Transcript Victoria Hospital - Abundant Life Hospice Palliative Care

A new approach
Dr Clint Cupido And Sr Pitout
Problem
• Victoria Hospital M & M
statistics of 2007 – 48.8% of
patients died from predicted
unavoidable.
• Every year 683 beds get taken
up by admissions of regular
revolving door patients.
• Most common repeated
admissions
» Chronic organ failure
patient
» Elderly frail patient
VICTORIA HOSPITAL
Admissions /year ( % )
Deaths/year ( % )
Cardiac disease : CCF
33.2
12
Pulmonary disease: COPD
25.7
8.2
Chronic Renal Failure
10.5
3.1
CVA
21.6
14.8
Cancer
9.6
6.3
The Lancet: 12 September 2009: Burden of non-communicable
disease in South Africa
• Cardiovascular diseases, diabetes mellitus, respiratory diseases, and
cancers together contributed to 12% of the overall disease burden, and
neuropsychiatric disorders accounted for 6%.
• WHO estimates place the burden from non-communicable disease in
South Africa as two to three times higher than that in developed
countries
• Agincourt study emphasises the emergence of non-communicable
diseases & increase in mortality: 270 and 180 per 100 000 population for
men and women, respectively, by 2002—05.
Problems encountered at Victoria
Hospital
1.
Same patient with multiple admissions –
2.
Ad hoc plans get made on each admission – a
3.
Lots of problems with symptom control -
4.
No long-term management plan gets made or
Bed
shortage and hospital functioning at capacity >100%
different doctor sees to the patient and causes lack in
continuity of care.
creates high anxiety in the patient, leading to family
bringing patient to the Emergency Unit
plan regarding similar situation in the future
Problems encountered at Victoria
Hospital - cont
5.
Overworked doctors with large number of patients – no
time to council family
6.
Only 2 social workers for massive workload
7.
Families struggle to get to hospital and when do come
during visiting hrs no doctors around
8. Patient dies in hospital – away from his family and surroundings.
9. Family or the patient’s carer is given minimal support: often a
phone call in middle of the night saying that their loved one has suddenly passed away.
10. Hospices are barely coping with current patient load Cancer and
HIV, they feel they will not be able to cope with the projected
number of patients
4. Intervention
Public Hospital Palliative
Care Program
Improve
Quality of Care
Save costs
What Is Palliative Care?
(WHO definition)
Palliative Care is an approach to care which improves the
quality of life of patients and their families facing
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 physical, psychosocial and spiritual
problems.
Its goal is much more than comfort in dying; palliative
care is about LIVING
Improve Quality of Care
• Improved pain & symptom control
• Decrease anxiety & psychological strain.
• Improve communication between patient &
health care provider
• Allow to plan for future & increase time spent
with loved ones
• Support for family & carer – acceptance &
bereavement
Cost savings & increase
available beds
• Journal of General Internal Medicine, Sept 2008
– 78 356 patients enrolled
– Measure hospital visits in final 6 months of life & primary care physician
visits in preceding 12 months
More primary care visits associated with
– fewer hospital days at end of life ( 13.4 days vs 15.3)
– Less in hospital deaths (40% vs 44%)
• Journal of Palliative Medicine: Cambell Hungtington Hospital,
Kentucky
– Study in patients with advanced disease not yet fitting hospice admission
– Average cost/patient = $1200 - $3000 but decreased $700/day + savings
up to $3000/ pt through early discharge - Palliative Care for 48 patients
@average of 2.5 days = cost savings of $276 000 in first quarter of 2007
PDE = R1039/bed/day
5. Methods
That each patient can not only experience life but life in abundance
ABUNDANT LIFE PROGRAM
•
•
•
•
Pilot project
Out patient program: 2 weekly sessions
Multi-disciplinary team approach
Patient support at all levels – physical, social,
spiritual
• Paradigm shift form ‘cure’ to ‘care’
• Thinking ahead & making a future plan
• Recognise death as natural closure to life
Which patient’s qualify?
1. Would you not be surprised if the patient dies within the
next 6 months – 1 year?
2.
Condition
Referral criteria
CCF
• symptoms despite maximal medical therapy
• ≥ 5 admissions in last 6 months
• other associated organ involvement eg renal
COPD
• disabling SOB at rest ( NYHA class IV)
• ≥ 5 admissions in last 6 months
• associated cardiac failure
Renal failure
• not suitable / declined for dialysis
• End stage renal disease ( GFR < 15ml/min )
Stroke
• severe disabling
•Severe dysphagia
•Recurrent fever & sepsis
Miscellaneous
• patient in need of surgery but not medically fit
• severely bedridden + bedsores
3. Functional decline
Karnofsky Performance scale
≤ 50%
Out patient program
SESSION 1
SESSION 2
1. Disease explanation + education
1. Movement & functionality
2. Spiritual care
DOCTORS +SPIRITUAL CARER
SESSION 3
1. Nutrition & Social stuctures
2. Spiritual care
DIETICIAN +SOCIAL WORKER
2. Spiritual care
PHYSIOTHERAPIST + OCCUPATIONAL
THERAPIST
SESSION 4
1. Program evaluation
2. Q & A
Support from the community
Hospice Palliative
Care Association
• Continuous
support
• Team Training
St Luke’s Hospice
Living Hope
Hospice
• Spiritual care
counsellor
• Home Base care
co-ordinator
• Co-ordinating
nursing sister
• Social worker
Rotary Club
Claremont
• Initial start-up
funding for Pilot
Project
Public Private Partnership
6. Measurable aims
1. Improved understanding & acceptance of
condition
2. Decreased anxiety surrounding death
3. Subjective improved care delivery
4. Improved understanding of health care
facilities & appropriate service seeking
5. Decreased hospital admissions
6. Cost savings
7. Results of Pilot Program
Patients participation:
• 55 patients were referred to the program
since mid-April 2009
• 7 of the referred patients died before the start
of the program
• 11 patients were enrolled.
