Geriatric Certificate Program (GCP) For more information visit:

Transcription

1 Geriatric Certificate Program (GCP) For more information visit:

2 7 th Annual Care of the Elderly 2016 Conversations about goals of care with elderly patients who have serious illness John You, M, MSc, FRCPC epts of Medicine, and Clinical Epidemiology & Biostatistics, McMaster University June 1, 2016

3 Faculty/Presenter isclosure Faculty: John You Rela1onships with commercial interests:* Grants/Research Support: CIHR, Canadian Frailty etwork, Heart and Stroke Founda1on, Hamilton Academic Health Sciences Organiza1on (HAHSO) AFP Innova1on Fund Speakers Bureau/Honoraria: one Consul1ng Fees: one Other: one

4 Objec5ves Is it important to discuss goals of care with elderly pa5ents and their families? What is current prac5ce related to goals of care discussions with elderly pa5ents who have serious illness? How can we enhance this important aspect of care for the elderly?

5 My perspec5ve Hospital based general internist Clinician-researcher Improving end-of-life communica5on and decision-making for seriously ill hospitalized pa5ents and their families 5

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7 Trajectories of dying 7

8 Living in fragile health. 2/3 will die with 2 or more chronic diseases amer yrs in state of vulnerable frailty Only 20% will die with a recognizable pallia5ve phase At 5me of death: 42.5% of pts required decision making (M) 70.3% lacked M capacity Lynn. Living Long in Fragile Health ; Bern-Klug. Health Soc Work. 2004; Silveira et al. Engl J Med;

9 How important is it To have trust and confidence in the octor looking amer you ot to be kept alive on life support when there is li[le hope for a meaningful recovery That informa5on about your disease be communicated to you in a honest manner % Extremely Important To complete things and prepare for life s end 43.9 To have an adequate plan of care & services available at home upon discharge 41.8 To not be a physical or emo5onal burden 41.8 Heyland K et al. CMAJ

10 Feelings of peace Availability of their doctor Assessment and treatment of emo5onal problems octor and took a decision-making personal interest and listened Consistent informa5on from care team Having things explained in a way they can understand Good end-of-life communication Heyland K et al. CMAJ

11 EOL communica5on & decision-making

12 Benefits of EOL discussions 37% of pa5ents with advanced cancer reported an EOL discussion at baseline Pa5ents followed un5l death (median 4.4 months) EOL discussions associated with: ecreased ICU use; decreased chemotherapy Greater use of hospice care Caregivers: Percep5on of increased quality of life (pt) with less intensifica5on of care & be[er long term outcomes (less anxiety, depression or regret) and felt more prepared Wright et al. JAMA 2008;300:

13 ACCEPT Study esign SePng: 16 acute care hospital sites across Canada Par1cipants: Elderly pa5ents at high-risk of dying 80 years of age or older OR clinical indicators of advanced disease OR Surprise Ques5on Family members Target sample of 30 pa5ents and 30 family members per site 13

14 ocumented goals of care are omen discordant with pa5ent preferences % of pa1ents CPR Full med, no CPR Comfort Mix Unsure Missing Other Pa5ent's preferences Goal Heyland K et al. JAMA Intern Med

15 Asked about prior discussions or wri[en documents Offered a 5me to meet to discuss goals of care Provided informa5on to review about ACP prior to discussions iscussed prognosis Asked what is important to pa5ent as they consider health care decisions 10% 16% Provided informa5on about outcomes, risks, benefits of LST Provided informa5on about outcomes, risks, benefits of comfort care Helped access legal documents to document ACP Asked the respondent if they had addi5onal ques5ons about goals of care Gave an opportunity for the respondent to express fears or concerns Asked about preferences for care in event of life-threatening illness 23% 22% 0% 20% 40% 60% 80% 100% You JJ et al. CMAJ

16 Most omen, pa5ents report that none of the 11 items were completed umber of patients Mean+S, Median, umber of items completed You JJ et al. CMAJ

17 More items = greater concordance Proportion of concordant patients p value= n/* 21 / / 38 6 / 20 6 / 20 7 / 14 7 / 10 2 / 3 1 / 3 2 / 2 1 / 2 A / A A / umber of items completed You JJ et al. CMAJ

18 What really ma[ers to pa5ents and families in EOL discussions? 1. Preferences for care in the event of life threatening illness 2. Values 3. Prognosis 4. Fears or concerns 5. Any addi5onal ques5ons about goals of care You JJ et al. CMAJ

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20 Scenario A 70 year old pa-ent who has severe COP (on home oxygen), is housebound, and requires assistance for most ac-vi-es of daily living, is admied to the medical ward under your care with an exacerba-on of their COP. The pa-ent s acute symptoms have resolved. You are uncertain about the pa-ent s goals of care and preferences regarding the use (or non-use) of life sustaining technology. 20

21 Barriers to goals of care discussions BARRIERS 1.1f FM difficulty accepting loved ones poor prognosis 1.1g FM lack understanding re limitations/harms LST 1.1h Lack of agreement amongst FMs about goals of care 1.1d Patient lack understanding re limitations/harms LST 1.1e Patient lacks capacity to make goals of care decisions Family members and patients 1.1c Patient difficulty accepting poor prognosis 1.1i Language barriers 1.3b Lack of availability of SM(s) 1.1j Cultural differences 1.3c Uncertainty about w ho is the SM 1.2a Uncertainty in estimating prognosis 1.3a Lack of time 1.3g Unaw are of w hat other team members have said 1.3h Healthcare team disagreement about goals of care 1.3f Lack of pre-existing relationship w ith patient/family 1.2b Lack of training to have these conversations 1.1a Patient does not have advance directive 1.1b Advance directive lacks sufficient detail 1.3d Lack of appropriate location (confidential/private) 1.2d esire to maintain hope 1.2c esire to avoid being sued 1.3e Insufficent remuneration for this activity 3.1 Initiate discussions 3.2 Exchange information 3.3 ecision coach 3.4 Make final decision w ith patients/fms Unimportant Important Average Scores ACCEPTABILITY FOR OTHERS TO IITIATE ISCUSSIOS: 3.5a Staff physician You JJ et al. JAMA Intern Med octors urses 21

22 Common barriers to goals of care (GoC) discussions Clinicians uncomfortable ini5a5ng GoC discussions Emo5onal barriers that impede pa5ents from engaging in GoC discussions Focus on procedures, not values, leads to lack of pa5ent engagement in GoC discussion Physicians fail to disclose prognosis Poor clinician communica5on leads to inadequate understanding of prognosis by pa5ents 22

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27 The interven5on is feasible, acceptable, and effec5ve in s5mula5ng more, be[er, and earlier conversa5ons about serious illness goals Iden5fying the appropriate pa5ents Training program is adopted and viewed as effec5ve by clinicians. Reminder system s5mulates discussions with a vast majority of pa5ents within 2 visits. Pa5ents and clinicians find the interven5on acceptable. The interven5on results in more, beer, and earlier conversa5ons about serious illness care values and goals. The interven5on results in more comprehensive and retrievable documenta5on in the EMR Bernacki R, Paladino J, Lamas, et al. Pallia5ve Care in Oncology Symposium, Boston, MA, 2015.

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