Transcript physician`s responsibility to determine plan of care

What you need to know about
Palliative Care
Jill R. Nelson, MSN, ANP-BC, ACHPN
Palliative Care Consult Service
Vanderbilt University Medical Center
September 9, 2013
Objectives
• List indications for palliative care
• Describe common barriers to palliative
care initiation
• List possible resources available for those
who are facing end of life
Palliative Care Definition
• World Health Organization Definition:
– “An approach that improves the quality of life of
patients and their families facing the problems
associated with life-threatening illness, through the
prevention and relief of suffering by means of early
identification and impeccable assessment and
treatment of pain and other problems, physical,
psychosocial and spiritual needs”
– Multidisciplinary approach that focuses on the
whole patient and family
– Note that the “unit of care” is more than the patientto include family/friends, caregivers
A Palliative Care Trajectory
May represent decades
End
of
Example of a Bereavement
Theoretical Model:
“Continuing Bonds”
Life
Care
Death Event
Diagnosis of a Potentially
Active
Life-Limiting Illness,
Dying
Condition
(24-72 hrs)
To Include: Remission(s)
Worried Wellness
Cautiously Cured
(Anxious) Survivorship
Chronically well/ill
Who needs palliative care?
Indications for Consultation:
• Working definition of palliative care:
Patients who are facing a potentially lifethreatening illness. We assist with
1) pain and symptom management
2) hospice information and placement
3) goals of care*
4) patient and family support
5) advance care planning
*Goals of Palliative Care
• Alleviate the suffering of the patient and family
by focusing on comprehensive care
• Enhancing patient’s quality of life
• Assisting patients and families through the
transition from wellness -->sickness --> dying -> bereavement
• Help patients/families navigate their search for
meaning/ hope
• Assist patients in developing and achieving goals
--allowing patients to die on their own terms-World Health Organization 2013
Why is Hospital Based Palliative Care
important?
• 53% of Americans die in hospitals each year 1
• 33.5% of Medicare beneficiaries died at home in 2009, although
70% of Americans say that they would prefer to die at home 2
• Typically more deaths occur in the ICU than anywhere
else in the hospital 1
• Many patients benefit from palliative care, complementing their
curative or life-prolonging treatments in the hospital
• Palliative care programs aim to provide very ill patients access to
pain and symptom management, coordination among their
health care team, and help with transition between care settings
including hospice, home care, or nursing home placement
1 Center to Advance Palliative Care (CAPC), 2009
2 Change in End-of-Life Care for Medicare Beneficiaries Site of Death, Place of Care, and Health Care Transitions in 2000, 2005, and 2009, Teno, JM, et all,JAMA. 2013;309(5):470477
Hospitals are where the most
money is being spent
• 29.2% of Medicare beneficiaries spent last 30 days of life in the
ICU 1
• Nearly 20% of patients who leave the hospital today will be
readmitted within the next month. More than 3/4th are
potentially preventable. 2
• The cost of readmission to Medicare is $17.4 billion. 2
• Medicare is considering site of death as a quality measure for
end-of-life care, on the theory that dying at home may be less
stressful than dying in an institution.
• Enormous resources are expended on the seriously ill, putting
the hospitals that treat them at financial risk if they cannot find a
way to provide care that is both high quality and fiscally
responsible.
1 Change in End-of-Life Care for Medicare Beneficiaries Site of Death, Place of Care, and Health Care Transitions in 2000, 2005, and 2009, Teno, JM, et all,JAMA. 2013;309(5):470-477
2 Centers for Medicare and Medicaid Services
Americans’ Current Health Care
Expenditures Are Concentrated in the Final
Part of the Life Span
Hospice Care
• Based on Medicare Hospice Benefit
• Signed statement by 2 MDs
-qualifying pt is terminally ill and has six
months or less to live if the illness runs its
normal course
• Do not have to be a DNR
• Treatments are intended for palliation, not for
cure
• Assists pt/family to live each day as fully as
possible for the remaining time together
Hospice Facts
• In 2011, NHPCO estimates that approximately
44.6% of all deaths in the United States were
under the care of a hospice program.
• In 2011, approximately 35.7% of hospice patients
died or were discharged within seven days of
admission.
• Most patients referred to hospice programs
survive no more than 3-4 weeks.
• Of the 1 million patients enrolled in hospice,
more than 66.5% died at home.
•
www.NHPCO.org Facts and Figures on Hospice Care
Hospice by Diagnosis
2011
Cancer
37.7%
Non-Cancer Diagnoses
(62.3%)
» Debility Unspecified
13.9%
» Dementia
12.5%
» Heart Disease
11.4%
» Lung Disease
8.5%
» Other
4.8%
» Stroke or Coma
4.1%
» Kidney Disease (ESRD)
2.7%
» Liver Disease
2.1%
» Non-ALS Motor Neuron
1.6%
» Amyotrophic Lateral Sclerosis (ALS) 0.4%
» HIV/AIDS
0.2%
www.nhpco.org
What does Hospice cover?
