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HOSPICE AND PALLIATIVE MEDICINE
Sandra Sanchez-Reilly, MD, AGSFAssociate Professor
Division of Geriatrics, Gerontology andPalliative Medicine
The University of Texas Health Science Center at SanAntonio
South Texas Veterans Health Care SystemFebruary 20th, 2009
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OBJECTIVES
•To introduce the concept of PalliativeCare for all patients with chronic disease,
•To define hospice and palliative medicineas a sub-specialty
•To discuss benefits of and barriers to thedelivery of palliative care
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Clinical Case: My father in law
•74 years old•Moderate AD•COPD•CHF•Active Smoker•Hypertension•Not compliant with
doctor’s visits
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CLINICAL CASE: MR REILLY
•Previously very “functional”•Lives with his wife (50 years) , has 2 sons•Pt started experiencing increased urinary
frequency•Pt fell going to the bathroom and broke his L hip•Pt admitted to hospital: Pre-op•Underwent surgery•Complications: Post-op delirium, urinary
retention (Foley), restrains, UTI, hospitalacquired pneumonia, pressure ulcers
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CLINICAL CASE: MR. REILLY•Pt was very confused, weak, unable to walk or transfer
due to pain•Requires assistance with all ADLs•Requires 24 hour supervision•Depression (GDS)• Inpatient Rehab, more complications: GU mass• Ideal Interventions: Pain management, anxiety
management, depression treatment, advance careplanning discussions
• interdisciplinary team approach (social work, psychology,nursing, nutrition, medicine)
•Passed away 2 months after surgery
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What is Palliative Care?
Interdisciplinary care that aims torelieve suffering and improve qualityof life for patients with advancedillness and their families.
It is offered simultaneously with allother appropriate medical treatment.
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Goals of Palliative Care…
• To relieve physical and emotionalsuffering
• To improve patient-professionalcommunication and decision-making
• To coordinate continuity of care acrosssettings
• To match care to patient needs
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The Cure - Care Model:The Old System
LifeProlongingCare
Palliative/
Hospice
Care
D
E
A
T
HDisease Progression
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Diagnosis ofseriousillness
Death
Palliative Care’s Place in the Course of Illness
Life Prolonging TherapyLife Prolonging Therapy
Palliative CarePalliative Care Medicare HospiceMedicare HospiceBenefitBenefit
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“ModernMedicine” Hospice
Palliative Care
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PALLIATIVE CARE TEAM ISESSENTIAL
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PALLIATIVE CARE
•Symptom management (i.e. pain)•Advance Care Planning•Family Meetings•Ethical Issues•End of life issues (near dying experience)•End of life communication issues•IDT Care•Discharge planning
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WHY PALLIATIVE CARE?
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WHY PALLIATIVE CARE?
1. PATIENT AND CAREGIVERBURDEN
2. COST
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WHY PALLIATIVE CARE?
PATIENT AND CAREGIVERBURDEN
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Patients With Mod-Severe Pain Between Hospital Days8-12
Colon cancer 60%Liver failure 60%Lung cancer 57%Multisystem organ failure + cancer 53%Multisystem organ failure + sepsis 52%COPD 44%CHF 43%
Symptom Burden of Patients With SeriousIllness at 5 U.S. Academic Medical Centers
Desbiens & Wu. JAGS 2000
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Family Satisfaction with Hospitals asthe Last Place of Care2000 Mortality follow-back survey, n=1578 decedents
Not enough contact with MD: 78%Not enough emotional support (pt): 51%Not enough information about what to expect with
the the dying process: 50%Not enough emotional support (family): 38%Not enough help with symptoms: 19%
.
Teno et al. JAMA 2004;291:88-93
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The Family Burden ofSerious Illness
Needed large amount of family caregiving 34%Lost most family savings 31%Lost major source of income 29%Major life change for family member 20%Other family illness from stress 12%At least one of the above 55%
Covinsky et al, JAMA, 1994
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The Family Burden ofSerious Illness• 25 million caregivers deliver care at home to a seriously ill older
relative– Mean hours caregiving per week: 18– 60% work full time– 61% are women– 33% over age 65– 33% in poor health themselves– 87% state they need more help
• Stressed caregivers are at significantly increased risk of deathand major depression
• Cost equivalent of uncompensated care: 450 billion dollars(assume $10/hr)
Emanuel et al. Ann Intern Med 2000, Levine C. N Engl JMed 1999, Schulz et al. JAMA
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WHY PALLIATIVE CARE?
