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?
3Palliative 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
Palliative care
Who is eligible? • Anyone with a serious, life-limiting illness • No prognostic requirements • Patient can chooseconcurrent 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
ndCVA 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
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
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
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
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
20Members?
Roles?
Settings?Umass Palliative Care:
growth & opportunity
21 = Full Time
Non-clinical staff
22When
23 Disease course HospitalizationIllness journey milestone
Titration of PC visits
Triggers for palliative care
• Complex symptom assessment andmanagement
• 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
Timing is everything
• Family meeting is a complex procedure, needright 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
“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” 3031 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