transitioning to palliative care: starting the conversation dr. josé pereira head division of...
TRANSCRIPT
Transitioning to Palliative Care: Starting the Conversation
Dr. José PereiraHead Division of Palliative Care, University of Ottawa
Medical Chief, Palliative Care Service, Bruyère Continuing Care & The Ottawa Hospital
Provincial Medical Lead for Palliative Care, Cancer Care Ontario
Faculty/Presenter Disclosure
Faculty: Dr. José Pereira Program: 51st Annual Scientific Assembly
Relationship with commercial interests:– Grants/Research Support: Takeda (past) Education grant to
conduct review of breakthrough pain– Speakers Bureau/honoraria: Nil to report– Consulting Fees: Nil to report– Other: Nil to report
Disclosure of Commercial Support
This program has NOT received financial support This program has NOT received in-kind support
(except for myself and my organization who have allowed me to be here to present on their time)
No potential for conflict(s) of interest to declare
QUESTIONSWhat is the annual mortality rate of patients with NYHA Class II?
What is annual mortality rate of patients with NYHA Class IV?
CHF Mortality
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QUESTIONSWhat is the annual mortality rate of patients with NYHA Class II?
What is annual mortality rate of patients with NYHA Class IV?
CHF Mortality
NYHA Class II - Annual mortality rate 5-
15%- 50-80% die suddenly
NYHA Class IV- Annual mortality rate
30-70%- 5-30% die suddenly
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Heyland DK et al. Discussing prognosis with patients and their families near the end of life: impact on satisfaction with end-of-life care. Open Medicine 2009;3(2):101-110
QUESTIONIn a study of 440 patients with end-stage disease, the % of patients who recalled prognosis discussions with their families :
1. Cancer patients?2. CHF patients?3. COPD patients?
Participants who recalled prognosis discussions
Patients (n=440) : 18% Family members (n=160): 30%
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Patients Had discussion %
Did not have discussion %
Cancer patients (n=151) 27% 73%
CHF (n=99) 14% 86%
COPD (n=115) 9% 91%
Cirrhosis (n=47) 21% 79%
Heyland DK et al. Discussing prognosis with patients and their families near the end of life: impact on satisfaction with end-of-life care. Open Medicine 2009;3(2):101-110
Participants who recalled prognosis discussions
RCT of patients with newly diagnosed metastatic lung cancer
Early palliative care consultation versus standard of later referral for end of life care
Compared to late referred patients, patients with early palliative care consultation had:– Less depression & anxiety– Better quality of life– Lived longer (3 months)
Temel J, et al. Early Palliative Care for Patients with Metastatic Non–Small-Cell Lung Cancer. NEJM 2010; 363:733-42
Activating palliative care does not shorten life
Palliative Alerts
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For some patients the decline may be more gradual while for others it may be more precipitous
Death
Explore pt’s understanding of illness,
discuss prognosis & goals of care.
Explore pt’s understanding of illness,
discuss prognosis & goals of care.
Encourage patient to see family
physician regularly or find one.
Encourage patient to see family
physician regularly or find one.
Advance care planning. Discuss code status
Review treatment plan
Advance care planning. Discuss code status
Review treatment planEnsure ESAS &
PPS/ECOG done at each visit.
Ensure ESAS & PPS/ECOG done at
each visit. Initiate home care
Initiate home care
Establish plans to deal with emergencies
(e.g. pain crisis)
Establish plans to deal with emergencies
(e.g. pain crisis)
DNR & Advanced directives
DNR & Advanced directives
Discuss preferred
versus optimal place of death
based on needs &
circumstances
ILLNESS TRAJECTORY IN PROGRESSIVE CANCER
Consult Palliative Care
Team as needed
Consult Palliative Care
Team as needed
%
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How did you feel while viewing the video?What was done well?What can be done better?What are some useful phrases?
Goals of care 1
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How did you feel while viewing the video?What was done well?What can be done better?What are some useful phrases?
“How long do I have to live?”