Capital Region Capital Region Family Medicine ConferenceFamily Medicine Conference

September 8, 2012

Primary Primary Palliative Palliative

CareCare

Objectives

Describe shared skills of palliative care and primary care

Identify useful communication techniques

Medical Orders for Life Sustaining Treatment

Diagnosis -------Diagnosis ------- Chronic Illness ---- Chronic Illness ---- DeathDeath

Curative Efforts---------------------

Life Prolonging Measures----------------------------------------

Palliative Care (Hospice)----------------------------------------------------------------

Russell Portenoy, MD

All of hospiceAll of hospiceis palliativeis palliativecare, care, but notbut notall of all of palliativepalliativecare is care is hospicehospice

Hospice

Palliative Care

“ “ The American College of Chest The American College of Chest Physicians strongly supports the Physicians strongly supports the position that palliative and end-position that palliative and end-of-life care of the patient with an of-life care of the patient with an acute devastating or chronically acute devastating or chronically

progressive pulmonary or cardiac progressive pulmonary or cardiac disease and his/her family should disease and his/her family should

be an integral part of be an integral part of cardiopulmonary medicine.”cardiopulmonary medicine.”

Chest 2005 / VJ Vanston AAHPM Chest 2005 / VJ Vanston AAHPM 20102010

40% report acute and chronic pain at 40% report acute and chronic pain at levels similar to patients with cancerlevels similar to patients with cancer

23% report neuropathy, fatigue, 23% report neuropathy, fatigue, depression, sleep disturbancedepression, sleep disturbance

““Diabetes care management should Diabetes care management should include not only good include not only good

cardiometabolic control, but also cardiometabolic control, but also symptom palliation across the symptom palliation across the

disease course.”disease course.” J General Internal Medicine Aug 2012

Newly dx’d ambulatory metastatic non-small cell lung cancer MGH

Standard treatment vs. Standard treatment + palliative care

Intervention groupbetter QOL scoreslower rates of depression2.7 month survival benefitless chemotherapy

Temel, et al NEJM Aug. 2010

Hospital based interdisciplinary teams Hospital based interdisciplinary teams – – MD, NP, RN, SW, PCMD, NP, RN, SW, PC

89% of hospitals > 300 beds 89% of hospitals > 300 beds

Palliative Care Skill SetPalliative Care Skill Set

Advance care planningAdvance care planning

Symptom Managment Symptom Managment

Establishing patient-centered / realistic Establishing patient-centered / realistic goals of caregoals of care

Appropriate level (setting) of careAppropriate level (setting) of care

Coordination of careCoordination of care

Palliative Care Palliative Care Information Act Information Act 2/20112/2011

Public Health Law section 2997-c requires the "attending health care practitioner" to offer to provide patients with a terminal illness with information and counseling regarding palliative care and end-of-life options appropriate to the patient, including:

Prognosis; Range of options appropriate to the patient; Risks and benefits of various options; Patient's "legal rights to comprehensive pain

and symptom management at the end of life."

http://www.health.ny.gov

Case StudyCase Study88 year old female88 year old female

Dementia, HBP, osteoporosis, Dementia, HBP, osteoporosis, hyperlipidemia, anemia, arthritis, hyperlipidemia, anemia, arthritis, impaired nutritionimpaired nutrition

Assisted living facilityAssisted living facility

June 2008June 2008

sent to ER for increased confusion - utisent to ER for increased confusion - uti

MRI/Neuro consult/ EEG/ carotid USMRI/Neuro consult/ EEG/ carotid US

Discharge meds: Iron, Nexium, Norvasc, Discharge meds: Iron, Nexium, Norvasc, Fosamax, Zocor, Folic Acid, Levaquin, Fosamax, Zocor, Folic Acid, Levaquin, Aricept, AspirinAricept, Aspirin

Sept 2008Sept 2008 Sent to ER for lethargy Sent to ER for lethargy Hematemesis and aspiration Hematemesis and aspiration

pneumoniapneumoniaGI consult EGD – severe esophagitisGI consult EGD – severe esophagitisPulmonary consult CT, thoracentesisPulmonary consult CT, thoracentesisIV antibioticsIV antibiotics

Discharge meds: Zocor, Aricept, Discharge meds: Zocor, Aricept, Nexium, Cardiezem, Norvasc, Nexium, Cardiezem, Norvasc, Fosamax Fosamax

