Transcript Palliative Care

Demystifying Palliative Care:
Evidence, Guidelines, &
Quality Care
Akshai Janak M.D.
Palliative Care Medical Director
Huntsville Hospital
Co-author: Lizzie Giles M.D. PGY-3
Objectives
• Clarify basic myths around palliative
care
• Understanding the concept of
Palliative Care and evidence
supporting it.
• Differentiate between hospice &
palliative care
• Concept of IDT
• Role in HH health system
10 myths of Palliative Care
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Palliative Care means…
My doctors have given up on me.
No more treatment .
Only for people with cancer.
Only for old people.
I’m very close to death.
10 Myths of Palliative Care
• They dope you up & you sleep until
you die.
• If I get morphine, I will stop
breathing.
• I can only get palliative care if I’m in
the hospital.
• My family can’t help if I’m in
palliative care.
• I will have no control if I agree to
palliative care.
You're not alone in being unaware...
The “elephant” service @
Huntsville Hospital
Once they know, people want a
piece of that “elephant”
What is Palliative Care?
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Specialized medical care for people
with serious illnesses.
Care is focused on providing 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 their
family.
So, is Palliative Care the same as End-of-life Care
or Hospice Care?
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NO! Palliative care is appropriate at any age & at any stage in a serious
illness
Palliative Care can be provided along with curative treatment.
Why do non terminal patients need Palliative Care? Because Serious
illnesses come with:
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Complex, difficult decisions about treatment options
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High symptom burden
Desire for CLEAR prognostication
Many patients with serious illness, even when they are not in terminal
phases, have complex psychosocial situations that would benefit from a
team approach.
Serious illnesses affect the patient & their loved ones. Both need support.
Palliative Care providers have advanced training in:
Communication about serious medical conditions & shared decisionmaking:
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»PALLIATIVE MODEL: “What are your goals and how can we help you
achieve them?”
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Prognostication:
»PALLIATIVE MODEL: A caring discussion of projected illness
timelines and scenarios for future decision-making.
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Complex Symptom Management:
»PALLIATIVE MODEL: inpatient/outpatient mgt of recalcitrant physical
& psychosocial symptoms
• Pharmacologic
• Non-pharmacologic
• Team Approach
It's Part of the Same Spectrum of Care...
Is this a new idea?
Lessons from 1995 & End-of-Life Care
Care Changes after 1995
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More-frequent discussions of “Code Status” when patients
become critical in the hospital. (Too late?)
More referrals to Hospice when patient is a “non
responder” to curative therapies or is @ the “end-stage” of
a chronic disease. (Will these pts get the full, 6m.
Benefit?)
Research into aggressive pain & symptom management
resulting better care for patients who are actively dying in
the hospital.
• E.G. opioid drips @ end-of-life
• E.G. “comfort care” order sets
So... Wasn't that enough?
…Well, in 2010 research found
The New Model for Medical Care: Palliative
Care from the Beginning & Even more @ the
End
Where is Palliative Care Being Used?
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Ideally, throughout the course of a disease
In all treatment settings: inpatient, outpatient,
specialized clinics, at home, etc...
So, who provides this “palliative care”?
At HH Palliative Care is a Interdisciplinary
TEAM:
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• Lead by a physician & includes:
• Nurse practitioners
• Chaplain service
• Music therapy
• Pharmacy, SW, & Nutrition support
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Team members work together to ensure
that palliative goals are met for each patient
Daily & Weekly mtgs to discuss patient care
& troubleshoot difficult cases.
Case #1: Severe Renal Disease
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Betty is a 56 yo living with CKD Stage 4
2ndary to insulin-dependent DM2
Comorbidities: HTN, obesity (BMI: 31%),
& CAD.
Social: Betty is married, with 3 grown
children, & her husband is disabled from
chronic back pain from spinal stenosis.
Betty's CKD is transitioning to stage 5.
Her nephrologist is unsure that any
further pharmacological treatment can
slow her disease progression.
How does palliative Care fit into Betty's care?
The Renal Physician's Working Group on Shared Decision Making, Nephrologists should...
