Transcript Palliative Care - American Academy of Home Care Medicine

Palliative Care and HomeBased Primary Care: An
Intertwined Population
Health Delivery Model
Moderator:
Theresa Soriano, MD MPH
Panelists:
Ina Li, MD
Pam Miner, MD
Steven Robertson, MD
Mary Sayre, MSN RN
Barbara Sutton MSN APRN ACHPN
Faculty Disclosures
• Li – no relevant disclosures
• Miner – no relevant disclosures
• Robertson – no relevant disclosures
• Sayre – no relevant disclosures
• Soriano – no relevant disclosures
• Sutton – no relevant disclosures
Objectives
• Describe the burden of chronic illness and suffering in
the home-limited population, and how palliative care
can address these needs
• Identify practical ways to effectively incorporate
palliative care principles into home-based clinical
practice
Agenda
• Introduction
• Goals of Care & Anticipatory Guidance
• Pain Management 101
• Non-pain symptom management
• Delirium
• Panel Q&A
Improving the U.S. Health Care System
• improving the experience of care,
• improving the health of populations,
and
• reducing per capita costs of health
care.
5
Illness, complexity and cost
10% of patients account for 64%
of total costs
40% account for 31% of
total costs
50% account for 3%
of total costs
Conwell LJ, Cohen JW. March 2005. AHRQ
6
Shifting Expectations
• Our population:
• Homebound
• Average age 84
• Requiring assistance with ADLs, multiple comorbidities
• About 26% die each year.
• Frailty, functional dependence, cognitive impairment,
symptom distress and increasing family support needs due
to long-term caregiving burden.
• In addition to geriatric decline, specific disease progression
which in our population include multiple progressive chronic
diseases, add to the need to move to a palliative focus of
care.
Chai, E., Meier, D., Morris, J., & Goldhirsch, S. (2014).
Medicare Definition of Palliative Care
Palliative care means:

patient and family-centered care that
optimizes quality of life by anticipating,
preventing, and treating suffering
Palliative care throughout continuum of illness
involves:

addressing physical, intellectual, emotional,
social, and spiritual needs and

facilitating patient autonomy, access to
information, and choice.
73 FR 32204, June 5, 2008
Medicare Hospice Conditions of Participation – Final Rule
8
Palliative Care – Principles vs.
Specialty
All clinicians should be skilled at palliative care principles of:
(1) basic pain and symptom management concurrent with active disease
management
(2) communication with patients and loved ones about prognosis,
expectations, and advance care planning
Complex or late-stage conditions and situations require palliative care
specialists who are:
(1) Specialty trained/certified
(2) Typically part of a trained interdisciplinary team (physician, an
advanced practice nurse, a social worker and a chaplain)
(3) Separate from, or part of, hospice benefit
https://www.capc.org/payers/palliative-care-definitions/
Population-Based Health
An integrated system of services
and partnerships meeting the needs
of the community throughout the
entire continuum of health
Well
Optimize health
Wellness Services:
 Wellness
 Diet and Nutrition
 Mammography
 Colonoscopy
 Mental Health
 Social programs
 Advance Directives
 Goals & Preferences
Palliative
Care
Severely Ill
Manage symptoms>
conditions
Chronically Ill
Manage conditions >
symptoms
Slide adapted from Buxton & Twaddle
Value of HBPPC
• ↑ Primary care visits; ↑ Home health; ↑ Hospice
• High vaccination rates
• High rates Advance Care Planning
• ↑ Patient/Caregiver Satisfaction
• ↓ Caregiver Burden
• Improved symptom management including pain, anxiety, depression,
fatigue, and loss of appetite
• 10-17% lower Medicare Costs ($8,477 savings per beneficiary; $6.1
million total savings)
 ↓ Hospitalizations 9-44%
 ↓ Emergency Department 10%
 Low institutionalization rate (<10% NH admission)
•
•
•
•
DeJonge, et al. Effects of Home-Based Primary Care on Medicare Costs in High-Risk Elders. JAGS, Oct 2014
Edes, et al. Better Access, Quality and Cost for Clinically Complex Veterans with Home-Based Primary Care JAGS Oct 2014
Ornstein, et al. Reduction in Symptoms for Homebound Patients Receiving Home-Based Primary and Palliative Care. Journal of
Palliative Medicine Sept 2013
Melnick, et al. House Calls: California Program For Homebound Patients Reduces Monthly Spending, Delivers Meaningful Care. Health
Affairs Jan 2016.
