Transcript Best Practices in EO..

In Search of
BEST PRACTICES
IN
CARE OF THE DYING
James Hallenbeck, MD
Hospice Medical Director
VA Palo Alto HCS
Overview
Best Practices
A conceptual framework
• Various groups working on guidelines
– AMA
– ABIM
– National Cancer Care Network
• Position papers/policies
Among others
– Last Acts: Precepts of Palliative Care
– VA policy on Pain as the Fifth Vital Sign
Domains of EOL Care
Pain Management
Non-pain Symptom Management
Communication
Ethics
Psychosocial, Spiritual Care
System issues
Pain Management
Standards of Care
• Patient Centered
• Standardized assessment tools
– Pain as the Fifth Vital Sign
• Monitoring is incorporated into quality
management
• Specific prescribing guidelines
– Ex. For chronic pain, rely on long-acting oral
opioids with short-acting breakthrough doses
Pain Management
Controversies
• Generalist vs. specialist
• Palliative Care specialist vs. Pain
Management specialist
• In Geriatrics- traditional vs. palliative
approach:
– Polypharmacy vs. mult-modality therapy
– Emphasis on functional status vs. relief of
suffering
Non-pain Symptom Management
•
•
•
•
What symptoms are we talking
about?
Constipation
Dyspnea
Nausea and vomiting
Dry mouth
• Plus approximately 50 more...
Non-pain Symptom Management
Standards of Care
• Overall- emphasis on tailoring drug therapy to
specific cause(s) of symptoms
• Constipation
– start treatment when starting opioids
– more patient/nurse autonomy in treatment
• Dyspnea
– central role of opioids, benzodiazepines
• Nausea and vomiting
– dopamine antagonists for opioid related nausea
Non-pain Symptom Management
Controversies
• Role of antibiotics in certain infections
• Role of artificial hydration/nutrition
• Use of newer, often more expensive
palliative medicines
– Ex. 5HT3 antagonists for nausea
• Overlap/differences between traditional and
palliative care for certain symptoms
Communication
Standards of Care
• Active Listening
• Assessment of patient preferences
– Current as well as advance directives
• Sharing of bad news
• How to “pronounce” a patient
• Patient/family education
– Prognosis, care options, goals of therapy,
normal changes of dying
Communication
Controversies
• Who should communicate what?
• Time and money involved in good
communication
• Cultural factors
• Attending physician role in
modeling/teaching communication skills
– Much EOL communication part of resident subculture
Ethics
Controversies
•
•
•
•
Physician Assisted Suicide (PAS)
Voluntary Euthanasia (VE)
Terminal Sedation (TS)
Voluntary Self-discontinuation of Eating and
Drinking (VSED)
• Futility
• Who pays for what? (Issues of justice)
• Cultural factors
Ethics
Standards of Care
• Discussion and documentation of current
and advance directives
• Non-abandonment
• Respect for patient, family, healthcare
worker values
• Importance of cultural competency
• Availability of ethics consultation
Psychosocial, Spiritual Care
Standards of Care
•
•
•
•
Recognition/treatment of depression
Recognition of the family as the unit of care
Appreciation for economics of EOL care
Importance of addressing patient/family
spiritual needs
• Bereavement support
Psychosocial, Spiritual Care
Controversies
• Treatment of terminal delirium
• Role of the physician in this area, esp.
addressing spiritual suffering
• Are we at risk of forcing our notion of a
“good death” onto others?
• Reimbursement for this care
• In Geriatrics- Independence vs.
Interdependence
System Issues
Standards of Care
• Universal access to appropriate EOL care
• Coordination of care across venues
• Treatment of patients in the venue of care
desired to the extent possible
• Interdisciplinary approach to care
• Incorporation of monitors into quality
management structure and accreditation
System Issues
Controversies
•
•
•
•
? Right to EOL care
Hospice vs. Palliative care
Role of managed care
Proper reimbursement structure (taking into
account):
– different dying trajectories (problems with prognosis)
– different patient/family preferences for care
– differences in case-mix
Summary
• Standards of care are beginning to evolve
• Large gaps between “best practices” and
current level of practice
• Major controversies exist as to what
constitute best practices