Transcript Assessing Progrnosis and Patient Preferences at Admission

Assessing prognosis and patient
preferences at admission:
A research proposal
Stephen Workman
General Internal Medicine
Dalhousie University
Halifax Nova Scotia
Outline
• Genesis of this proposal
– Philosophy of end of life care currently
• End of life care and the medical teaching unit
– Institutional statistics
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# deaths/service
ATLOS
Total beds
Comparators
• Educational research proposal
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
3 Palliative/curative models of
care delivery
1. Sequential (current)
2. Exclusionary
curative
Palliative
curative
Palliative
3. Complementary
Palliative
Curative
EOLC at a 1000 bed teaching center:
A Major Commitment
• 1250 deaths (2003-2004)
– Average terminal length of stay:
– Last six months of life:
– MTU
20 days (median 18)
25 days
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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DOM TOTAL BED DAYS APRIL - DECEMBER 2003
4356
4500
3801
4000
TOTAL BED DAYS
3500
3000
2500
1619
2000
970
1500
1000
138
500
258
387
474
570
594
601
646
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A comparison to 77 US Centres
QEII
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
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
Six steps
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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
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)
unlikely
Very likely
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___
Step 4
Patient ___proxy___ preferences and goals
Are family members present? Yes___No___
1.
Assessment deferred for 24__48__ hours___Indefinitely___
2.
Reason for deferral—patient 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
FIFE* (feeling ideas fear expectations)
Yes___No___
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________________________________________
___________________________________________________________
STEP 1: Prognosis* (Conrev data)
(+) High functional class, Independent for ADL’s, 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 sick…Hospital 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 6:Developing 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.
Safety measures
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Not part of the chart
Defer at leisure
Risk stratify patients
Consider both goals and treatment preferences
FIFE when in doubt
Outcomes
• Descriptive statistics as provided
• Chart review
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Time to palliative care / care transition
Identification of goals of care
Time to end of life care discussions
Quality of end of life care
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?