The proof is in IAH . . .
“…Independence at Home participants saved
over $25 million in the demonstration’s first
performance year – an average of $3,070 per
participating beneficiary – while delivering high
quality patient care in the home.”
https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2015-Press-releases-items/2015-06-18.html
HBPC and Palliative Care are Uniquely
Effective in Achieving the Triple Aim
Both HBPC and Palliative Care:
• Treat the patient and family, not the disease
• Reduce symptom burden
• Incorporate caregivers, social factors and care
preferences into care plans
• Advocate for appropriate care in line with
above
Which thereby:
• Creates appropriate, patient-centered plans of
care
• Improves patient and family satisfaction
• Reduces costs
Goals of Care &
Anticipatory Guidance
Pam Miner, MD
Mary Sayre, MSN RN
Housecall Providers, Portland OR
Advance Care Planning involves:
• Exploration of values, priorities, preferences, what
gives meaning to one’s life, and what defines an
acceptable quality of life.
• Identification of personal goals of care in the event
of a severe illness, and the discussions of different
treatment options in the context of these goals.
• May include: future hospitalizations,
home/homecare preferences, resuscitation,
goals and expectations of comfort and symptom
management, spiritual support, life-sustaining
treatment (ventilator, artificial nutrition).
IOM Dying in America –http://www.iom.edu/Reports/2014/Dying-In-America-ImprovingQuality-and-Honoring-Individual-Preferences-Near-the-End-of-Life.aspx.
Case
• 96 yo female
• ischemic cardiomyopathy,
aortic regurgitation, heart
failure with preserved EF,
atrial fibrillation with RVR
and anxiety
• Functional status had been
declining
• multiple hospitalizations and
procedures
Key Points in Conversation
• Understanding:
• “What is your understanding now of where you are with
your illness?”
• Information Preferences:
• “How much information about what is likely to be ahead
with your illness would you like from me (or from your
PCP)?”
• “With whom do you prefer I share this information with?”
• Prognosis:
• Share based on information preferences
• Goals:
• “If your health situation worsens, what are your most
important goals?”
Bernacki R, Block S JAMA Internal Medicine published online Oct 20, 2014.
doi:10.1001/jamainternmed.2014.5271
Key Points in Conversation
• Fears/Worries:
• “What are you biggest fears and worries about the future with your
health?”
• Function:
• “What abilities are so critical to your life that you can’t imagine living
without them?”
• Trade-offs:
• “If you become sicker, how much are you willing to go through for the
possibility of gaining more time?”
• Family:
• “How much does your family know about your priorities and wishes?
Bernacki R, Block S JAMA Internal Medicine published online Oct 20, 2014.
doi:10.1001/jamainternmed.2014.5271
Additional Language
• What is life like for you right now?
• What do you understand about your illness?
• You seem to understand a lot, but let me clarify some items . . .
• Given what you understand about your illness now, what do you hope
for?
• What do you worry about?
• While we hope for the best response to treatments, if you do decline
further despite everyone’s best efforts, it is important to understand if
there are any situations that you would consider an unacceptable sort
of life (give examples of realistic outcomes expected with progression
of their disease process)
Case
Challenges to advance care
planning
• Designated health care agent must understand
and agree to follow the patient’s wishes for care
• Patient and family fear of discussing health care
issues
• Conversations may be time-consuming and
require prognostication on the part of the
clinician
• Completed documentation of patient
preferences for care need to be accessible to
those providing the care
Chai, E., Meier, D., Morris, J., & Goldhirsch, S. (2014). Geriatric palliative care, a practical guide for
clinicians. New York: Oxford University Press.
