deletcc.coh.org
• EPERC www.eperc.mcw.edu
• AAHPM www.aahpm.org
• Harvard www.hms.harvard.edu/cdi/pallcare/
• Fellowship training
• www.aahpm.org
• ANP palliative care training programs, ANCC
  certification www.hpna.org
  www.nursingworld.org
• MD Certification ABHPM www.abhpm.org

117
I dont know enough about palliative care.

• Get training (EPEC, ELNEC, DELeTCC, AAHPM-HPNA,
  Harvard advanced courses)
• Subscribe to the J of Palliative Medicine. Get
  the Oxford Textbook of Palliative Medicine
• Do a site visiting program (Palliative Care
  Leadership Centers, Cleveland Clinic, Beth Israel
  Med Ctr in NYC, San Diego Hospice, others)
• Take a year off and do a fellowship or an APN
  degree program

118
Our hospital doesnt have expertise in
palliative care.

• www.epec.net -MD
• www.aacn.nche.edu/elnec -RN
• www.deletcc.coh.org
• www.EPERC.mcw.edu
• APN www.hpna.org
• Fellowships www.aahpm.org
• Site visiting programs

• Read
• Harvard course
• Go to the AAHPM annual meeting
• Use the web
• www.palliativedrugs.com
• www.growthhouse.org
• www.stoppain.org
• Learn by doing