• 2 of the patients enrolled died during
the course of the program.
A. Disease understanding: qualitative assessment
PRE -PROGRAM
% of patients answering yes
Do you know what your disease is called?
50%
Has doctor explained your disease to you?
50%
Do you understand your condition &
prognosis?
33%
Is your family aware of your condition &
prognosis?
14%
POST -PROGRAM
% of patients answering yes
Did you learn something new about your
disease?
100%
Do you have clear understanding of what
doctor said?
100%
Do you understand your disease better?
83.4%
Do you understand your medication
better?
83.4%
B. Evaluation psychological aspects and anxiety
surrounding death
• Questions was asked based on the standardized APCA
AFRICAN POS questionnaire
PRE- PROGRAM
37.5
Have you felt worried about your illness in the past 3
days?
Over the past 3 days, have you been able to share how
you are feeling with your family and friends?
Over the past 3 days have you felt that life is
worthwhile?
Over the past 3 days have you felt at peace?
Have you had enough help and advice for your family to
plan for the future?
Are you scared of dying?
Yes ( %)
75
No (%)
25
75
25
62.5
37.5
62.5
37.5
75
25
50
50
B. Evaluation psychological aspects and anxiety
surrounding death : POST-Program
POST-PROGRAM
Yes ( %)
No (%)
0
100
Do you feel at peace?
83.3
16.7
Do you feel your life is worthwhile?
87.5
12.5
Did we address your fears?
66.6
37.4
Did we address your problems?
71.4
38.6
50
50
Are you scared of the future?
Are you scared of dying?
B. Evaluation psychological aspects and anxiety
surrounding death : POST-Program
SPIRITUAL CARE
•‘for the first time I was given a opportunity to talk about the issues that
were worrying me.
•‘it was good to speak to people going through the same thing.’
•‘I was very worried at the start of the program but now I feel like a load
has been lifted...I feel free.’
•‘ it was nice to have a more than just my
physical needs addressed’
C. Subjective Improvement in Quality of Care
1. Quality of Program
– Patient’s rated each session. ( 1= unhappy with session, 5 = excellent session, no
changes)
– Average satisfaction rating = 4 ( very happy, minor changes)
2. Improved Quality of Life
– Increased awareness to treat patient’s symptoms, not just disease.
– Less time spent in hospital
3. Freedom to choose preferred place of death
–
–
Patients given free choice: 90% prefer to die at home, amongst family
Increase home deaths - All Abundant Life patients who died had
home deaths
4. Quality medical attention
–
Senior doctor & medical interns spend dedicated time with patient &
family
“ None of the other hospitals has ever cared about me in this way...”
D. Further admissions
• 2 x admissions during the course of the
program.
• 3 x admissions at 3 months after program–
decrease from 3 admissions /patient/month
(33)
COST SAVING $$$
Where to from here? - Areas of
improvement
1. Attitude, awareness and approach: better quality of care; greater
confidence and job satisfaction; more focused and proactive approach to
identified patients; additional benefits – teamwork communication,
respecting roles
2. Patterns of working: better organization & consistency of standards;
fewer patients ‘slipping through the net’; better recording and coordinating of care; better collaboration with specialists
3. Outcomes for patients and family carers: reduced hospitalization
– fewer admissions & shorter length of stay; more achieve dying in
preferred place of care.
(gold standards framework)
Post Pilot Project
•
•
•
•
Funding for a Palliative Care Co-ordinator
Sr Pitout
BUT NO EASY ROAD
Multiple teething problems and loss of
support
• Office Space, Telephone, Internet access, late
referrals
• Despite this we have seen
• We have started doing home visits
•
•
•
•
Despite this we have seen
We have started doing home visits
Availability of wheelchairs, assistive devices
We have attracted volunteers for supplying
refreshments
• Better quality of care but limited number of
patients still
• Communication still remains a key problem
• Once labled Palliative Care then resistance to
readmission
Future Vision: Integrated approach
Hospice(St Luke’s/
Living Hope)
Victoria Hospital PC
team
Day Hospital PC
team
Community Based
Services ( home care)
• End stage admission
• Expert Palliative Care advice &
symptom control
• Advanced medical care
• Specialist decision to cessation of
further intervention
• Prognosis discussion with patient
• Support Groups
• Disease education
• Recognition of palliative care
• Assistant care & support
• Health promotion
• Treatment adherence
THANK YOU !
Hospice Palliative Care Association
• Ms Maria Demjan
• Dr Liz Gwyther
Victoria Hospital
• Dr Clint Cupido
•Dr Katherine Krige
•Dr Petro Frankenveld
• Ms Rufqa Isaacs
•Mr Caraleigh Otto
•Ms F Salie
St Luke & Living Hope Hospice
• Dr Rene Krauser
•Ms Julia Rixon
• Sr Megan Tucker
•Pastor John
•Michelle
•Sr Ester Pepper
Rotary Club Claremont
“I’ve told my children that
when I die, to release balloons
in the sky to celebrate that I
graduated. For me, death is a
graduation.” Elizabeth Kubler-Ross