Team Support
• What we’ve learned from IAH regarding
episodes of care, transitions and impact of
patient preferences.
• An integrated team approach that is patientcentered and coordinated can improve patient
outcomes as well as follow patient preferences.
(IOM, 2012).
IOM Core Principles & Values of Effective Team-Based Health Care -2012, Discussion Paper,
www.iom.edu/tbc.
Transitions of Care
• Key opportunities to re-clarify goals of
care when a team can help:
• Change in medical condition when
hospitalization may be warranted
• During a hospitalization
• Prior to hospital discharge
• After discharge
• How goals of care are documented in your
E.H.R. can affect how they are followed.
Documentation
• Physician Orders for Life Sustaining Treatment
(POLST) adopted in Oregon since 1991.
• Advance directives, POLST, and goals of care
conversations are documented multiple places
in our EHR.
• At the time of hospitalization the POLST is a
key item of information that sent to the hospital
and reinforced by our transition team members.
www.polst.org
Case
Effective Goals of Care
Discussion
• Focus on the patient’s life, goals,
experience of illness, fears and concerns
• Allow silence and acknowledge and
explore emotions
• Provide prognostic information in ranges,
acknowledging inherent uncertainty
• Gets the patient or family talking more
than 50% of the time
• Explores effective treatments that
support patient goals
Basic Principles of End-of-Life
Communication
• Patients want the truth about prognosis.
• You will not harm your patient by talking about
end-of-life issues.
• Anxiety is normal for both patient and clinician
during these discussions.
• Patients have goals and priorities besides living
longer.
• Learning about patient goals and priorities
empowers you to provide better care.
Bernacki R, Block S JAMA Internal Medicine published online Oct 20, 2014.
doi:10.1001/jamainternmed.2014.5271
Pain Management
Steven Robertson, MD, Medical Director
Kindred House Calls, Cleveland, OH
Kindred at Home Hospice – Cleveland, OH
AAHCM Clinical Competencies
What is Pain?
Merriam-Webster Dictionary:
• An unpleasant feeling occurring as a result of
injury or disease, usually localized in some part
of the body
• Bodily suffering characterized by such feelings
Taber’s Medical Dictionary:
• Unpleasant feeling conveyed to the brain by
sensory neurons
• More than sensation, but physical awareness of
pain
• Includes subjective interpretation of the
discomfort, including the emotional
response
How is it described and measured?
Need for Comprehensive Assessment to Identify
Site & Type of Pain:
• Bone, soft tissue, nerve-related, smooth
muscle, others
• Sharp, dull, achy, burning, crampy, constant,
intermittent
Use Pain Scales to Rate Severity and Track
Changes
• 0-10 Numeric Rating Scale
• Wong Baker FACES Pain Rating Scale
General Principles of Pain Medication
1.
2.
Three step approach: scheduled non-opioid for mild pain, low dose
opioid for moderate pain, strong opioid for severe pain
Schedule medications based on duration of action rather than
allowing pain to spiral out of control
•
•
3.
4.
5.
6.
7.