• GIVE INFORMATION
• DISCUSS PROGNOSIS
• DETERMINE GOALS OF CARE
• GIVE ANTICIPATORY GUIDANCE
• PROVIDE SYMPTOM CONTROL
So, what happened next?
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Betty, her husband, & her eldest daughter (by phone)
discuss with her nephrologist the risks/benefits of dialysis.
All agree that Betty wants to start hemodialysis with an
understanding of the lifestyle limitations & how long she
can expect to live while on dialysis.
Yearly check-ins with her nephrologist and a team at the
dialysis center are scheduled to discuss
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her dialysis treatment
Betty's symptom control
advance directives
how well her co-morbidities are controlled
When to consult a Palliative IDT?
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2 years into dialysis, Betty voices concern that her symptoms are not
as well controlled as they used to be. Her epogen dose is optimized
but her pleuritis continues.
Her polyneuropathy from her CKD & DM is not as well controlled with
medications from her family doctor.
Betty is also seeming more fatigued after each dialysis session & her
BMI is now 25%. Her appetite has declined.
Her husband and daughter note that she's not as positive about her
health as she used to be.
Is this a good time to consult Palliative Care?
YESSS!!
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Symptom Burden
Anticipatory guidance
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AFTER consultation:
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• Betty has better symptom control: a new regimen is
started
• Betty revises her Advance Directive
No Artificial Nutrition/Hydration
No artificial life support except HD
• AND/DNR
• Betty wants to continue dialysis because her symptoms
are better controlled.
Guidelines: Where does Palliative fit
into CKD?
Nephrology 16 (2011) 4-12
& now to crisis
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Betty does well for another 3m but then suffers 2 back-toback infections with 1 week hospitalizations each.
She is again more fatigued & less willing to go to her
dialysis sessions.
Her husband's health is also declining & he is advised to no
longer drive. Both Betty’s daughters are concerned.
Betty’s BMI is now 19%.
Betty is hospitalized again for a 3rd infection. The IDT is
consulted & the family requests spiritual support & agrees
to a visit from the music therapist.
Inpatient Results/Care
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After an IDT meeting, Betty decides to continue dialysis for
6 months with monthly visits with an outpatient, Palliative
IDT to see if her symptoms can be better controlled.
Betty expresses reluctance to come back to the hospital if
she contracts another infection: she requests a “do not
transfer” order.
Betty is open to aggressive outpatient care including abx,
should she need it.
Betty reaffirms her AND/DNR status & her wish that her
eldest daughter be her surrogate should she be
incapacitated.
The final chapter
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Betty continues dialysis.
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She also starts attending church more regularly.
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...3 weeks later, Betty becomes delirious at home. Her husband
panics & calls 911.
Betty is started on broad spectrum abx in the ED & is admitted
by the hospitalist service.
Records are reviewed and both Nephrology & Palliative Care are
reconsulted on Day 1 of admission.
Betty becomes more lucid on day 2 of admission but is very
fatigued. She requests to be transferred home.
Hospice
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After a tearful family meeting & prayer with the
IDT chaplain, Betty & her husband agree (with
daughter via phone) to transition to hospice care.
Betty agrees to continue her current course of
antibiotics to appease her husband but then wants
to discontinue dialysis and pursue hospice care.
Social Work provides Betty's daughter with a list of
Hospice agencies & discharge is arranged on
hospital day 4.
Case Review Take-Aways
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Idealization: @ this point there are no out-patient Palliative Care Teams in
Huntsville.
Real-Life: Transition to Hospice was not seamless. Caregivers (e.g. Betty's
husband) are not always ready to change goals of care.
Primary vs. Specialist Palliative Care: Primary Palliative Care was achieved
by a nephrologist-lead team before a Specialist Palliative team was
consulted/needed.
• Nephrology guidelines followed due to sufficient resources for a team
approach.
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Resource Management: Hospital Stay shortened by consultation of the IDT
along with readmissions once pt is enrolled in hospice.
Patient/Family Satisfaction: Family appreciates the time to decide, the IDT
conversations, & are comfortable with the D/C plans.