$$$$$$$$$$$$$$
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Variation and Overuse of MedicalResources in the Seriously Ill
Dartmouth Atlas, 2008
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Medical Spending in theU.S.•2.2 trillion dollars in 2007•15% Gross National Product (GNP), rising to
20% by 2015•Highest per capita spending, but ranks 20th in
quality indices among developed nations•The 63% of Medicare patients with 2 or more
chronic conditions account for 95% of Medicarespending
•The costliest 5% account for 43% of Medicarespending
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Care For the Seriously Ill atthe Turn of the Century (2000)
•Unprecedented gains in life expectancy: exponentialrise in number and needs of frail elderly
•Cause of death shifted from acute sudden illness tochronic episodic disease
•Untreated physical symptoms•Unmet patient/family needs•Disparities in access to care• Inadequately trained health care professionals•An unresponsive health care system facing enormous
and increasing expenditures
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The Reality of the LastYear of Life
Lunney, J. R. et al. JAMA 2003
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Cost Savings from PalliativeCare at 8 U.S. Hospitals
400500600700800900
100011001200
-6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6
Days before (-) and after (+) palliative care consultation
Dir
ectc
osts
/day
($)
400
600
800
1000
1200
1400
1600
-6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6
Days before (-) and after (+) palliative care consultation
Dir
ectc
osts
/day
($)
Before PC
After PC
Day of PC Consultation
Trend line for average daily costs for usual carepatients over the same time fame
Live Discharges In-Hospital Deaths
Morrison et al, Arch Intern Med. 2008Sep 8;168(16):1783-90.
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Cost Savings from PalliativeCare at 8 U.S. Hospitals
Live Discharges Hospital Deaths
UsualCare
(n=18427)
PalliativeCare
(n=2630)
P UsualCare
(n=2124)
PalliativeCare
(n=2278)
P
Admission $12,089 $10,608 <.001 $23,682 $16,543 <.001
Laboratory $1,413 $999 <.001 $3,026 $1,835 <.001
ICU $6,974 $1,726 <.001 $15,531 $7,755 .045
Pharmacy $2,651 $2,534 .27 $6,148 $3,684 <.001
Imaging $901 $997 <.001 $1,789 $1,346 .75
Died in ICU X X X 18% 4% <.001
Morrison et al, Arch Intern Med. 2008 Sep8;168(16):1783-90.
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Palliative Care Is Cost-Saving,supports transitions to more appropriate care
settings•Palliative care lowers costs (for hospitals and
payers) by reducing hospital and ICU length ofstay, and direct (such as pharmacy) costs.
•Palliative care improves continuity betweensettings and increases hospice/homecare/nursinghome referral by supporting appropriate transitionmanagement.
Lilly et al, Am J Med, 2000; Dowdy et al, Crit Care Med, 1998; Carlson et al, JAMA, 1988;Campbell et al, Heart Lung, 1991; Campbell et al, Crit Care Med, 1997; Bruera et al, J Pall
Med, 2000; Finn et al, ASCO, 2002; Goldstein et al, Sup Care Cancer, 1996; Advisory Board2002; Project Safe Conduct 2002, Smeenk et al Pat Educ Couns 2000; Von Gunten JAMA
2002; Schneiderman et al JAMA 2003; Campbell and Guzman, Chest 2003; Smith et al. JPM2003; Smith, Hillner JCO 2002; www.capc.org.
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Growth of Palliative Care Programin Hospitals (>50 Beds)
500600700800900
10001100120013001400
2000 2001 2002 2003 2004 2005 2006
75% of AllHospitals
with >300Beds
53% of AllHospitals
Goldsmith et al, J Palliat Med, 2008
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March 10, 2004
53% of Americans die in hospitalHalf spend time in ICU
Half have mod to severe pain
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The Clinical State of theField: 2009
•Hospital palliative care programs: 1,294•ABHPM certified MDs: 2,100•ABMS certified MD’s: 1,400 aproximately•HPNA certified nurses: 15,133•Medicare certified hospices: 4,160•Hospice patients/year: 1.2 million
–30% of total U.S. deaths–82% over age 65–23% of hospice patients are in nursing homes
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But…
•Lack of a solid evidence base to guideclinical care–Pain, symptoms, bereavement
•Lack of health services research to guidedelivery of care–Hospitals, Hospice, NHs, Ambulatory Care–Cancer, COPD, CHF, AD
•Lack NIH funding to support research andinvestigators
NIH State of the Science Conference, 2004
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NIH Funding for PalliativeCare (2001-2005)•418 Funded Grants
–189 (45%) were funded by NCI•0.4% of all NCI grants
–94 (22%) by NINR•3% of all NINR grants
–74 (18%) by NIA•0.5% of all NIA grants
–21 (5%) by NIMH• 0.1% of all NIMH grants
–40 (10%) were funded by 8 other Institutes•NIDDK did not fund a single grant in palliative care
Gelfman LP, Morrison RS. J Palliat Med, 2008
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Why the Lack ofResearch Funding?•Symptoms are unimportant
– Interesting in so far as they guide the astute clinician to adiagnosis
–Will go away when the disease is cured
•Difficult population to study–Multiple symptoms and concurrent problems–Very sick population with limited tolerance for lengthy protocols
and instruments–High mortality rate–Missing data from death and disease burden–Difficult outcomes to study
•Population that is not amenable to traditional researchmethodologies (RCT)
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The Result:
•Current palliative care practice is guidedby:–Data from other populations–Results from small series of patients from
single institutions–Anecdote and hearsay
•Is this the type of care that we want for ourparents or for ourselves?