Always have Short Acting “Rescue” available for Breakthrough Pain
Rescue dosage is 10-15% of the 24 hour around the clock dose
Always think ahead to manage known opioid side effects (expected
and manageable: constipation, nausea, pruritis, sedation versus
serious: anaphylaxis)
Plan ahead for route of administration, but understand IM, IV and
SQ pumps often unnecessary, uncomfortable, problematic
Add Co-analgesics as indicated by type of pain to reduce need for
opioid escalation and for better pain control
Reassess often, reduce opioids when able and when undue effects
Request expert help for switching between opioids,
especially Methadone
www.ohiopaininitiative.org
Non-Opioid Co-Analgesics
Bone and Soft Tissue:
• NSAIDS (Ibuprofen, Naproxyn), COX2 (Celebrex)
• Steroids (Dexamethasone, Prednisone) for
Metastases
Anxiety:
• Benzodiazepine (Lorazepam, Diazepam)
• Butyrophenon (Haloperidol)
Nerve Damage (Neuropathy, Entrapment):
• Anticonvulsants (Gabapentin, Pregabalin, Valproic
Acid)
• Antidepressants (Cymbalta, even Zoloft)
Smooth Muscle Spasms (Bladder, Bowel):
• Anticholinergic (Hyoscyamine, Dicyclomine,
Oxybutinin)
The Myths of Morphine
• Morphine causes addiction: There is a very small chance of
psychological addiction in one who is prescribed appropriate
doses of opiates for the treatment of pain or dyspnea
• Morphine is too strong: It is exactly as strong as hydrocodone
(equianalgesic)
• Morphine caused delirium in the hospital: Hospitalization and
untreated pain more often cause delirium
• Morphine causes respiratory depression: Massive doses to opioid
naïve patients would be required
• Morphine Accelerates Death and is Euthanasia: When the
medication is given to ease active pain or dyspnea, that is the
desired effect. It does not cause the death that is actively
occurring apart from and without the Morphine
Opioid Induced Neurotoxicity
• Increasingly recognized undue effect of opioids
• Accumulation of Toxic Metabolic Byproducts which
are actually neuroexcitants
• Clinical Manifestations:
• Myoclonus
• Hyperalgesia and Allodynia
• Seizures
• Misinterpreted as disease related pain, and opioid
dose is often rapidly escalated, worsening
symptoms
• Do not provide reversal agents (Naloxone)
• Reduce dose, rotate to another opioid, hydrate,
benzodiazepines
www.palliative.info/teaching_material/oin.ppt
Not all distress is due to Physical
Pain
www.palliative.info/teaching_material/oin.ppt
Summary
• HBPC clinicians are the first line defense against
pain, with readily available specialist backup
• Become familiar with Morphine Equivalent Daily
Dosing, Equianalgesic tables (Fentanyl)
• Schedule according to half life, with breakthrough
dosing available, adjust frequently based upon
response
• Counsel patients, families, caregivers regarding the
myths of pain medication, advocate for pain relief
• Recognize that all distress is not due to physical pain
• Experienced, expert interdisciplinary team are readily
available for difficult cases
Non-Pain Symptoms
Barbara Sutton, MSN APRN ACHPN
Amita Healthcare
Objectives
Understand Management of Dyspnea at Home
• Understand pharmacologic and nonpharmacologic treatment options
Brief discussion of:
• Nausea/vomiting
• Anorexia/cachexia
Oxford Textbook of Palliative Medicine (5ed) Cherney, Fallon, Kaasa, Portenoy, Currow 2015
Fast Facts; Palliative Care Network of Wisconsin http://www.mypcnow.org/#!fast-facts/c6xb
Managing Dyspnea
Dyspnea is subjective, just as pain is.
Dyspnea is whatever the patient says it is.
Dyspnea is associated with many
disease states
• Respiratory infection
• COPD/Asthma
• Ascites
• CHF
• Anemia
• Pulmonary fibrosis
• Tumor invasion
Dyspnea Assessment
• Acute or chronic?
• Does it change with position change?
• What are associated symptoms: anxiety,
restlessness, spiritual/existential issues?
