Transcript What is palliative care? - Curriculum for the Hospitalized Aging

CHAMP
How to Approach Palliative Care
in the Older Patient
Déon Cox Hayley, DO
University of Chicago
Objectives of session
1. To understand and be able to apply the
concept of gradual implementation of
palliative care.
2. Teach others
Traditional approach to end of life care
Curative care
Death
Continuum of Care Model
Curative
Curative Intent
Care
Disease Progression
D
E
A
T
Palliative Care
H
Death
Gradual implementation of
end of life care
• Curative measures:
– go all out toward prolonging life
• Hospice and palliative care:
– go all out toward symptom relief
• Challenge to sensitively negotiate
between those extremes with patients &
families
Outline
• Who?
• What?
• Where?
• When?
– Prognostication
• How?
Who?
• For patients who have serious or lifethreatening disease(s).
– Many appropriate conditions
• Not just cancer
• Don’t even have to have a traditional “diagnosis”
What is palliative care?
• Care with focus on quality of life.
– Symptom management
– Decision-making
Weighing benefits
and burdens
All decisions should
go through the lens
of how they will
impact the patient
Decisions in palliative care
• Will it help the patient?
– In their remaining life?
– Within their goals of care?
• If it will help, what are the burdens?
– Pain or other symptoms
– Physical limitations
– Risk of adverse events
– Cost
Is it worth it?
The model shows that the 4 steps in medication decision making
form a pyramid, visually representing the appropriate
medications at any level
Holmes, H. M. et al. Arch Intern Med 2006;166:605-609.
Use of the model in 3 distinct cases illustrates how it is used
depending on the 4 components
Holmes, H. M. et al. Arch Intern Med 2006;166:605-609.
An example of a distorted model shows that all 4 components may
not readily agree
Holmes, H. M. et al. Arch Intern Med 2006;166:605-609.
Palliative Care/Hospice
Palliative Care
Hospice
Where?
• Hospital
• Home
• Outpatient
• Nursing home
When?
• Prognostication
– Would you be surprised if this person
died within the next year?
– Other prognostic markers
•Age
•Co-morbidities
•Function
Many elderly are near the end of their
lives as indicated by the following
markers:
– Limited life expectancy
– Decreased reserve
– Co-morbidities and geriatrics syndromes
– Functional impairments
Upper, Middle and Lower Quartiles of
Life Expectancy: U.S. WOMEN, 1997
Quartile:
Age: 70
75
85
90
95
Top 25 %
21.3 17.0 13.0 9.6
6.8
4.8
50th percentile
15.7 11.9 8.6
5.9
3.9
2.7
Lowest 25%
9.5
2.9
1.8
1.1
6.8
80
4.6
(NCHS. Life Tables of the United States, 1997. Adapted from Walter & Covinsky. JAMA 2001;285(21):27506.)
Upper, Middle and Lower Quartiles of Life
Expectancy: U.S. MEN, 1997
Quartile:
Age: 70
75
80
85
90
95
Top 25 %
18.0 14.2 10.8 7.9
5.8
4.3
50th percentile
12.4
9.3
6.7
4.7
3.2
2.3
Lowest 25%
6.7
4.9
3.3
2.2
1.5
1.0
Comorbidity and prognosis: Simply
add up the co-existing conditions
180
160
140
120
3-year mortality 100
/1000
80
60
40
20
0
Breast cancer
Other causes
0
1
2
# of comorbidities
3+
Geriatric Syndromes and
Remaining Life Expectancy (RLE)
• Cognitive Impairment (Dementia): Acquired
decline in memory and in at least one other
cognitive function sufficient to affect daily life.
• Disability: Dependency in carrying out
activities essential to independent living and
maintaining quality-of-life.
• Frailty: A state of high vulnerability for
adverse health outcomes characterized by
weakness, weight loss, poor endurance, low
physical activity, and slow gait speed.
RLE, 70 y.o. Men,
with and without Alzheimer Disease
18
16
14
12
Upper Quartile
Middle Quartile
Lower Quartile
10
8
6
4
2
0
Overall
Alzheimer's
Functional Impairment
• Percent of Persons Reporting Problems with
Two or More Activities of Daily Living (ADLs), By
Age
1994-1995
Percent*
• Total
65+
6.0
• Age Group (yrs)
65-74
75-84
85+
3.1
7.8
18.1
2-year mortality rate
age ≥ 70 years
8%
14%
27%
 40%
if fully independent,
if dependent in IADL,
if dependent in ADL,
if institutionalized.