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The Educational State of theField: 2009
•ABMS-approved subspecialty–First ABIM certifying exam in fall 2008–10 boards sponsoring
•65 active fellowship programs (with several indevelopment), 149 fellowship positionsincluding 21 research slots
•32 programs have been accredited by thePalliative Medicine Review Committee (PMRC)
•ACGME Accreditation for 50 fellowshipprograms (January 2009)
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Deficiencies in MedicalEducation
•74% of residencies in U.S. offer no training inend of life care.
•83% of residencies offer no hospice rotation.•41% of medical students never witnessed an
attending talking with a dying person or hisfamily, and 35% never discussed the care ofa dying patient with a teaching Physician.
Billings & Block JAMA 1997;278:733.
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The Good News:Palliative Care Education Is Improving•Medical school LCME requirement:
“Clinical instruction must include important aspects of… end of life care.”
•Residency ACGME requirements forinternal medicine and internal medicinesubspecialties:“Each resident should receive instruction in theprinciples of palliative care…it is desirable that residentsparticipate in hospice and home care…The programmust evaluate residents’technicalproficiency,…communication, humanistic qualities, andprofessional attitudes and behavior…”
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UTHSCSA
•Few lectures onDeath and Dying
•Elective Course inGeriatric PalliativeCare
•Clinical Electives•Center for Ethics and
Humanities
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UTHSCSA INITIATIVE
•UT Academy of Health Science Education InnovationsProgram: An Educational Intervention Project in End-of-Life for UT medical students and primary care residents
•Longitudinal Curriculum• Increase numbers in fellowship positions•Geriatrics rotation mandatory for IM residents, rehab,
psychiatry•Pain fellows, oncology fellows
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The Administrative State ofthe Field: 2009
•Joint Commission has created voluntaryaccreditation for palliative care programs
•VA has mandated palliative care to be oneof their performance measures
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University of Texas Health Science Center at SanAntonio and The South Texas Veterans HealthCare System
Palliative CarePalliative CareProgram:Program:
Consultation ServiceInpatient Hospice
UnitCommunity Home
Hospices ClinicPediatric
Palliative Care
Fellowship
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Geriatrics and Palliative Care
What is the Relationship?
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Why is palliative medicineimportant in geriatrics?•Physical and emotional suffering•Burden on family caregivers•Widespread dissatisfaction•Overuse•Mismatch of current system to patient
needs
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GERIATRICS AND PALLIATIVECARE
FACTSFACTS GERIATRICSGERIATRICS PALLIATIVEPALLIATIVECARECARE
POPULATIONPOPULATION OLDEROLDER EVERYONE: MANYEVERYONE: MANYOLDER ADULTSOLDER ADULTS
QUALITY OF LIFEQUALITY OF LIFE VERY IMPORTANTVERY IMPORTANT VERY IMPORTANTVERY IMPORTANT
GERIATRICGERIATRICSYNDROMESSYNDROMES
MENTAL STATUSMENTAL STATUSCHANGES, PAIN,CHANGES, PAIN,FALLS, WEAKNESSFALLS, WEAKNESS
MANY SYMPTOMSMANY SYMPTOMS
FAMILYFAMILY VERY IMPORTANTVERY IMPORTANT VERY IMPORTANTVERY IMPORTANT
SUBSUB--SPECIALTYSPECIALTY YESYES YESYES
FUNCTIONAL STATUSFUNCTIONAL STATUS VERY IMPORTANTVERY IMPORTANT COMFORT ANDCOMFORT ANDQUALITY OF LIFEQUALITY OF LIFE
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PALLIATIVE CARE ANDUROLOGY
FACTSFACTS PALLIATIVE CAREPALLIATIVE CARE UROLOGYUROLOGY
POPULATIONPOPULATION EVERYONE: MANY OLDEREVERYONE: MANY OLDERADULTSADULTS
EVERYONE: MANY OLDEREVERYONE: MANY OLDERADULTSADULTS
QUALITY OF LIFEQUALITY OF LIFE VERY IMPORTANTVERY IMPORTANT VERY IMPORTANTVERY IMPORTANT
GERIATRIC SYNDROMESGERIATRIC SYNDROMES MENTAL STATUS CHANGES,MENTAL STATUS CHANGES,PAIN, FALLS, INCONTINENCEPAIN, FALLS, INCONTINENCE
MANY SYMPTOMSMANY SYMPTOMS
FAMILYFAMILY VERY IMPORTANTVERY IMPORTANT VERY IMPORTANTVERY IMPORTANT
SUBSUB--SPECIALTYSPECIALTY YESYES YESYES
FUNCTIONAL STATUSFUNCTIONAL STATUS IMPORTANT, COMFORT ANDIMPORTANT, COMFORT ANDQUALITY OF LIFEQUALITY OF LIFE
IMPORTANT,IMPORTANT,
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