End of Life Care - It Takes a Team

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1 End of Life Care - It Takes a Team ROME New England August 16, 2015 Christina E. Fitch, DO, MPH, DTM&H Objectives "At the conclusion of the presentation, the learner will be able to:..." *Explain the difference between palliative and hospice care for both in-patient and out-patient *Appropriately set treatment goals, incorporating comfort measures and patient directives *Coordinate with the caregiving team Palliative care What? Who? When? How? 3 1

2 Palliative Care Core Concepts Bio-psycho-socialspiritual approach Intra-disciplinary team Match treatments with values Relieve suffering Improve quality of living and dying Clear communication Family-centered care Meticulous care coordination Non-abandonment Expert symptom control How We Can Help Palliative Care is specialized medical care for people with serious illnesses. This type of care 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 is provided by a team of doctors, nurses, and other specialists who work with a patient s other doctors to provide an extra layer of support. Palliative care is appropriate at ay age and at any stage in a serious illness, and can be provided together with curative treatment. Mr DR 86 yo M PMH: Afib on coumadin, CAD, DMII s/p amputated toes, SCC sternum Presented down, Vtach, MI, intubated Cath lab: 3 vessel dz, cannot intervene Right MCA stroke, embolic hemorrhagic Review Code Status 2

3 Palliative care Who is eligible? Anyone with a serious, life-limiting illness No prognostic requirements Patient can choose concurrent curative or life-prolonging treatments with palliative care What does it cover? Hospital consult services: Interdisciplinary team Symptom management, communication, coordination of care Outpatient clinic Community-based palliative care Palliative care Where is care provided? Hospitals Outpatient clinics Nursing homes Home How is it paid for? Medicare Part B Funded by hospitals Improves quality and reduces cost Partnerships with hospices, nursing homes Health care reform ACO development Mr. DR continued Extubated, intermittently interactive 2 nd CVA off anticoagulation Refusing to eat though passed S&S, refusing meds Goals of Care conversation Repeat stroke risk extremely high with or without anticoagulation No rehab potential End of life care, what setting? 3

4 Hospice: a service & a benefit Who is eligible? People with a terminal illness who are likely to die within 6 months or less if the disease runs its natural course Certified by patient s doctor and hospice medical director Patient chooses hospice care rather than curative treatments What does it cover? Interdisciplinary team (doctor, nurse, chaplain, social worker, CNA) Medications related to terminal illness and symptoms Medical equipment and supplies 24/7 hotline for questions, crises Volunteers Bereavement counseling Hospice Where is care provided? Wherever the patient lives: Home Nursing home Assisted living Hospice house Other Goal is to stay out of hospital How is it paid for? Medicare Part A Levels of care (routine, inpatient, respite, continuous) Per diem reimbursement Cost of healthcare rising faster than reimbursement rate Not giving anything up Most comprehensive care possible to support you at home You can still go to the hospital if you can t be cared for at home They can help support your family emotionally after you cannot Won t sense a difference, but you and your family will feel better Helps keep you feeling well at home so you don t have to go back and forth to the hospital 4

5 What? Most common consult questions Most common consulting services? Most common primary diagnoses? What is Palliative Care? 13 Top reasons for consult Jun-Dec Top Diagnoses for Consult 5

6 Consults by Service Primary palliative care Pain and Symptom Management Depression and Anxiety Management Goals of care discussions about Prognosis Goals of treatment Suffering Code status 17 "I have an advance directive, not because I have a serious illness, but because I have a family." Ira Byock, MD The Best Care Possible, The Four Things That Matter Most, Dying Well 6

7 Specialty palliative care Management of refractory pain or other symptoms Management of more complex depression, anxiety, grief, and existential distress Assistance with conflict resolution regarding goals of care or methods of treatment Patient s family Staff and family Among treatment teams Assistance in addressing cases of near futility 19 WHO Members? Roles? Settings? 20 = Full Time = Outpatient Umass Palliative Care: growth & opportunity 21 7

8 Non-clinical staff 22 When Disease course Hospitalization Illness journey milestone Titration of PC visits 23 Triggers for palliative care Complex symptom assessment and management Complex medical decisions Complex goal-setting for end of life planning Conflict concerning goals of care between patient, family, and care team Complex disposition planning in patients with life-threatening or life-limiting condition 24 8

9 Timing is everything Family meeting is a complex procedure, need right players So helpful if you can help us expedite timing When in hospitalization Earlier the better If want outpatient follow-up, need inpatient time to make relationship When in course of illness For first goals of care conversation At time of diagnosis, not when complications from treatment already present 25 Consultation management options PC team will provide interdisciplinary services determined by referral questions and patient/family needs One time visit for focused problem (prognosis, eligibility for hospice) Co-management role for specific issue: daily visits, symptom management Intermittent involvement as goals of care conversations arise or symptoms evolve 26 How Introduce PC Contact a palliative care provider Focus a consult question Co-management 27 9

10 We are going to get another team involved in your care The Palliative Care team does many things, but in your situation I think they can help Support you and your family as you approach difficult decisions Understand what your goals are and match them to what is medically possible Help manage your challenging symptoms/pain Clarify what your needs are going to be when you leave the hospital and match those needs to a setting that can provide the best care for you 28 ANATOMY OF A PALLIATIVE CARE CONSULT Trajectory of illness B Attempted therapies A CONSULT C Psychosocial milieu Previous GOC conversations E D Co-morbidities 29 Family meeting Palliative provider Chaplaincy Case Manager Patient and Family Learner Attending Nurse 30 10

11 What *else* is palliative care? Global Health Education Policy Research Clinical 31 Issues and Solutions Family Resistance Misinformation Uncertainty of benefit of consultation Missed opportunity Belief PC just for dying 32 11

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