November 2008November 2008

Sent to ER for lethargy and anemiaSent to ER for lethargy and anemia

Contracted, minimal verbalizationContracted, minimal verbalization

4 stage III-IV pressures sores4 stage III-IV pressures sores

Urinary tract infectionUrinary tract infection

Family contactedFamily contacted

HC Proxy and Living Will HC Proxy and Living Will

Comfort and Returning to Community Comfort and Returning to Community

Stopped Fosamax, ZocorStopped Fosamax, Zocor

Started RTC pain medicine, Wound Started RTC pain medicine, Wound care care

Allowed to eat as toleratedAllowed to eat as tolerated

NonHospital DNR NonHospital DNR

Hospice referralHospice referral

Quality in healthcare is Quality in healthcare is defined as:defined as:

Patient-centeredPatient-centered Timely Timely Beneficial Equitable Beneficial Equitable Safe Safe EfficientEfficient

National Quality Forum National Quality Forum www.qualityforum.org

Institute for Healthcare Improvement Institute for Healthcare Improvement www.ihi.org

Medicine used to be simple, Medicine used to be simple, inexpensive, and relatively inexpensive, and relatively

safe.safe.

Now its complex, effective, Now its complex, effective, and potentially dangerous.and potentially dangerous.

Sir Cyril ChantlerSir Cyril Chantler

Hospitalization-Associated Disability

Covinsky, Pierluissi, Johnston JAMA October 2011

“occurs in approximately one-third of patients older than 70 years of age and may be triggered even when the illness that necessitated the hospitalization is successfully treated.”

Patient vulnerability and capacity to recover

Age Poor mobility Cognitive function ADLs Social functioning Depression Geriatric syndromes (falls, incontinence)

Severity of Illness

Hospitalization Factors Environment Restricted mobility Enforced dependence Undernutrition

Polypharmacy Little encouragement of independence

Covinsky, Pierluissi, Johnston JAMA October 2011

Don’t underestimate your role Don’t underestimate your role

Let the patient set the agendaLet the patient set the agenda

Encourage discussion and Encourage discussion and completion of advance directivescompletion of advance directives

““Hope for the best but be prepared Hope for the best but be prepared for the worst”for the worst”

Goals of Care Shift –Time for Goals of Care Shift –Time for DiscussionsDiscussions

43%43% 1 year mortality rate after hospitalization 1 year mortality rate after hospitalization for AECOPD with pCO2 > 50for AECOPD with pCO2 > 50

17-20%17-20% 1 year mortality from dx of CHF 1 year mortality from dx of CHF

25-30%25-30% 1 year mortality rate following 1 year mortality rate following Hip Hip FractureFracture

2 month median survival2 month median survival when majority of day in bed or chair in patients with metastatic

cancer

What Do Patients with Serious What Do Patients with Serious Illness Want?Illness Want?

Pain and symptom controlPain and symptom control

Avoid inappropriate prolongation of Avoid inappropriate prolongation of the dying processthe dying process

Achieve a sense of controlAchieve a sense of control

Relieve burdens on familyRelieve burdens on family

Strengthen relationships with loved Strengthen relationships with loved onesones

Singer et al. JAMA 1999;281(2):163-168.D Meier , CAPC 2009

Factors that Influence Factors that Influence HopeHope

Decrease HopeDecrease Hope

Feeling diminished Feeling diminished as a personas a person

Abandonment and Abandonment and isolationisolation

Lack of directionLack of directionUncontrolled pain Uncontrolled pain

and discomfortand discomfort

Increase HopeIncrease Hope

Feeling valued as a Feeling valued as a person (reminiscence)person (reminiscence)

Meaningful Meaningful relationships (humor)relationships (humor)

Realistic goalsRealistic goals

Pain and symptom reliefPain and symptom relief

Oxford Textbook of Palliative Medicine

http://www.oncotalk.info/

Robert Arnold, MD Director of the Institute of Doctor-Patient Communication at the University of Pittsburgh

http://www.oncotalk.info

http://www.oncotalk.info/

James Tulsky, MD Director of the Center for Palliative Care at Duke University

Communication Techniques

Sit Down Maintain eye contactSit Down Maintain eye contact

““Active” ListeningActive” Listening

PausePause

Manage emotionManage emotionNormalize feelingsNormalize feelings

Reflect patient’s own wordsReflect patient’s own words

Factual Questions / Expression of Factual Questions / Expression of EmotionEmotion

