Assessing prognosis and patient preferences at admission: A research proposal

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Assessing prognosis and patient preferences at
admission A research proposal

• Stephen Workman
• General Internal Medicine
• Dalhousie University
• Halifax Nova Scotia

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Outline

• Genesis of this proposal
• Philosophy of end of life care currently
• End of life care and the medical teaching unit
• Institutional statistics
• deaths/service
• ATLOS
• Total beds
• Comparators
• Educational research proposal

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Genesis of this proposal

• CTU Morbidity and mortality rounds held each
  month
• 25-30 deaths per month
• Often death seems (very) probable at admission
• (Progressive disease, no clear reversible cause)
• Goals of care often not determined until late
• Delay in starting palliative care
• Patients / family members may trigger the
  initiation of palliative care

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3 Palliative/curative models of care delivery
curative
Palliative
1. Sequential (current)
curative
2. Exclusionary
Palliative
Palliative
3. Complementary
Curative
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EOLC at a 1000 bed teaching centerA Major
Commitment

• 1250 deaths (2003-2004)
• Average terminal length of stay 20 days
  (median 18)
• Last six months of life 25 days
• MTU 35 days
• 25,000 bed days / 365,000 total available
• 7 of total beds
• 30 of deaths preceded by SCU admission
• 14,000 bed days in hospital for medicine
  patients, 1612 on palliative care ward

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deaths per service
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A comparison to 77 US Centres
QEII
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Research proposal

• Goal To address death and dying and the need to
  provide EOLC based upon risk not certainty
• (NNT vs NNP)
• Ensure patients who get aggressive treatment
  truly desire it.
• Include palliative goals before death is certain.
• Approach
• Utilize a decision aide that addresses EOLC in a
  structured manner
• Explicitly consider prognosis and treatment
  options.
• Assess patient preferences for treatment and
  treatment goals as part of the history and
  physical
• Address emotional responses and fears if they
  should arise

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Intervention

• Have the resident in the ED estimate prognosis
  and assess patient preferences for treatment and
  treatment goals in the history and physical
• Exclude patients at discretion of
  resident/admitting MD (Palliative only or
  clearly full code)
• Complete a flow sheet (example) at or around the
  time of admission

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Six steps

• Likert scale to estimate prognosis
• Assess treatment options
• Assess for prior advance care plans
• Assess patient preferences
• FIFE on an as need basis
• Record treatment plan or full code by default

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Step 1. Would you be surprised if this person
died within 6 months? Yes__No__ Could the patient
die this admission? (Mark estimate or
range)   Step 2 Treatment goals appropriate for
this patient (Choose One or more) 1. ___Comfort
as primary goal of care 2. ___Comfort plus ward
based treatments to prolong life. 3. ___As above
plus (CPAP BiPAP)___Intubation___ for respiratory
support 4. ___As above plus CPR and admission to
an ICU. 5. ___Other Describe_____________________
____________________________   Step 3 Are patient
preferences previously documented? No____ Yes___
Old chart___ Living Will___ Other_________________
_______ Plan documented Full code___ No
code____Palliative ___Other_______________________
__________ Do you believe preferences need to be
reassessed? Yes___No___
Very likely
unlikely
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  Step 4 Patient ___proxy___ preferences and
goals Are family members present?
Yes___No___ 1.                  Assessment
deferred for 24__48__ hours___Indefinitely___ 2.  
                Reason for deferralpatient
request___Family not present___ Other_____________
____________________________________ 3.           
       Patient__Proxy___ preferences for
treatments and goals of care 1.      ___Comfort
as primary treatment goal 2.      ___Comfort
measures plus ward based medical
treatments. 3.      ___Comfort ward treatments
(BIPAP or CPAP)__ INTUBATION___ 4.     
___Full medical treatment including CPR and
admission to an ICU 5.      ___Other______________
_________________________________ 6.     
___Patient / proxy wishes to defer decision
making Aware___Not aware___ of full code by
default Step 5 Patient / family evidence of
distress Yes___No___ FIFE (feeling ideas fear
expectations) Done-___Not done___   Step
6 Outcome Goals NOT established is this
recorded in chart? Yes____No___ Goals
established___ and recorded___ In chart___In
orders___ Describe goals__________________________
______________ ___________________________________
________________________
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STEP 1 Prognosis (Conrev data) () High
functional class, Independent for ADLs, clearly
reversible illness component   (-)Bedridden,
functional class 4, low albumen, decline despite
medical treatment, lack of reversible cause for
progressive worsening, permanently depressed
level of consciousness, persistent hypothermia,
recurrent/recent hospital admissions, cachexia,
low blood pressure chronically   STEP 4
Assessing treatment preferences Low probability
of dying I routinely ask patients about the kinds
of treatment they would like if they became very
sickHospital policy is that if you became very
sick suddenly whatever treatments are necessary
to keep you alive would be used including CPR,
Life support. Have you thought about the kinds of
treatment you would like if you became very
sick? What do you understand about your / your
mothers illness? Do you want to talk about the
kind of treatments you would want if you became
critically ill? Would you want to go to the ICU
or receive CPR   Moderate / high probability of
dying Consider talking about death as a
possible/probable outcome Have you thought that
you / your mother could die from this illness /
during this admission? What do you hope we can do
for you during this admission? What do you hope
for the future  UNDECIDED PATIENTS Patients who
are undecided should be informed of hospital
policy (Full code by default)   STEP 5 FIFE
(Fears Ideas Feeling Expectations) Some patients
may have anxiety or fears about their illness.
If distress appears to be present FIFE
important How do you feel about.? Would you like
to talk about your worries? Is there anything you
are worried or afraid of? What do you hope we can
do for you   STEP 6Developing a care
plan Address emotions Educate about unrealistic
expectations Describe what can be done in terms
of comfort and improving survival. (Improving
comfort may improve survival as well) Reassure
low risk patients Be sure to address fears
about death and dying for high risk
patients.      

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Safety measures

• Not part of the chart
• Defer at leisure
• Risk stratify patients
• Consider both goals and treatment preferences
• FIFE when in doubt

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Outcomes

• Descriptive statistics as provided
• Chart review
• Time to palliative care / care transition
• Identification of goals of care
• Time to end of life care discussions
• Quality of end of life care

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Questions

• For me?
• For you
• What do you think are the major hurtles facing
  this reasearch?
• Which steps most likely to be problematic
• Risk vs benefit?
• Need for resident training?
• Suggestions?