Cost of all medications, related to terminal illness
Durable medical equipment
Physician services
Visiting nurse services
Home attendants
Ambulance/Transportation
Short term inpatient stays for management of acute
conditions/symptoms
• Respite care limited to 5 days maximum
• Bereavement support
• Use of a multidisciplinary team
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So why do so few use the hospice
benefit?
• Cultural denial regarding death on the part
of patients and health care
• Lack of an awareness of the Medicare
Hospice Benefit
• Patients’ and families hesitation to
transition from “curative care to palliative
care”
• Physicians apprehension about accurately
predicting prognosis
How Accurate Are We?
“Give it to me straight. How
much longer do I have left?”
Estimating prognosis
U. Chicago Medical Center Study: extent and
determinants of error in prognostication.
Study participants:
– 343 physicians
– 468 terminally ill patients
Extent and determinants of error in doctors' prognoses in terminally ill prospective
cohort study. .Christakis NA, Lamont EB.BMJ. 2000 Feb 19;320(7233):469473.patients:
Conclusions
– Median survival for patients 24 days
– 20% predictions were accurate (within 33%
estimated survival time)
– 63% predictions were overly optimistic
– 17% predictions were overly pessimistic
Extent and determinants of error in doctors' prognoses in terminally ill prospective cohort
study. .Christakis NA, Lamont EB.BMJ. 2000 Feb 19;320(7233):469-473.patients
:
Implications
• Most all physicians regardless of specialty
overestimate life expectancy
• The better a physician knows the patient,
the more likely he/she will err in
determining prognosis
• Experienced physicians are more likely to
make accurate predictions
So back to the question....
“How much longer do I have left?”
• Many patients and families understand
this easy rule:
-if a patient is making “changes” month by
month, they generally have months to live
-if a patient is making “changes” week by
week (day by day, hour by hour), they
generally have weeks (days, hours) to live
Real World Application
in BICU
Goals Of Care Consult
Mr. C
• 80 yo male, admitted with 40% total surface area
burns to bilat lower extremities
• Intubated, on pressors, milrinone
• Hx of HTN, asbestos exposure
• per my admission note: “very active,
independent and stubborn. Works outside
everyday, all day. Mows the lawn, chops wood,
etc. Is rarely sick and has never been "down" for
any length of time”.
• Called in on HD 3 for “goals of care, advance
care planning, family support” as patient is
critically ill
How to conduct a family meeting:
• Decide who the “key players” will be in the
meeting- patient, family, caregivers, clinicians,
consultants
• Pre-meet if necessary
• Meet in a quiet and comfortable place
Family meeting continued…
• Make introductions, explain everyone’s role
• Explain purpose of the meeting (set rules, if
needed)
• Ask patient or family what their understanding
is of pt’s illness
• Fill in the gaps in pt/family knowledge
• Inquire about pt’s goals, wishes, values, quality
of life
• Combine pt’s goals with what is medically
appropriate
• Summarize, answer questions
Mr. C (cont)
• Met with family and discussed role of palliative care.
Plans are to begin aggressive treatment of burns
(excision and grafting of skin) the next day. Family in
agreement with plan of care.
• Discussed patient’s ideal quality of life with family:
-would not want to be kept in a "permanently
unconscious condition."
-would be content living with "permanent confusion,
dependent in all ADLs, and end-stage illness“
-would be content living in nursing home
-patient has stated that he does not want to be a
“burden”
Mr. C (cont)
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underwent several surgical procedures
weaned off vent
weaned off pressors
trached (due to need for re-intubations)
moved to step-down unit
participated in physical therapy- walked in halls
daughter remained with patient, assessed
patient and spent time with daughter each day
Mr. C (cont)
• HD 57: decompensated, hypotensive, concern
for bacteremia
• transferred back to ICU, placed on vent, pressors
• HD 58: had family meeting, explained
seriousness of pt’s condition
• made patient DNR based on medical futility,
family in agreement
• Plan to continue aggressive treatment of
infections
To code or not to code?
• In the largest and most comprehensive study of in-hospital CPR
outcomes, survival 20 minutes after CPR was 44%. 1
• However, only 17% of all CPR patients survived until discharge.
• In a meta-analysis of CPR outcomes, depending on the rigor of CPR,
immediate survival was 41-44% and survival to discharge was 13-15%.
• Outcomes for cancer patients is worse. In a recent meta-analysis, only
6.7% of cancer patients survived CPR to discharge. 2
• Outcomes are also poor for renal patients. In 3 studies of renal patients
and CPR outcomes, survival to discharge was seen in 14% of patients. 3
• Roughly 15% or 1 in 6 patients, who undergo CPR in the hospital may
survive to discharge.
1 Peberdy MA, Kaye W, Ornato JP, et al. Cardiopulmonary resuscitation of adults in the hospital: A report of 14,720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation. 2003: 58 297-308.
