Transcript Palliative Care, Quality, and everything that lies in between*

Palliative Care, Quality, and
everything that lies in
between…
James Downar, MDCM, MHSc, FRCPC
Critical Care and Palliative Care
University Health Network
Conflicts of Interest
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Objectives
1. Appreciate how the quality "agenda" might
worsen EOLC
2. Define the challenges for EOLC providers
working in an age of "quality”
3. Propose a framework for improving and
measuring quality in EOLC
Quiz
What is the most common health
event in Canada?
EOL Care in Canada
Institutionalized
• ~80% of Canadians want to die outside of
hospital
• 71% of Canadians die in an institution
• 58% die in an acute hospital
• Average Canadian spends 14 of final 30 days of
life in a hospital
CIHI. Health Care Use at the End of Life in Western Canada (2007)
Aggressive
Location of Inpatient Deaths
Location
SHSC (2011)
TGH/TWH (2010)
ICU
Ward
46%
41%
45%
55%
PC Unit
Other
5%
7%
N/A
N/A
• More than half admitted to ICU at some point
Downar et al. Resuscitation 2013. epublished.
Sadler E et al. Am J Respir Crit Care Med 187: A3882.
Aggressive
• 22% of cancer pts in Ontario receive
• Chemotherapy in final 2 weeks of life
• ICU admission, ER visit or acute admission in final 30 days of life
ChemoRx
Ho TH et al. J Clin Oncol 2011;29:1587-91.
ICU
Aggressive
• Lower QOL for patient
• Discordance with desired location of death
• Shorter survival (?)
• More depression/anxiety in bereaved caregiver
• Higher rates of burnout in staff
• Higher costs to healthcare system
Wright et al. JAMA 2008;300;1665-73.
Nappa et al. Ann Onc 2011;22:2375-80.
Temel et al. N Engl J Med 2010;363(8): 733-742. Zhang et al. Arch Int Med 2009;169:480-8.
Nicholas et al. JAMA 2011;306:1447-53.
Poncet et al. AJRCCM 2007;175:698-704.
Mealer et a. AJRCCM 2007;175:693-7.
Disjointed
• 300 consecutive RRT referrals
• 24 (8.3%) – Family meeting, new DNR
• 80% called for classic ABC criteria, 63% died
Time
Palliative
Care
Spiritual
Care
PRN
Opioids
PRN
Sedatives
Next 48h
17%
8%
17%
8%
12%
75%
42%
Entire
29%
Admission
• 2 patients died without EOL meds or consultations
Downar et al. J Crit Care 2013; epub Jan 18, 2013.
Disjointed
• Turning off an ICD after DNR - 27%
• 8% shocked <1 hr from death
• Advance care planning in adult congenital
heart disease
• First conversation 2d before death
• 50% die receiving CPR
Ann Intern Med 2004;141:835-8.
Tobler et al. Pall Med 2012;26:72-9.
Poor Access to Palliative Care
• 30% of Canadians have access to PC
• 13-16% of hospitalized patients receive PC
prior to death
Carstairs, S. Raising the bar: a roadmap for the future of palliative care in Canada (2010)
CIHI. Health Care Use at the End of Life in Western Canada (2007)
Unsatisfactory
• Only 9-57% are “fully satisfied” with EOL care
• Lowest satisfaction, highest priority
– Emotional support for patients
– Quality of relationship with MD
– Communication and decision-making
• Logistics of EOL care
• Limitations of life-support
Heyland et al. CMAJ 2010;182(16)
EOL Care in Canada
• Institutionalized
• Unplanned
• Aggressive
• Disjointed
• Non-palliative
• Unsatisfactory
EOLC and the Quality Agenda
You have 10 discharge summaries
to complete…
• Was this a “palliative” admission?
• Hospitalized “for the purpose of palliative care”
• Received “palliative care” for the “largest portion” of
admission
• Excluded from HSMR
Canadian Institutes of Health Information
Hospital Standardized Mortality Ratio
Pros
Cons
•
Cheap, easy to collect
•
Deaths usually not preventable
•
Correlated (weakly) with quality of
•
Quality problems rarely cause death
care
•
Most mortality determinants
nonmodifiable
•
Access to discharge/transfer
resources
CMAJ • JULY 15, 2008 • 179(2)
http://news.nationalpost.com/2012/11/13/canadian-hospitals-may-be-manipulating-death-rates-new-study-suggests/
• 12,593,329 discharge abstracts
• Crude mortality rose
• HSMR fell 8.55 points
Chong CAKY, Nguyen GC, Wilcox ME. BMJ Open 2012;2:e001729.
Increasing “Palliative” Coding
HSPR rose 50% in 3 years
HSPR rose more in reporting hospitals
Chong CAKY, Nguyen GC, Wilcox ME. BMJ Open 2012;2:e001729.
• Incentives
• Financial
• Avoid scrutiny
• Public image
• Overprioritization
• Labeling patients
• Accidental disclosure
• Palliative Code vs.
Palliative Care
J Med Ethics 2010;36:387-90.
Palliative Code vs. Palliative Care
Excellent Health Care for All Act, 2010 (Ont.)
