Palliative Care in Kingston and the SE LHIN

Dr. Natalie Kondor

DFM Grand Rounds

Jan 20 2015

Outline

What is palliative care?Why is palliative care important?Trends in palliative care provisionRegional and local resources for palliative

care provisionFAQs

What is Palliative Care?

Palliative care is a philosophy of care that aims to help individuals and families to:

Address physical, psychological, social, spiritual and practical issues

Prepare for and manage end of life choices and the dying process

Cope with loss and griefTreat active issues and manage symptomsPrevent new issues from occurringPromote opportunities for meaningful and valuable

experiences

Why do we need palliative care?

1900 Average age of death 46 years Usually a rapid death Leading causes: infectious disease, childbirth, accidents

2015 Average age of death 85 Only 5% die sudden deaths, 95% decline over time 2-4 years of decline

Functi on

High

Low

Time

Sudden Death

Death

Our Reality

By 2036, seniors will account for 23-25% of the total population

32 % of Canadians suffer from a chronic illness • 39% have a sufferer in their immediate family

74% of seniors have one or more chronic conditions

24% of seniors have three or more chronic conditions

Chronic diseases account for 70% of all deaths

Palliative Care – Not Just End of Life Care

The Need for Palliative CareESAS symptom profile for cancer patients

Benefits of Earlier and Integrated Palliative Care

Leads to better outcomes for Patients & Families:• Reduced symptom burden• Less anxiety and depression• Less caregiver burden• Better quality of life• Less aggressive treatments• More appropriate referral to and use of hospice• Lower health care costs

Smith et al., 2012; Temel et al., 2010; Bakitas et al., 2009; Myers et al., 2011; Zimmerman et al 2013

Benefits of Earlier and Integrated Palliative Care - Improved Survival

Longer and better survivalBetter understanding of prognosis Less IV chemo in last 60 daysLess aggressive end of life careMore and longer use of hospice$2000 per person savings to insurers and society

Temel J, et al. NEJM 2010; Temel J, et al, JCO 2011; Greer, et al. Proc ASCO 2012

Current state of Palliative Care in Canada

Only 16-30% of Canadians have access to formalized palliative/end-of-life care services

At least 25% of the total cost of palliative care is borne by families

Approximately 70% of deaths occur in hospital• 40% of terminally ill cancer patients visit the emergency department

within the last 2 weeks of life• 41% of long term care home residents have at least one hospital

admission in their last 6 months of life

96% of Canadians believe it is important to have conversations with their loved ones about their wishes for care• 34% have actually had a discussion• 13% have completed an Advanced Care Plan

CHPCA Fact Sheet – Hospice Palliative Care in Canada (2014)

Building capacity for palliative care

A palliative approach to care should be practiced by all providers caring for people with life-threatening illnesseso Primary, Secondary and Tertiary care settingso Community settings

Not a “one size fits all” approach, but key common elementso Person-centred careo Inter-professional teamo Single access pointo 24/7 care to ensure continuity & coordinationo Building community capacity

Regional Implementation – Results in Alberta Edmonton & Calgary: 1993 to 2000

Acute care

Hospice care

Costs for last year of

life Services Introduced:Hospices

Community consult teams

Results• Health system costs

reduced

• Acute care costs reduced (from 83% to 63% )

• In-hospital days reduced (from 39 to 27 days)

• # of deaths in acute hospitals reduced

• # of home deaths increased

Fassbender K et al. Utilization and costs of the introduction of system-wide palliative care in Alberta, 1993 to 2000. Palliative Medicine. 2005:19-513-520

Regional Implementation – Results in Ontario

Pockets of palliative care excellence in rural & urban areas

Community capacity building initiatives across Ontario have created innovative programs

A recent analysis of community based, specialist palliative care teams found:o Reduced acute care use o Reduced hospital deaths at the end of life

What’s Next in Ontario

The Provincial HPC Steering Committee & the Clinical Council are now active

HPC now a priority for system transformation in all LHINs

All LHINs have committed to:o 10% reduction in one or more of the following areas:

Overall palliative-related ALC daysInpatient days per capita among patients that died in

hospital;Palliative-related avoidable hospitalizations (repeat ER

visits/readmissions) o Implementing regional HPC programs

Work underway to develop palliative care indicators

Palliative Care In Our Region - SE LHIN Regional PrioritiesStrengthen capacity of local communities in providing hospice palliative care

• Increase capacity in providing palliative care in all care settings especially primary care

• Support the uptake of common palliative care plans, guidelines and tools• Promote use of shared information among care settings

Create regional mechanisms to enable early identification of patients who would benefit from hospice palliative care

• Implement the adapted Gold Standards Framework for Early Identification

Increase the understanding and implementation of Health Care Consent and Advance Care Planning

Strengthen caregiver support including bereavement

Palliative Care in Our Region - ResourcesInpatient Consult ServicesCommunity Palliative Care Services

• CCAC – Nursing, PSW, SW, OT, PT, Dietician• Physicians

Inpatient Palliative Care Units• SMOL PCU, Brockville PCU

Community Hospices• Inpatient, ambulatory

Outpatient Ambulatory Clinics• KRCC, Advanced dyspnea management clinic

Hospice Palliative Care Nurse Practitioners

Community Palliative Care Services

For patients with PPS < 50%FamMD makes CCAC referralFamMD +/- colleague follows patient at home and

provides 24/7 call coverageFamMD refers to community palliative care physician for

concurrent care or transfer of care Patients are seen same day to within 2 weeks depending on

urgency On referral, helpful to indicate whether you are requesting

community, PCU assessment or clinic visit. If unsure, feel free to phone to suss out which might be most appropriate (548-2485)