• Aggravating/alleviating activities
• Response to medications
• Use of Borg Scale (American Thoracic Society)
Cause
Assessment
Management Options
COPD/Asthma
Wheezing, cough
Bronchodilators,
corticosteroids, oxygen
Respiratory
infection
Fever, cough, inspiratory
crackles, secretions
Expectorants, antibiotics
Ascites
Decreased breath sounds, Diuretics, paracentesis
fluid on palpation
CHF
Early inspiratory crackles,
edema, anemia
Pulmonary
fibrosis
Diminished breath
Opioids, oxygen
sounds, cough, cyanosis,
tachycardia, fatigue, chest
pain
Anemia
Dizziness, hypotension,
pallor, fatigue
Diuretics, oxygen
Blood transfusions, oxygen
Center to Advance Palliative Care https://www.capc.org/
Non-Pharmacological
Management of Dyspnea
• Open windows or use fan (trigeminal nerve)
• Position to facilitate chest expansion
• Pursed lip breathing
• Cool humidified air
• Relaxation/distraction
• Reiki
• Spiritual practices
• Energy conservation
• Oxygen 1-3 Liters per minute
Medications
Morphine is the gold standard
• 10-20 mg by mouth (pill or liquid) every 1-4
hours as needed
• may use extended release for chronic dyspnea
• Risks:
• Constipation
• Use with caution in bradycardia,
hypotension, CO2 retention
• Reduced respiratory rate
• Start low, go slow
• For tachypnea, may be beneficial
Anxiolytics
• Opioids
• Benzodiazepines
• Lorazepam 0.5-2 mg every 6-12 hours as
needed
• Not first line
Nausea and vomiting
• Nausea – an uneasiness of the stomach that
does not always lead to vomiting
• Vomiting – forcible voluntary or involuntary
emptying of stomach contents
Causes
Unrelieved pain/headaches
Constipation
GI stasis
Bowel obstruction
Anxiety
Oral candidiasis
Medication side effects
Chemotherapy
Hypercalcemia
Motion sickness/dizziness
Infection
Dehydration/electrolyte
imbalance
GERD
Peptic ulcer disease
Gall bladder disease
CAD
Esophagitis – cancer or infectious
Medications – NSAIDs, ASA,
steroids, caffeine, alcohol
Center to Advance Palliative Care https://www.capc.org/
Non-pharmacologic Treatments
• NPO
• Clear liquid diet
• Reduce stress
• Small frequent meals
• Eat slowly
• Good oral hygiene
• Sit upright for 1 hour after eating
Anorexia/Cachexia
• Defined as lack of appetite and tissue wasting
• Complex pathophysiology
• Interventions should be addressed as part of
the patient and family’s goals
• Often irreversible related to a terminal disease
process
• Normalize the natural way we eat and drink
less
Potential Causes
•
•
•
•
•
•
•
•
•
•
Pain
N/V
Depression
Medication side effects
Constipation
Altered mental status
Fatigue
Impaired gastric emptying
Dyspnea
Mucositis/candidiasis
Non-pharmacological
Treatments
• Avoid weighing
• Good oral hygiene
• Favorite foods
• Different textures/temperatures
• Nutritional supplements
• Nurture non-food activities
• Normalize decrease in appetite
• Give permission to eat less/feed less
Delirium
Ina Li, MD, Director of Clinical Geriatrics
Christiana Care Health System, DE
Definition
• Is a syndrome of
disturbance of
consciousness, with
reduced ability to
focus, sustain, or shift
attention, that occurs
over a short period of
time and fluctuates
over the course of the
day
Under-Recognized
• Only 20% of cases recognized by
physicians
• Only 50% of cases recognized by
nurses
Outcomes
• Delirium in elderly (>65 years) patients was
associated with an increased risk of
• Death
• Institutionalization
• Dementia
1.
2.
Witlox J, Eurelings LS, et al. Delirium in the elderly patients and the risk of post-discharge mortality,
institutionalization, and dementia: a meta-analysis. JAMA. 2010; 304(4): 443-451
Siddiqi N, House AO. Occurrence and outcome of delirium in medical in-patients: a systematic
literature review. Age Ageing. 2006; 35(4): 350-364.