• Publication of hospital Quality Improvement Plans
Balanced Scorecard
• Target goals based on Performance Indicators (PIs)
• Measure effectiveness of corporate initiatives and
improvements
• Ensure other PIs concurrently remain stable/improve
Weiss and Downar. J Pain Symp Management. Online May 13, 2013.
Balanced Scorecard
Objectives of the EHCFAA
Promote transparency to improve care
• If you don’t measure it, you can’t manage it
• The BSC = corporate priorities
Incentive for improvement
• Executive compensation
Weiss and Downar. J Pain Symp Management. Online May 13, 2013.
Are we measuring Palliative Care?
• Audit of Ontario hospitals with >100 beds
• QIP/BSC from 2011
• Performance indicators from care domains
• Specific to Palliative Care (ESAS)
• Related to pain/symptom management
• Communication
• Psychosocial/spiritual well-being
Weiss and Downar. J Pain Symp Management. Online May 13, 2013.
Table 1. Use of Suggested QIP PIs and Mandatory Reporting PIs in Hospital BSCs
PI
Hospital Standardized Mortality Ratio*
C. Difficile Infection rate*§
% Hospitals Using PI in BSC
74%
74%
Vancomycin-Resistant Enterococcus colonization rate*
Methicillin-Resistant Staphylococcus Aureus colonization
rate*
Hand Hygeine auditing*§
Ventilator-associated Pneumonia rate*§
Central Line Infection rate*§
Surgical Site Infection Prophylaxis*§
Surgical Safety Checklist Use*
Rate of Pressure Ulcer Development§
Rate of Falls§
Hospital Readmission Rate§
% of hospital stay classified as Alternate Level of Care§
Emergency Room Waiting Time§
Patient Satisfaction (NRC Picker)§
*Mandatory reporting PIs; §Suggested PIs for inclusion in QIPs
Weiss and Downar. J Pain Symp Management. Online May 13, 2013.
25%
31%
94%
94%
64%
23%
30%
48%
54%
80%
90%
93%
85%
Table 2. Palliative or End-of-life Care (PELC) Performance Indicators
PI
Number (%) Hospitals
Reporting
Hospitals Using PELC PI
Patients Completing the
ESAS
Pain Management
1 (2%)
Guelph General Hospital
3 (5%)
Hospital for Sick Children, Trillium
Health Centre, Timmins and District
General Hospital
Treatment with "Dignity and
Respect”(NRC Picker)
Communication with Patients
1 (2%)
The William Osler Health Centre
7 (11%)
Hospital for Sick Children, The William
Osler Health Centre, Quinte Healthcare
Corporation, York Central Hospital,
Toronto East General Hospital,
Lakeridge Health Corporation,
Northumberland Hills Hospital
Weiss and Downar. J Pain Symp Management. Online May 13, 2013.
Interpretation
• 16% of Ontario hospitals measure EOLC PIs
• Inclusive definition
• NRC Picker Survey not sent to dying patients
• Limitations
• EOLC initiatives without EOLC PIs in BSC
• EOLC PIs in BSC but no EOLC initiatives
• If you don’t measure it, you can’t manage it
Weiss and Downar. J Pain Symp Management. Online May 13, 2013.
What is “better” EOLC?
A “Good” Death
“…free from avoidable distress and suffering for
patients, families, and caregivers; in general accord with
patients’ and families' wishes; and reasonably
consistent with clinical, cultural, and ethical standards.”
Institute of Medicine (1997)
A “Good” Death Pathway
Recognition of
Dying
• Patient/family
• Physician/HCP
Discussion
• Appropriate Goals
Plan of Care
• Realistic
• Concordant with goals
Use of Palliative
Care Resources
“Good Death”
• Symptom control
• Non-acute setting
• Support for pt/family
• Inpatient
• Outpatient
A policeman walking at night…
Cardiology Study
• Problem: People are dying from acute MI
• Population: People with acute MI in the ER
• Intervention: Thrombolysis
• Control: Saline
• Outcome: Mortality
• Design: Double-blinded RCT
EOL Care Study
• Problem: People are dying badly
• Population
• Subjects: Patients? Physicians? Nurses? “The system”?
• Setting: Early? Late? Community? Clinic? Ward?
• Intervention: Living will? Communication? “Palliative Care”?
• Control: “Usual Care”
• Outcome: Symptoms? Satisfaction? Quality of Life?
• Design: RCT? Retrospective? Before-after?
Challenges
• Patients + Families
• Die before follow-up (18% in “early PC” study)
• Accuracy of surrogates
• Selection bias (willingness to participate)
• Timing
• Early- diluted effect, not “in earnest”
• Late- too late to influence outcome
Temel et al. NEJM 2010;363:733-742.
Challenges
• Design
• Before-After confounded by temporal trends
• RCT- Blinding? Crossover and attrition?
• Standardized Interventions
• “Advance Care Planning”
• “Palliative Care Consultation”
Challenges
• Process- relevance of steps?
• Outcomes
• “Symptom Control”
• Satisfaction based on expectations
• Quality of Life
– 6.5 points on scale of 0-136?