2 Reisfield GM, et al. Survival in cancer patients undergoing in-hospital cardiopulmonary resuscitation: a meta-analysis. Resuscitation. 2006; 71: 152-160.
3 Hijazi, F, Holley, JL. Cardiopulmonary resuscitation and dialysis: outcomes and patients’ views. Seminars in Dialysis. 2003; 16(1): 51-5.
Code status discussions
• Unfortunately, code discussions usually take place when
patients are seriously ill. This is a stressful time for both
patient and family, often not the most ideal time to have
end of life discussions.
• There are times when providers feel that CPR would be
medically futile. This means that CPR cannot be
expected to either restore cardiopulmonary function or
to achieve the expressed goals of the patient. Providers
are not legally or ethically obligated to participate in a
futile medical treatment. Therefore, some patients are
made DNR/DNI based on medically futility. This is also
true in discontinuing or not offering medical treatments
(ie chemo, hemodialysis).
Medical Futility
 When it is determined that care is medically
futile
It is the physician’s responsibility to
determine plan of care
Physicians should remove burden of decision
from family
Many families are unable to make decisions
Physicians are not obligated to offer all
treatments, only those that are medically
indicated1
1 Luce, John. Physicians do not have a responsibility to provide futile or unreasonable care if a patient or
family insists. Critical Care Medicine.. 1995;23:760-66.
Back to Mr. C
• HD 66: making improvements, off pressors, on trach
collar, stating he does not want to “give up”
• HD 71: Creatinine rising, requiring more time on the
vent, held family meeting to discuss realistic goals, not
recommending initiating dialysis, family to discuss
• HD 73: Creat now 4, oliguric, unresponsive, on vent,
family considering dialysis
• Met with family, discussed that “everything” has been
done. Family in agreement to focus on comfort
• Patient dies comfortably with family at bedside early on
the morning of HD 74
Real World Application
in CCU
Goals Of Care Consult
Mr. F
• 68 year old male with chronic CHF,
chronic renal failure admitted with fluid
overload
– Noted to have worsening renal function
– Started on CVVHD
– Milrinone initiated
Mr. F
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Lives in rural part of Tennessee
Limited resources locally
He cannot get ultrafiltration locally
Wife (who is a LPN) has been pushing
120mg of lasix IV at home bid
• Palliative Care consulted to assist with
“goals of care”
Introducing the elephant in the
room
End of Life Discussions
• What does the patient/family know?
• What does the patient want to know?
• Who are the key decision makers? Patient’s
support system?
• What are the present concerns? Future
concerns?
Common Patient Concerns
• Physical Symptoms (provider)
– Pain
– Fatigue
– Insomnia
• Emotional Symptoms (social worker)
– Worries about welfare of family
– Dependence on others
Common Patient Concerns
(cont)
• Psychological Concerns (social worker)
– Making peace with ones own mortality
– Completing life tasks
• Spiritual Concerns (chaplain)
– Faith and religion
Common Family Concerns
• Physical:
– “If she would just eat more”
• Psychological:
– “Will my wife suffer?”
More Family Concerns
• Emotional:
– “We need to make plans, but will
discussing these details depress her?”
– “I get that she is dying, but how do I talk
to her about it?” …..or…
– She has gotten through rougher times
than this one, she will get through this
one too
Discussions surrounding death
• Patients are generally relieved to be
able to openly communicate their
concerns
• Families want assistance in opening
up a dialogue
• Most patients/families appreciate
honesty
Back to Mr. F
• Dialysis catheter placed
• Patient discharged on Milrinone but was
readmitted within a week with fluid
overload
• Discharged again & gains about 20 pounds
over holidays
Mr. F
• Readmitted with worsening fluid overload
• Team feels that it is not useful to continue
dialysis
• Patient understands he is dying but not
ready to transition to comfort
• Information about hospice given during
last admission
• Unfortunately, local Hospice can not
provide Milrinone
Mr. F
• Palliative Care re-consulted, pt back in CCU
• Explore patient/wife’s perception of
patient’s condition.
Mr. F
• Patient is confused-lacks capacity to make
decisions
• Wife does not think he is worse
• Cardiologists feel he is worse
• What do you do????
Changing goals
• Shifting to a different goal requires
change:
– Acute decompensation
– Physician setting limits
But back to Mr. F…
• Primary cardiologist informs patient and
wife that hemodialysis is not helping and
they will not continue it.
• Also discusses that Milrinone is not
helpful at this time, pt’s death is
unavoidable
• Patient is discharged home with hospice
• He dies peacefully at home 2 weeks later
Resources for Palliative Care and
Hospice
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www.capc.org
www.nhpco.org
www.eperc.mcw.edu
www.hpna.org
www.aahpm.org
www.getpalliativecare.org
Thank you for your attention!
Please feel free to contact me with
any questions:
Jill Nelson
[email protected]