Levels of palliative expertise:
everyone can be a little palliative
In-patient Palliative Consults save
Costs, Resources, & Re-admits
Arch Inten Med/vol 168 (No.16), Sep 8, 2008
Palliative Care can fill the
“Stage 4” Care GAP
Now... James
a Cardiac Case
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60 y/o AAM
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ROS: SOB, early satiety, LEE, wt gain 10lb/wk
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PFSH: HTN, DM. Father-CVA, Mother-CHF. 30 pack year.
Married, Financial Manager, 2 adult children.
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James is hospitalized for...
CC: acute respiratory failure, intubated on the way to the
hospital.
HPI:
• Chuck E Cheese birthday party for granddaughter
yesterday. Wife says he held diuretics for social gathering.
Says, “It was a great day”.
• AM of admission, she reports that he “passed out” walking
from the bed to the bathroom but regained consciousness.
• Wife says, “he was working hard to breathe”. Called 911.
• Intubated on scene & transferred to ED.
Initial ICU Care
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Cardiology (1st day)
Started IV Inotropes: Milrinone
Renal dose dopamine
Diuretic challenge  FAILED
Renal consulted (1st day)
Medical management
Mgt Fails  Recommend dialysis day #2
Palliative Input:
after Dialysis proposed
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Palliative Care (2nd day)
Family meeting to discuss treatment options
Family Meeting  New Goals of Care:
Decline Dialysis
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Disable AICD
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Compassionate Extubation
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Comfort measures
Transition of Care:
Home with hospice of choice
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Take-Aways from Case #2
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Integration in the hospital of curative/restorative care &
palliative care
Goals of Care/Treatment shift over time
SHARED Decision-Making: Palliative Care Team meets the
patients & families where they are & respect family choices
Note the Distinction between AND/DNR status & patient's
desire for treatment:
• Patients often decide to forgo CPR & intubation while still
desiring other forms of curative/restorative care
• IV diuretics, pacemakers, abx, etc. VS. Intubation & CPR
Palliative Resource-Savings in ICU Care:
To Review
Examples of Reasons to Consult Palliative Care
Triggers to Consult the Palliative Care
IDT in the Hospital
1)Presence of a Serious, Chronic Illness that is becoming burdensome or hard to
manage, or newly diagnosed, or with limited treatment options
2)Declining ability to complete activities of daily living
3)Weight loss / Multiple hospitalizations / DNR order conflicts
4)Difficult to control physical or emotional symptoms related to medical illness
5)Patient, family or physician uncertainty regarding prognosis or regarding goals of
care
6)Patient or family requests for futile care
7)Use of tube feeding or TPN in cognitively impaired or seriously ill patients
8)Limited social support and a serious illness (e.g., homeless, chronic mental
illness)
9)Patient, family or physician request for information regarding hospice
10)Patient or family psychological or spiritual distress
When Palliative can help in the ICU
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Admission from a nursing home in the setting of one or more chronic
life-limiting conditions (e.g., dementia, chronic CHF, COPD)
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Two or more ICU admissions within the same hospitalization
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Prolonged or difficult ventilator withdrawal
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Multi-organ failure
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Consideration of ventilator withdrawal with expected death
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Metastatic cancer or Anoxic encephalopathy
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Consideration of patient transfer to a long-term ventilator facility
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Family distress impairing surrogate decision making
Source: http://getpalliativecare.org/resources/clinicians/
Current Model
Increased cost
Increased dissatisfaction
EMR
Integrated
Palliative
Decreased dissatisfaction
Decreased cost
Primary
Care
Care
Med System
Better Model
Swinging of the Pendulum
•Disease Mgt System
•Paternalism
•Treat until death
•Health Mgt System
•Consumer Directed
•Palliative Focus
Huntsville Hospital Palliative Care
• Since Sept 2012….
• 800+ strong and growing
• Goals:
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Inpatient Palliative Care Unit
Outpatient Palliative Care Clinic
Home Palliative care with HFC
Inpatient Hospice with HFC
Healthcare system integration
In Summary…
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When in doubt & the case is complex with either
patient/family or caregiver uncertain about treatments or
favorable outcomes, CONSULT Palliative Care
We're here to help deliver patient-centered, cost-conscious
care supported by evidence!!
WHO Definition
Health
is…
a state of complete physical, mental
& social well-being & not merely the
absence of disease or infirmity.