What Is a Palliative Care Consult Service?

1
What Is a Palliative Care Consult Service?

• More importantly What can it do for you?

2
Palliative Care Consulting

• Making the Case
• Services Rendered
• Staffing
• A Note of Caution
• The Role Of Acute Care Hospitals In Caring For
  the Dying

3
Why Palliative Care?

• The sickest people congregate in hospitals
• These people often feel a loss of control in
  their medical travails
• Often they experience profound suffering
• The people who care for them often experience
  tremendous burden, burnout
• Hospitals and accreditation organizations
  recognize these struggles, want to do better

4
What Do Patients with Serious Illness 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.
5
National Data on the Experience of Advanced
Illness 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

6
SUPPORT Suffering and Costs, Phase I Results

• Half of patients had moderate-severe pain gt50 of
  last 3 days of life.
• 38 of those who died spent gt10 days in ICU.

7
Self-Reported Symptom Experience of Critically
Ill Cancer Patients Receiving Intensive Care
Nelson JE, Meier DE, Oei EI et al. Crit Care Med
200129277-282
75
71
68
63
56
55
39
34
8
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.

9
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.
10
Caregiving Needs Among Seriously Ill Persons

• Interviews with 900 caregivers of seriously 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

11
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.

12
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
13
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

14
Symptom Improvement for 3,707 Palliative Care
Patients at Mount Sinai Hospital (6/97-12/04)
Pain
Nausea
Severe
Severe
Mod.
Mod.
Mild
Mild
None
None
Shortness of Breath
Anxiety
Severe
Severe
Mod.
Mod.
Mild
Mild
None
None
Source Patient Interviews, Mount Sinai
Hospital, New York City
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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
16
High Satisfaction -Mount Sinai Hospital
DataPercent of Palliative Care Families
Satisfied or Very Satisfied 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
17
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 treatments (no
  requirement to give up curative care)
• provide practical and emotional support for
  exhausted family caregivers

18
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

19
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
• ration the use of hospital resources
• increase bed/ICU capacity, reduce costs

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Summary

• Palliative care improves quality of care for our
  sickest and most vulnerable patients and
  families.
• Palliative care improves the ability of
  physicians to deliver high quality care to this
  difficult patient population
• Palliative care saves the hospital time and money
  while improving overall patient satisfaction

21
This is My Job

• Palliative Care Specialist at CPMC
• Pain Management (Terminal or non-terminal)
• End Of Life Counseling
• Code Status Discussion
• Prolonged ICU stays
• Introduction to Hospice
• Symptom Management
• Dyspnea (CHF, COPD, malignancy)
• Nausea/Vomiting
• Pruritis (ESRD, ESLD)
• Physician/House Staff Education

22
My Colleagues

• 1 Geriatrician
• 1 Fellowship-trained Nurse Practitioner
• 2 Oncology Clinical Nurse Specialists
• Psychology Service
• Health and Wellness
• Massage Therapy
• Acupuncture
• Herbal Medicine

23
In My Dreams

• Dedicated Social Worker
• Dedicated Case Manager
• Trained Psychologist in End Of Life Issues
• 0.5 FTE Massage Therapist
• Annual Retreats at Pebble Beach
• All Expenses Paid

24
The Pitfalls and Perils

• Stepping On Toes
• Disrupting long-held notions
• Attending/House Staff Miscommunication
• Answer the Question! (and only the question)
• Spoiling the Movie
• Commandeering