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End of Life Care

-It Takes a Team

ROME New England

August 16, 2015

Christina E. Fitch, DO, MPH, DTM&H

Objectives

"At the conclusion of the presentation, the learner will be

able to: ..."

*Explain the difference between palliative and hospice care for both in-patient and out-patient *Appropriately set treatment goals, incorporating

comfort measures and patient directives

*Coordinate with the caregiving team

Palliative care

What?

Who?

When?

How?

3

(2)

Palliative Care Core Concepts

• Bio-psycho-social-spiritual approach • Intra-disciplinary team • Match treatments with

values

• Relieve suffering • Improve quality of

living and dying

• Clear communication • Family-centered care • Meticulous care coordination • Non-abandonment • Expert symptom control

How We Can Help

Palliative Care is specialized medical care for people with serious illnesses. This type of care is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness – whatever the diagnosis.

The goal is to improve quality of life for both the patient and the family. Palliative care is provided by a team of doctors, nurses, and other specialists who work with a patient’s other doctors to provide an extra layer of support. Palliative care is appropriate at ay age and at any stage in a serious illness, and can be provided together with curative treatment.

Mr DR

• 86 yo M

• PMH: Afib on coumadin, CAD, DMII s/p

amputated toes, SCC sternum

• Presented down, Vtach, MI, intubated

• Cath lab: 3 vessel dz, cannot intervene

• Right MCA stroke, embolic  hemorrhagic

• Review Code Status

(3)

Palliative care

Who is eligible? • Anyone with a serious, life-limiting illness • No prognostic requirements • Patient can choose

concurrent curative or life-prolonging treatments with palliative care

What does it cover?

• Hospital consult services: – Interdisciplinary team – Symptom management, communication, coordination of care • Outpatient clinic • Community-based palliative care

Palliative care…

Where is care provided?

• Hospitals • Outpatient clinics • Nursing homes • Home

How is it paid for?

• Medicare Part B • Funded by hospitals

– Improves quality and reduces cost

• Partnerships with hospices, nursing homes

• Health care reform – ACO development

Mr. DR continued

• Extubated, intermittently interactive

• 2

nd

CVA off anticoagulation

• Refusing to eat though “passed” S&S,

refusing meds

• Goals of Care conversation

– Repeat stroke risk extremely high with or without anticoagulation

– No rehab potential

(4)

Hospice:

a service & a benefit

Who is eligible?

• People with a terminal illness who are likely to die within 6 months or less if the disease runs its natural course

– Certified by patient’s doctor and hospice medical director • Patient chooses hospice

care rather than curative treatments

What does it cover?

• Interdisciplinary team (doctor, nurse, chaplain, social worker, CNA) • Medications related to

terminal illness and symptoms

• Medical equipment and supplies

• 24/7 hotline for questions, crises

• Volunteers

• Bereavement counseling

Hospice…

Where is care provided?

• Wherever the patient lives: – Home – Nursing home – Assisted living – Hospice house – Other

• Goal is to stay out of hospital

How is it paid for?

• Medicare Part A • Levels of care (routine,

inpatient, respite, continuous) • Per diem

reimbursement

• Cost of healthcare rising faster than

reimbursement rate

Not giving anything up

You can still go to the hospital if you can’t be cared for

at home

Helps keep you feeling well at home so you don’t have to go back and forth to the hospital

They can help support your family emotionally after you cannot

Most comprehensive care possible to support

you at home

Won’t sense a difference, but you and

your family will feel better

(5)

What?

13

Most common consult questions

Most common consulting services?

Most common primary diagnoses?

What is Palliative Care?

Top reasons for consult

14

Jun-Dec 2014

(6)

Consults by Service

Primary palliative care

• Pain and Symptom Management • Depression and Anxiety Management • Goals of care discussions about

– Prognosis – Goals of treatment – Suffering

– Code status

17

"I have an advance

directive, not

because I have a

serious illness, but

because I have a

family."

Ira Byock, MD

(7)

Specialty palliative care

• Management of refractory pain or other symptoms • Management of more complex depression, anxiety, grief,

and existential distress

• Assistance with conflict resolution regarding goals of care or methods of treatment

– Patient’s family – Staff and family – Among treatment teams

• Assistance in addressing cases of near futility

19

WHO

20

Members?

Roles?

Settings?

Umass Palliative Care:

growth & opportunity

21 = Full Time

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Non-clinical staff

22

When

23 Disease course Hospitalization

Illness journey milestone

Titration of PC visits

Triggers for palliative care

• Complex symptom assessment and

management

• Complex medical decisions

• Complex goal-setting for end of life planning • Conflict concerning goals of care between

patient, family, and care team • Complex disposition planning

… in patients with life-threatening or life-limiting condition

(9)

Timing is everything

• Family meeting is a complex procedure, need

right players

– So helpful if you can help us expedite timing • When in hospitalization

– Earlier the better

– If want outpatient follow-up, need inpatient time to make relationship

• When in course of illness

– For first goals of care conversation

– At time of diagnosis, not when complications from treatment already present 25

Consultation management

options

• PC team will provide interdisciplinary services determined by referral questions and

patient/family needs

– One time visit for focused problem (prognosis, eligibility for hospice)

– Co-management role for specific issue: daily visits, symptom management

– Intermittent involvement as goals of care conversations arise or symptoms evolve

26

How

27

Contact a palliative care provider Focus a consult question

Co-management Introduce PC

(10)

“We are going to get another team involved

in your care”

28

“The Palliative Care team does many things, but in your situation I think they can help…”

•Support you and your family as you approach difficult decisions

•Understand what your goals are and match them to what is medically possible

•Help manage your challenging symptoms/pain •Clarify what your needs are going to be when you leave the hospital and match those needs to a setting that can provide the best care for you

CONSULT B E C D A Attempted therapies Trajectory of illness Psychosocial milieu Previous GOC conversations Co-morbidities ANATOMY OF A PALLIATIVE CARE CONSULT

29

Family meeting

Palliative provider Learner Attending Nurse Case Manager Chaplaincy Patient and ”Family” 30

(11)

31 Clinical Research Education Policy Global Health

What *else* is palliative care?

Issues and Solutions

32 Family Resistance Misinformation Uncertainty of benefit of consultation

Missed opportunity

References

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