• Concordance with Advance
Directives from 6 months ago
Curtis and Engelberg. CCM 2006;34:s341-7.
Temel et al. NEJM 2010;363:733-742.
Meyers FJ et al. JPSM 2004;28:548-556.
Detering et al. BMJ 2010;340:c1345.
“Integrating PC and ICU”
• 5 Elements
• Education - Principles of PC in ICU
• Local Champions - Role Modeling
• Academic Detailing - Barriers
• Feedback - Local Data
• System supports - Order forms, pamphlets
• Self-efficacy Theory
• Knowledge, Attitudes, Behaviours
Treece et al. Crit Care Med 2006;34:S380-7.
Cabana et al. JAMA 1999;282:1458-65.
“Integrating PC and ICU”
• Single-centre before-after
study
• Lessons
• Improved nurse-rated QODD
• Uptake of study sites?
• No change in family-rated
• Internal vs. External source of
QODD, FS-ICU
• Cluster-randomized trial
• No change in N-QODD, FQODD, FS-ICU
• Increased LOS in ICU predeath
Curtis et al. AJRCCM 2008;178:269-75.
Curtis et al. AJRCCM 2011;183:348-55
change
• Bringing palliative care
clinicians to bedside
Liverpool Care Pathway - ICU
• 5 Key elements
• Explicit goals/key elements of care
• Facilitation of communication with pt/family
• Coordinating roles and activities of team, patient and family
• Documentation, evaluation of outcomes
• Identification of appropriate resources
• 10-Step Implementation plan
What is the LCP? Marie Curie Palliative Care Institute
Effectiveness of EOL Pathways
• LCP
• Better documentation, lower symptom burden
• Palliative Care for Advanced Disease (PCAD)
• High adherence, reduced CPR, ?use of medications
• Bailey et al.
• Increased documentation of symptoms, availability of
opioids, DNR orders
Veerbeek et al. Pall Med 2008;22:145-151.
Bookbinder et al. JPSM 2005;29:529-43.
Bailey et al. Arch Int Med 2005;165:1722-7.
http://www.telegraph.co.uk/health/healthnews/9631334/Doctors-to-investigate-use-of-controversial-Liverpool-Care-Pathway.html
Next steps…
PALLIATIVE
http://www.leedan.com/SF-341B.htm
Quality Dying Initiative
• Framework for studying and implementing
Quality EOLC
• Knowledge development
• Knowledge translation
Courtesy J. Myers, R. Fowler
Quality Dying Initiative
• Multidisciplinary Group
• Critical Care, Palliative Care
• General Medicine, Oncology
• Nursing
• Spiritual Care
• Social Work
• Bioethics
• Local studies of dying experience, staff
attitudes/beliefs
Courtesy J. Myers, R. Fowler
Quality Dying Initiative
• Existing checklists/pathways
– MEDLINE search- 1394 articles
• Palliative Care or End of Life Care
• Medical order entry systems, Standardization, Clinical protocols,
Clinical decision support systems
– Cochrane Review- 920 articles
– Title/Abstract review
– Google search
• 201 Articles or Web-published protocols
Chan and Webster. Cochrane Database of Systematic Reviews 2011.
Goals of Care Intervention
• Death would not be surprising on this admission
• Clarify/Document Goals of Care
University of Calgary Goals of Care Designation
Standardized Order Sets
• Ward- QDI
• ICU- International review
Other Projects…
• U of T Department of Medicine Integration
Grant
– Communication training for MDs
– CPR video decision aid
– Medical and Public engagement
– Decision-maker engagement
Courtesy R. Fowler
EOLC Performance Indicators
Process
– Documentation of goals
Recognition of
Dying
• Patient/family
• Physician/HCP
Discussion
• Appropriate Goals
– Family meetings
– Use of order sets
– Coordination with PC (timing)
Outcome
Plan of Care
• Realistic
• Concordant with goals
– Satisfaction with care
Use of Palliative
Care Resources
(CANHELP, QODD)
– Picker survey for hospice
– Avoidance of “intensive” care
environments
– Costs
“Good Death”
• Symptom control
• Non-acute setting
• Support for pt/family
• Inpatient
• Outpatient
EOLC Performance Indicators
• Cancer Care Ontario Palliative Care
Integration Project
• Cancer Quality Council of Ontario
• NICE quality standard for end of life care
Heyland DK, et al. CMAJ. 2010 November; 182(16): p. E747-E752.
Cancer Care Ontario. Regional Models of Care for Palliative Cancer Care: Recommendations for the Organization and Delivery
of Palliative Cancer Care in Ontario - Cancer Care Ontario. [Online].; 2012. Available from:
https://www.cancercare.on.ca/ocs/clinicalprogs/pallcareprog/.
Earle CC, et al. J Clin Oncol. 2003; 21: p. 1133-1138.
Objectives
1. Appreciate how the quality "agenda" might
worsen EOLC
2. Define the challenges for EOLC providers
working in an age of "quality”
3. Propose a framework for improving and
measuring quality in EOLC
Thank you for your attention