nicheprogram.org 16th Annual NICHE Conference Forging New Paths and Partnerships 1

Transcription

1 Use of the Palliative Performance Scale Version 2 (PPSv2) in Obtaining Palliative Care Consults Patrice Fedel MS, RN, BC Objectives At the end of this presentation the learner will be able Identify patients appropriate for palliative care by utilizing the Palliative Performance Scale version 2 (PPSv2) Identify how to use the PPSv2 in requesting palliative care consults from the physician Problem Older adults with chronic illness may not be receiving the benefits of palliative care 1

2 Definition of Palliative Care Specialized medical care for people with serious illnesses Goals: Relief from the symptoms, pain, and stress of a serious illness whatever the diagnosis Improve quality of life for both the patient and the family Team of doctors, nurses, and other specialists Work together with a patient's other doctors to provide an extra layer of support Appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment Center to Advance Palliative Care, 2012 Why is Palliative Care Necessary? National Data on the Experience of Advanced Illness in 5 Tertiary Care Teaching Hospitals: 9000 patients with life-threatening illness, 50% died within 6 months of entry Less than 50% of physicians knew when patients preferred to avoid CPR 79% of patients who died with a DNR order, 46% of those orders were written within 2 days of death Half had moderate-severe pain in last 3 days of life 38% of those who died spent >10 days in ICU, in coma, or on a ventilator. The SUPPORT Principal Investigators, 1995 Desbiens, Connors, and Lynn, 1999 What Patients with Chronic Illness Want Pain and symptom control Avoid inappropriate prolongation of the dying process Achieve a sense of control Relieve burdens on family Strengthen relationships with loved ones Desbiens, Connors, and Lynn,

3 Barriers to Palliative Care Prognostication Physician clinical prediction of survival can be overly optimistic Physicians overestimate survival by a factor of five Glare et. al, 2003 Chow et. al, 2001 Christakis, Lamont, Parkes, and Smith, 2000 Barrier: Prognosis in Chronic Illness Lorenz et. al., 2008 Lunney, Lynn, Foley, Lipson, & Guralnik, 2003 What Tools Exist to Help in Prognostication? 3

4 Palliative Performance Scale version 2 (PPSv2) Assessment tool developed by Victoria Hospice in British Columbia Modification of Karnofsky Performance Scale Includes ambulation ability, oral intake, and patient consciousness level Score patient from 0-100% in 10% increments Ambulation Activity Level Self-care Intake Conscious level Anderson, Downing, Hill, Casorso, and Lerch, 1996 Palliative Performance Scale version 2 (PPSv2) Victoria Hospice, 2013 Palliative Performance Scale version 2 (PPSv2) Evidence based Validity tested in various settings including acute care Each 10% increment score of the PPSv2 showed statistically ti ti significant ifi differences in survival rate Easy to use Can be used as evidence for needing palliative care 4

5 Mrs. C Mrs. C is 86 year old female PMH of PVD, CAD, atrial fibrillation, and chronic kidney disease Mrs. C has been unable to get out of bed for past 6 months Complete bath, turn q2 hours NPO with tube feeding per G-tube She has occasional episode of confusion Palliative Performance Scale version 2 (PPSv2) Victoria Hospice, 2013 Research Purpose Does educating nurses on the PPSv2 tool increase their comfort level in identifying patients appropriate for palliative care? Does educating nurses on the PPSv2 tool increase their comfort level in asking physicians for palliative care consults? 5

6 Study Design Pre and Post test with educational intervention Pre and post test sent out via Survey Monkey Included participant identifier Educational intervention at unit staff meeting Completed on a 35 bed acute care medical unit within a Midwest Tertiary Hospital Nursing experience level 0-3 years Pre-test/Post Test Comfort questions Rate 1-5 on Likert scale Developed and validated using content experts How comfortable are you in identifying which patients are end of life? identifying which patients have chronic illness with limited treatment options? identifying which patients have decreased functional ability? assessing that a patient needs a palliative care consult? requesting a palliative care consult from the physician? Pre-test/Post Test Knowledge questions Answers: true, false, or I don t know Adapted from the Palliative Care Quiz for Nursing (PCQN) Palliative care is appropriate only in situations where there is evidence of a downhill trajectory of deterioration (answer: false) Palliative care should only be provided for patients who have no curative treatments available (answer: false) The philosophy of palliative care is compatible with that of aggressive treatment (answer: true) Ross, McDonald, & McGuiness,