Helpful to indicate urgency, PPS, decline in PPS, symptom issues, whether want concurrent vs. transfer of care

Palliative Care Unit – at SMOL

13 beds – 10 private and 3 semi-private roomsAll referrals are to go through the palliative care

office and are directed to the intake physician who manages a running list

Wait time often less than 2 weeks, can be as soon as same day

Patients at home get priority over patients waiting at KGH

Prognosis less than 3 monthsIf survive longer, may get transferred to LTC

Palliative Care Clinic at KRCC

Referrals from specialists (often oncologists), Family MD

For symptom management for ambulatory patients (PPS =/>50%)

For cancer-related symptoms or symptoms related to cancer therapy

Patient continues to receive primary care from Family MDPalliative MD is generally 1st contact regarding symptom

management issues

Hospice Palliative Care Nurse Practitioners

Some FAQs

What is a PPS and why is it important?

Do I have to have CCAC involved to care for my patient at home?

Yes – the short answerWhy:

CCAC is the “umbrella” organization that designates one of the nursing agencies to be the first call to patients/families

Coordinate and provide OT/PT/SW support, equipment (hospital beds, nebulizer machines etc)

Supplies needles, syringes, dressings, sc sets, catheters, some personal care items, etc.

Patient not eligible for CADD pumps or SRKs without CCAC involvement

Do I have to have CCAC involved to care for my patient at home?

How to get CCAC support:Fill in a CCAC Service RequisitionCan simply write: “please see for palliative

symptom assessment and management” and the ball will start rolling

How many hours of CCAC PSW and nursing support can my patient receive?Not 24/7 bedside care!CCAC’s “End-of-Life” Program

PPS less than 30Life expectancy/need for 30 days or lessPSW - Up to 360 hrs allotted for 30 days or 12 hrs per

dayNursing – visits as often as needed up to 4 times per

dayOption of hiring PSW support and nursing

privately but lack of manpower and expensive$60-80/hr for nurse$30-40/hr for PSW

Compassionate Care Benefits

Family member at risk of dying within 26 weeksDoctor completes application formEI programBenefits for up to a maximum of six weeks To be eligible for compassionate care benefits, you must be

able to show that:your regular weekly earnings from work have decreased

by more than 40 percent; and you have accumulated 600 insured hours of work in the

last 52 weeks, or since the start of your last claim (this period is called the qualifying period).

The basic benefit rate is 55 percent of your average insurable earnings, up to a yearly maximum insurable amount ($48,600 in 2014). This means that, in 2014, you can receive a maximum payment of $514 per week.

Compassionate Care Benefits

Do I have to refer my palliative patient at home to the community palliative care team?

No!If Dr. You is comfortable with and readily

available to provide symptom management and end of life care to your patients at home, you can do it

You or a colleague covering for you must be available to be called 24/7

The Queen’s palliative care team has a physician available to call for advice 24/7 (548-2485 or ask for the PC doctor on call through the KGH operator if after-hours)

Why do referrals to community palliative care need to come from the Family MD?Specialists (eg. CTU resident discharging

patient home, oncologist at KRCC) can refer patient to community palliative MD but must get confirmation of agreement (verbal or in writing) from patient’s Family MD

To ensure Family MD is aware of situation and give opportunity for Family MD to decide whether prefer they vs. community PC follow pt at home

If a patient does not have a Family MD, any MD can refer to community palliative care

What is a Symptom Response Kit and how do I order one?

What is a Symptom Response Kit and how do I order one?

Palliative Care Facilitated Access List

Can Bloodwork be done at home?

Yes, but not urgent b/wOrder on LifeLabs req and write HOME VISIT in the

“additional clinical information” areaLifeLabs will come to patient’s home usually “within the

next week” – may be as soon as next day depending on geography

Results available day after b/w is doneCosts the patient approximately $35 per visitOccassionally home care nurse can do b/w with an order

but only if b/w obtained via a PICC (generally don’t do peripheral venipuncture anymore) and if b/w taken immediately to lifelabs by nurse or family member

Can my patient receive IVF or blood transfusions at home?Patients can receive fluid hydration at home –

set up by the nurses through CCACRequires faxed order to CCACNS is easiest to obtain (vs. 2/3 1/3, NS with KCl, etc) IVF – can order if pt has IV access eg. PICC or Port-a-

Cath. CCAC provides pump for administrationHypodermoclysis – fluids run sc through a sc set by

gravity, generally overnight/over 8 hoursBlood transfusions cannot be done at home, can

be done through ER or KRCC as outpatient (with pre-orders)

What is a Yellow Folder?

SE LHIN initiative for “expected death at home”

Contains information on who/when to call for what situation

Contains SRK RxContains DNR confirmation form

What is a DNR Confirmation Form and does my DNR patient need one?

Does an MD need to pronounce and complete the death certificate?In Ontario, in the case of an expected death and

the death is caused by the expected cause then a nurse (RN or RPN) may pronounce

A physician or NP’s order is required for this to occur and the funeral home should be aware and agreeable

Once pronouncement has happened, the funeral home will retrieve the body with or without the death certificate

A physician or NP is required to submit an original copy of the death certificate to the funeral home as soon as possible (usually within 24 hours)

Summary

Palliative care is growing in scope and importance

By 2036, 25% of Canadians will be seniors and many of them will need some form of palliative care

Tools and resources are readily available for primary care practitioners to provide this care to their patients