Precipitating Factors
Mnemonic:
Drugs
Electrolyte Disturbances
Lack of Drugs
Infection
Reduce sensory input or mobility
Intracranial
Urinary, fecal
Myocardial, pulmonary
Surgery
Confusion Assessment Method
(CAM)
Diagnosis Requires #1 and #2 and either # 3 or #4
1. Acute Change in Mental Status and Fluctuating Course
• Is there evidence of an acute change in cognition from the
patient’s baseline
• Does the abnormal behavior fluctuate during the day?
2. Inattention: Does the patient have difficulty focusing inattention?
• Digit span
• Serial 7s
• “World” backwards
3. Disorganized thinking
• Is the patient’s thinking disorganized or incoherent?
4. Altered level of consciousness
• Is the patient’s mental status anything other than alert?
Khan, B, Zawahiri, M, et al. Delirium in Hospitalized patient: implications of Current Evidence on Clinical Practice
and Future Avenues for Research – A systematic evidence review. J of Hospital Medicine, 2012; 7(7): 580-589
Treatment
Step 1: Identify and treat reversible causes
Step 2: Maintain behavioral control
Step 3: Anticipate and prevent complications
Step 4: Restore Function
Agitation
• Pharmacologic treatment may be necessary for
behavior that is dangerous to patient or others and
does not respond to other management strategies
• Hypoactive Delirium was the most prevalent delirium
subtype
Hosie, A, Davidson, P, et al. Delirium prevalence, incidence, and implications for screening in specialist
palliative inpatient care settings: A systematic review. Palliative Medicine. 27(6): 486-498
Pharmacologic Therapy
Agent
Dosage
Benefits
Adverse Events
Haloperidol
0.25-1 mg po,
im, pr, or IV q
4 hr prn
agitation
Few Hemodynamic
effects
EPS, especially if >3
mg/day
Olanzapine
2.5 mg po or
im q 12, max
dosage 20 mg
q 24
Fewer EPS than
haloperidol
More sedating than
haloperidol
Quetiapine
25-50 mg po q Fewer EPS than
12
haloperidol
More sedating than
haloperidol;
hypotension
Risperidone
0.25-1 mg po
q 4h
Similar to
haloperidol
Might have slightly
fewer EPS
Lorazepam
0.25-1 mg po
or IV q 8 hr
Use in sedative or
alcohol withdrawal
More paradoxic
agitation, respiratory
depression than
haloperidol
Campbell N, Boustani M, et al. Pharmacological management of delirium in hospitalized adults: a systematic evidence review. J
Gen Intern Med. 2009: 24:848-853.
Prevention of Complications
• Non-Pharmacologic
• Return to usual routine
• High-quality Sleep
• Avoid psychotropics, anticholinergics,
Benzodiazepines, and opioids
• Prevent electrolyte disturbance and
dehydration
• Adequate lighting
• Hearing aids
• Improve communication and re-orientation
Restore Function
Panel Conclusions
• Both HBPC and palliative care expertly address
chronic illness and suffering in the home-limited
population
• Delivering HBPC and palliative care in the home
can improve patient experience, outcomes and
cost
• Clinicians can adopt basic palliative care
principles into daily HBPC practice, and should
help patients access specialty palliative care,
including hospice, when appropriate
Additional resources
• Hospice and Referral Criteria
http://www.caringinfo.org/i4a/pages/index.cfm?
pageid=1
• Clinical and Advocacy Resources
• https://getpalliativecare.org/
• https://www.capc.org/
• http://www.nhpco.org/resources/end-lifecare--resources
• http://www.epec.net/
• http://aahpm.org/
Panel Q&A
•
Pam Miner: [email protected]
•
Mary Sayre: [email protected]
•
Steven Robertson: [email protected]
•
Barb Sutton: [email protected]
•
Ina Li: [email protected]
•
Theresa Soriano: [email protected]
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