Perspectives on Palliative Care

Timothy G. Ihrig, MD, MAMedical Director, Palliative Medicine

Trinity Regional Health Systemihrigtg@ihs.org

Objectives

• Define the scope and role of palliative care as specialized medical care for people with serious illnesses

• Coordinate palliative care between professionals and across institutional settings

Definition

Palliative care is specialized medical care for people with serious illnesses. It is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness—whatever the diagnosis. The goal is to improve quality of life for both the patient and the family.

Palliative Care: Defined

Palliative care is provided by a team of doctors, nurses, and other specialists who work together with a patient's other doctors to provide an extra layer of support. It is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment.

Palliative Care: Defined

- Cancer- Cardiac disease (Congestive Heart Failure)- Chronic Obstructive Pulmonary Disease - Kidney failure- Dementia- HIV/AIDS - Amyotrophic Lateral Sclerosis (ALS)

Palliative Care: Defined

What is it?1. Pain & Symptom Management2. Communication/Counseling3. Care Planning

Pain & Symptom Management–Sx’s: Nausea, Anorexia, Anxiety, Delirium, Diarrhea,

Dyspnea–Education: • O2 and the Management of Dyspnea

–Systems: • Advocacy for opioid availability, including proper

dosing forms

Palliative Care: Pain & Symptoms

Communication– Determining the Decision Maker or Process– Facilitating decision making– Determining Goals of Care– Preferred Intensity of Care– Delivering Bad News– Prognostication: Average MD overestimates by average of 5 fold

Counseling– Grief Counseling– Anticipatory Guidance– Parenting– Depression– Spirituality

Palliative Care: Communication

Goals• Cure• Restore Function• Maintain Function• Live Longer• Be at Home• Avoid Bankruptcy• See the birth of a

grandchild

Treatments

• Mechanical Vent• CPR• Electrical Cardioversion• Artificial Nutrition• Rehospitalization

Communication: Goals First!

Personalized Care:1. Recommend treatment plans to match goals–Don’t recommend treatments that won’t accomplish stated goals.

2. Facilitate Continuity of Care Plan Across Settings– Discharge Planning / Case Management– Clear documentation– Rational DNR/LLST Orders– POLST (Physician Orders for Life Sustaining Treatment)

Palliative Care: Care planning

Harvard Oncology Group Study N Engl J Med 2010;363:733-42.

Patients who received Palliative Care: Less Depression Less Chemotherapy Less Hospitalization More Likely to Die at Home on Hospice More likely to be DNR Higher Quality of Life *Life Expectancy: 2.7 months longer!!!

Palliative Care: Myth of “giving up”

• Physician: Board Certified Specialty (same as Cardiology, etc)

• Nurse: HPNA, Hospice & PC Certification. ELNEC Training

• Chaplain: Clinical Pastoral Education, Board Certification

• Social work: Palliative Care Certification• Administrator: Certification (NHPCO)

Palliative Care: Expertise

Interdisciplinary Team

Unique model in health care:

• One Care Plan organized by patient issue.

• Shared accountability for all issues.

• Flat• MD, RN, LVN, NP, LCSW,

Chaplain, Admin., Volunteer, Pharmacist

Multidisciplinary Group

• Parallel Play• Individual care plans

organized by specialty• Hierarchical, with a

physician “In charge”.• Minimal shared

accountability amongst group members for individual patient outcomes

Palliative care: The Team

Palliative Care: Defined

Medicare Hospice BenefitLife Prolonging Care Old

Palliative Care Bereavement

Hospice CareLife Prolonging

Care

New

Dx Death

Objective Two

Coordinate palliative care between professionals and across institutional settings

22

5Physical

Therapists

37Nurses

A Year in the Life of a Patient

6Social

Workers

19Clinic Visits

2Home Care Agencies

6Community

Referrals

5Months of Home Care

4Occupational

Therapists

13Meds

2Nursing Homes

16Physicians

6Weeks SNF

Care

5Hospital

Admissions

Source Johns Hopkins, RWJ 2010 (G Anderson)

Coordinate Why: Transitions in Care Concerns• “Coordinating Care – A Perilous Journey through the Health Care

System” (T. Bodenheimer, MD NEJM 358 March 2008)

– 1/3 of patients with chronic illness and hospitalization had no post discharge follow-up arrangements

– Less than ½ of PCPs were provided discharge information / medications

– 3% of PCPs are involved in discussions with hospitalists regarding patients’ discharge plans

– PCPs are infrequently notified that patient discharged

Why: Readmissions

- 1 in 5 Medicare patients re-hospitalized within 30 days of discharge

- Half of these occurred before seeing outpt MD

- Estimated cost 17.4 billion

Jencks, Williams, and Coleman NEJM 2009, Vol 360, 1418-1428

Inpatient Care

Palliative Care Patients

Services / Design Options for Palliative Care

Coordinate: Difficulties

Generalist Palliative Care: all clinicians– “Routine” communication/symptom control

*** Specialty Pall Care ***– Family meetings—esp. “difficult cases”– Complex symptom management– Time management– Support for difficult decisions

Coordinate: Opportunities

What would the ideal look like?- Efforts to broaden the spread of palliative care

principles through1. early patient identification (triggers)2. systems change to guide right care at right time - routine family meetings3. emphasis on more generalist palliative care

4. specialists for truly complex problems5. quality improvement-data driven change

Coordinate: Opportunities

What would this look like to a patient?- I am screened on admission for unmet pall care needs; if present …

1. My primary providers have policy-defined roles in the assessment of my pall care needs

2. My providers have the training to complete routine, “generalist level” pall care interventions

3. My family is informed and engaged in the process of care

4. Specialist Pall Care services are involved by hospital standards, based on my condition/problems