7 Educational Intervention 30 minutes Philosophy of palliative care Services provided PPSv2- demonstrate how to use 50% or lower score indicative of needing palliative care Case studies How to use the PPSv2 in discussions with physicians Post Education Mentoring Conducted by unit Nurse Clinician and researcher Identified patients through discharge rounds and unit rounds Mentored nurses on the PPSv2 and discussion with physicians Utilized charge nurses as resource Example during rounds Results 30 nurses sent survey 23 pre-survey 16 post-survey 12 matched pairs 7

8 Results: Comfort questions Overall improvement in comfort of nurses p-value = How comfortable are you in assessing that a patient needs a palliative care consult? Pre-survey: 58.4% somewhat comfortable (4) Post-survey: 91.9% somewhat or very comfortable (4 or 5) p-value = Results: Comfort questions How comfortable are you in requesting palliative care consult from the physician? Not a significant increase in comfort p-value= Results: Knowledge questions Overall improvement in knowledge of nurses p-value= The philosophy of palliative care is compatible with that of aggressive treatment (answer: true) Pre-survey: 78.3% wrong answer or did not know Match pairs: 91.7% pre to 75% post wrong answer or did not know 8

9 Research Purpose Does educating nurses on the PPSv2 tool increase their comfort level in identifying patients appropriate for palliative care? Yes! Research Purpose Does educating nurses on the PPSv2 tool increase their comfort level in asking physicians for palliative care consults? Not really Conclusions Knowledge deficit of nurses related to palliative care and aggressive treatment Barrier to palliative care referral Education and PPSv2 can help nurses identify patients in need of palliative care Barriers still exist in approaching physicians 9

10 Limitations Remove ambiguity of survey questions Small sample Limited demographics Limited post intervention mentoring period Future Research Repeat study Larger sample Remove limitations of survey Varied demographics More involvement in mentoring period More education on palliative care Explore other barriers to palliative care Teach nurses how to advocate for patient using PPSv2/discussion with physicians Special Thanks To: Laura Joosse PhD, RN Lee Jeske MS, RN, GCNS-BC Aurora Health Care Center for Nursing Research Aurora St. Luke s Medical Center Administration 4KLM Leadership and Staff ASLMC 10

11 References Anderson, F., Downing, G. M., Hill, J., Casorso, L., & Lerch, N. (1996). Palliative Performance Scale (PPS): A new tool. Journal of Palliative Care, 12, Center to Advance Palliative Care (2012). Get Palliative Care: What is Palliative Care. Retrieved May 28, 2012, from Chow, E., Harth, T., Hruby, G., Finkelstein, J., Wu, J., & Danjoux, C. (2001). How accurate are Physicians' clinical predictions of survival and the available prognostic tools in estimating survival times in terminally ill cancer patients? A systematic review. Clinical Oncology, 13, Christakis, N. A., Lamont, E. B., Parkes, C. M., & Smith, J. L. (2000). Extent and determinants of error in doctors' prognoses in terminally ill patients: Prospective cohort study. British Medical Journal, 19, Desbiens, N. A., Connors, A. F., & Lynn, J. (1999). The symptom burden of seriously ill hospitalized patients. Journal of Pain and Symptom Management, 17, Glare, P., Virik, K., Hudson, M., Eychmuller, S., Simes, J., & Christakis, N. (2003). A systematic review of physicians' survival predictions in terminally ill cancer patients. British Medical Journal, 327, Lunney, J. R., Lynn, J., Foley, D. J., Lipson, S., & Guralnik, J. (2003). Patterns of functional decline at the end of life. Journal of the American Medical Association, 289, Ross, M. M., McDonald, B., & McGuinness, J. (1996). The palliative care quiz for nursing (PCQN): the development of an instrument to measure nurses' knowledge of palliative care. Journal of Advanced Nursing, 23, The SUPPORT Principal Investigators (1995). A controlled trial to improve care for seriously ill hospitalized patients: the study to understand prognoses and preferences for outcomes and risks of treatment (SUPPORT). Journal of the American Medical Association, 274, Victoria Hospice (2013). Health Professionals: Clinical Tools. Retrieved February 5,