integration of palliative care in the prehospital …...• massive hematemesis and melena •...
TRANSCRIPT
INTEGRATION OF PALLIATIVE CARE IN THE PREHOSPITAL SETTING
DAVID WILLISCROFT/JENNIE
HELMEROCTOBER 7, 2019
Prehospital Palliative Care
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DISCLOSURES
FACILITATOR FOR PALLIUM
LEAP PARAMEDIC
Is Palliative Care everywhere?
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Prehospital Palliative Care
• stems from increasing palliative needs in community
• calls are often in response to symptom needs, acute changes
• can result in uncomfortable stays/treatments in the ED.
• may help avoid death in hospital
Outline• Case• History• BC Experience• Future Directions• Questions...AND IDEAS!
50 M Met HCC• Massive UGIB at home• Wife RN• Acute dyspnea, distress++• EHS called• Does not want to be transferred
to hospital• Home DNR in place
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@ house• Massive hematemesis and melena• Cachectic/jaundiced patient• Drowsy, GCS 13-14, RR 35, moaning• Wife distressed over patient's pain,
dyspnea, and explosive bleeding• Adamant no transfer to hospital• Home DNR/Expected Death at Home
Document
Are
paramedics
equipped to
deal with this
at home?
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Emergency Room Experience
• Often patients/families don't want to be there
• ER teams are not set up well for end of life care (despite more training)
• QI Rounds are full of cases of patients being transferred to die
• Distressing experience for both staff and caregivers
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Why is the ER Bad?• Loud• No privacy• Lack of information/relationship• No space• Uncomfortable• Discomfort w/ patients with
palliative needs• Triage bias
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ED Improvements
• Better training of residents
• More awareness of Palliative
Care in ED
• EMR-better information faster
• More Palliative Care presence
in the ED
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HOW DO WE MEET THE NEEDS OF THE PUBLIC?
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PARAMEDICS AND PALLIATIVE CARE
PROJECT
YOUR PROVINCIAL PREHOSPITAL
RESOURCE
o 3,600+ Paramedics &
Dispatchers
o >500,000 9-1-1 calls per
year
o 3 dispatch operations
centres
o 188 stations
BCEHS ACTION PLAN
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Ensure the right care is
provided to the right patient
with the right resource at
the right time
TRANSFORMATION-SETTING THE TABLE
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o Ministerial Orders:
• Secondary Triage
• Community Paramedicine
• Clinical Pathways with non-
conveyance
o Culture Shift…not mandated,
but occurring
PARAMEDICS & PALLIATIVE CARE
PROJECT
17
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o Treat patients in line with
their wishes/goals of care
o Increased patient
satisfaction with place of
death
o Reduce ED conveyance
OBJECTIVES
INCLUSION CRITERIA
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• Have an advanced life-
limiting illness, or
• Care is currently focused on
comfort and symptom
management, rather than
curative interventions and
• Presenting symptoms are
considered related to the
patients’ palliative
condition
2500 PATIENTS WITH PALLIATIVE DIAGNOSIS
ACCESSED 9112016/17 (CIHI)
40% 45% 50% 55%
Metro Van
Rest of BC
Location
Time of Day
Day of Week
HOSPITAL DISPOSITION OF PATIENTS W/ A PALLIATIVE DIAGNOSIS TRANSPORTED
63%
16%
21%
2500 Palliative/EOL Patients Transported
Died
Discharged
Transferred
CIHI 2016/2017
Died in Hospital
GOALS OF CARE AVAILABILITY
0% 10% 20% 30% 40% 50% 60%
Written
In Progress
Verbal
None
Narrative ePCR
PALLIATIVE CLINICAL PATHWAY
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Determine appropriate dispatch procedure
AssessInclusion Criteria
Treat Refer
Case Conclusion• Portable suction for patient's mouth• SC Midazolam 5 mg• SC Fentanyl 25 mcg PRN q 10 min w
good effect• Patient changed, positioned comfortably
with dark towels on bed• Dies comfortably about 45 min after
EHS arrival
EHS Med Availability
• Midazolam• Ketamine• Fentanyl• Dimenhydrinate
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EHS Meds Not Available (yet)
• Haloperidol• Methotrimeprazine
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Issues to work on
• Communication with Primary Team-how does this happen?
• EPOS training?• Sensible broadening of
medication availability to EHS• Expanding roll out of LEAP
Paramedic
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THANK YOU