Rueben Am J Med 1992;93:663
99
7
99
7
99
7
99
7
8/
1/
19
97
10
/1
/1
99
7
12
/1
/1
99
7
6/
1/
1
4/
1/
1
2/
1/
1
1/
1/
1
Function
Prognosis Can Be Difficult to Predict
120
100
80
60
CANCER
CHF
40
20
0
Prognostication
• Disease Associated Prognostic Factors
• Non-disease-Associated Prognostic
Factors
– Age
– Functional status
– Co-morbidity
ALGORITHM for the TREATMENT OF OLDER CANCER
PATIENTS
Patient
Age
Comorbidity
Functional Status
Life Expectancy (LE)
LE>Cancer Survival
LE<Cancer Survival
Treatment Tolerance
Adequate
Inadequate
Life-prolonging Therapy
Palliative Therapy
Figure 20.1 Comprehensive Geriatric
Oncology
L. Balducci et al
How?
• Determine important factors influencing
life expectancy
• Determine important factors which might
influence approach to care
•Physical limitations
•Patient choice/goals
• Communicate with patient
• Determine plan
Potential Goals of Care
•A good death
•Relief of suffering
•Quality of life
•Maintenance or improvement in function
• Avoidance of guilt
• Staying in control
• Support for families and loved
ones
•Avoidance of premature death
•Cure of disease
The model shows that the 4 steps in medication decision
making form a pyramid, visually representing the appropriate
medications at any level
Holmes, H. M. et al. Arch Intern Med 2006;166:605-609.
Goals may change as disease
progresses
• Some goals may take priority over
others
• The shift in the focus of care is
– gradual
– an expected part of the continuum
• Review goals with any change
Mr. P—56 years old
• Admitted with sepsis secondary to chronic
pressure ulcers
• Hospitalized 2 months with multiple
complications
• Called to assess for palliative care
PMH
• IV drug abuse and alcoholism
• Epidural abcessparaplegiahorrible stage IV
pressure ulcers, non-healingchronic hardware
infection/osteomyelitis
• Re-current sepsis (Several admissions to the
hospital this year)
• PVD s/p Rt BKA
• HTN
• DVT
• Probable hepatoma dx’ed by CT + elevated AFP
Hospital Course
• Pain
– Hesitant to give too many narcs b/c of abuse history
• Been in the hospital 2 months, tired
– PICC line w/IV abx
– Frequent lab draws
– DVT
• Refusing therapies (completely competent)
– Diverting colostomy to prevent wound reinfection
– Liver bx
– Frequent lab draws
– More imaging
Exam
• BP= 110/70
• Alert, oriented, slightly uncomfortable
appearing
• Poor dentition
• Chest– HRRR, soft sys murmur
– Lungs clr
• Abd-tight distension
• Sacral ulcer-down to bone (metal)
• Rt BKA—stump clear, Lt foot dry, sl cool but
skin intact
Prognosis
• Hepatoma
– 20% survival at one year, 6% 5-year survival
• Infections
– Re-occuring
• Function
Communication
• Attending told him he had 100% mortality
at one year.
• “I was told I would live at least one year.”
Goals of care
• In light of limited life expectancy, he
wanted to spend his time with his mother
and granddaughter at home.
• Pain control
• Therefore, appropriate for
palliative care
How to implement palliative
care
• Look at every order,
• Evaluate benefits to him vs. burdens
– Medication
– Therapies
– Diagnostics
The Medication Appropriateness Index
Holmes, H. M. et al. Arch Intern Med 2006;166:605-609.
What orders?
•
•
•
•
•
Wound care
Telemetry
Diet
Echo
Labs—
– Frequent blood cultures
• Medications
– Pain
– IV Abx
– Antihypertensive
Improving Care for Patients
with Advanced Disease
• Challenge in those with long term
progressive disability and eventual
death:
– No point marks a dramatic
transition from ‘cure’ to ‘care’
– Disease-modifying treatments
mixed with symptom prevention
and relief
– Comprehensive advance care
planning
Summary
• Identify those with limited life expectancy
for starting palliative care
– Focus on symptom management
– Put all your orders through the lens of how it
will help the patient