Fire a “warning shot”Fire a “warning shot”

Hospitalizations During Last 6 months of Life Medicare Patients 2007

Percent of Decedents Admitted to ICU/CCU During the Hospitalization in Which Death

Occurred 2007 Medicare Patients

20% of all deaths in the US

occur in the ICU or shortly after

anICU stay

Angus CritCareMed 2004

The4

Stages of

Man

Advance Care DirectivesAdvance Care Directives

For All AdultsFor All Adults

Health Care Proxy Health Care Proxy FormForm

Living WillLiving Will

Organ Donation Organ Donation (optional)(optional)

For Those Who Are For Those Who Are Chronically Ill or Chronically Ill or

Near the End of Their Near the End of Their LivesLives

Nonhospital Do Not Nonhospital Do Not Resuscitate (DNR) OrderResuscitate (DNR) Order

Medical Orders for Life Medical Orders for Life Sustaining Treatment Sustaining Treatment

(MOLST) form(MOLST) form

POLST/POLST/MOLSTMOLST

CommunicationCommunication

DocumentationDocumentation

System System ResponsivenessResponsiveness

Core Elements of Core Elements of MOLSTMOLST

Actionable medical ordersActionable medical orders

Advanced, chronic progressive illnessAdvanced, chronic progressive illness

Limit or request all medically Limit or request all medically treatmentstreatments

Direction about resuscitation status Direction about resuscitation status

Other types of intervention – future Other types of intervention – future hospitalizations, tube feedingshospitalizations, tube feedings

POLST Research POLST Research findingsfindings

OregonOregonEffectively communicates requests for DNR, Effectively communicates requests for DNR,

comfort measurescomfort measuresFrail elderly make reasonable choicesFrail elderly make reasonable choicesNot all or none Not all or none (JAGS, J Gerontol Nurs 2000-2004)(JAGS, J Gerontol Nurs 2000-2004)

Oregon, W Virginia, WisconsinOregon, W Virginia, Wisconsin

Less likely to receive unwanted hospitalization Less likely to receive unwanted hospitalization and medical interventions and medical interventions (Hickman, (Hickman, JAGS July 2010)JAGS July 2010)

POLST 2006 POLST 2006

Paradigm of communication, documentation, and system responsivenessParadigm of communication, documentation, and system responsiveness

POLST Paradigm Program 2006 POLST.org

http://www.ohsu.edu/polst/programs/state+programs.htm accessed 4/2012

POLST 2012

Slide courtesy of P Bomba, MD April 2012

State of New York Department of Health

Nonhospital Order Not to Resuscitate (DNR Order)

Person's Name:___________________________________

Date of Birth: _____/_____/_____

Do not resuscitate the person named above.

Physician's Signature ____________________

Print Name _________________________

License Number ____________________

Date _____/_____/_____

It is the responsibility of the physician to determine, at least every 90 days, whether this order continues to be appropriate, and to indicate this by a note in the person's medical chart.

The issuance of a new form is NOT required, and under the law this order should be considered valid unless it is known that it has been revoked. This order remains valid and must be followed, even if it has not been reviewed within the 90 day period.

DOH-3474 (2/92)

Accepted in outpt settings but…

Does NOT include DNI

Does not cover additional Rx’s

1 in 20 children

will experience

the death of a parent

by the time they graduate

from high school.

Free Bereavement ResourcesFree Bereavement Resources

Does NOT have to be a Hospice patientDoes NOT have to be a Hospice patient

Wave Riders K -3rd grade 4th -8th grade Teens

At schools during the day; referrals thru school social worker

At Local Hospice office Kids Parents/guardians are in their own group ..how to

help their children and to support themselves in their grief.

  

1. Decrease isolation2. Normalize grief3. Provide a framework for

remembrance and meaning-making

ResourcesResources

compassionandsupport.org MOLST, advance directives, MOLST, advance directives,

patient/family friendlypatient/family friendly

eperc.mcw.edu/EPERC/eperc.mcw.edu/EPERC/FastFactsandConceptsFastFactsandConcepts pain and pain and symptom management, ethics, symptom management, ethics, communication skillscommunication skills