PALLIATIVE CARE 101 JEFF MCNALLY, MD

Transcription

1 PALLIATIVE CARE 101 JEFF MCNALLY, MD

2 Who am I Jeff McNally, MD Internal Medicine trained and board certified ER physician Utah Emergency Physicians 21 years Intermountain Hospice Medical Director past 2 years Intermountain Homecare and Hospice CMO Intermountain Palliative Care Systems Director

3 Disclosures I have nothing to disclose, declare, or admit at this time. I have no conflicts of interest. This will be free of commercial or industry bias.

4 Goals for Today Describe what Palliative Care is Discuss how Palliative Care can help patients/families/costs Review who can provide Palliative Care Education about Palliative Care Review Palliative Care services in your region and within Intermountain Healthcare

5 Palliative care comes from the word palliate - which means to ease.

6 Palliative Care Definition World Health Organization Definition: An approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and thorough assessment and treatment of pain and other problems, physical, psychosocial and spiritual needs Multidisciplinary approach that focuses on the whole patient and family

7 What does Palliative Care look like? Specialized care for patients and families affected by serious illness Team Approach physician, advanced practitioner, RN, SW, aides, chaplain, volunteer coordinator Help with decision making e.g. goals of care Support for patient and families Provide symptom and stress management/ psychosocial and spiritual support Multi-prong approach

8 What Patients Need Palliative Care? Adult Serious Illness CHF, ESRD, ESLD, Cancer, ALS, Dementia Combined with either high utilization, functional limitations, palliative care identifiers (pain, n/v, confusion)

9 Modern End of Life = Protracted Course 85% of people in the US will experience one of these trajectories at the end of life 20% Cancer 25% Organ Failure 40% Dementia/Frailty Average American 2-4 years of disability before death

10 Why Recent Focus on Palliative Care? We are maturing as a society both in age and in terms of thinking People are more involved in their care Financial Multiple studies: palliative care helps improve quality of care and is more cost effective

11 Old vs New Approach Life Prolonging Care Medicare Hospice Benefit Old Life Prolonging Care Disease Progression Palliative Care Hospice Care New Diagnosis of serious illness Death

12 A Palliative Care Trajectory May represent decades E n d of L i f e Care Diagnosis of a Potentially Life-Limiting Illness, Condition Active Dying To Include: Remission(s) (24-72 hrs) Worried Wellness Cautiously Cured (Anxious) Survivorship Chronically well/ill Death Event

13 Palliative Care Improves Value Quality improves Symptoms Quality of life Length of life Family satisfaction Family bereavement outcomes Care matched to patient centered goals Costs reduced Less frequent ED visits Need for hospitalization/icu decreases $1.3 to 4 million cost avoidance per study

14 Who Can Provide Palliative Care? Anyone who has contact with a patient Physicians, Nurses, Social Workers, NPs, Pas, Mas What they can provide is different, but all can provide Palliative Care Comfort level, experience and resources are the main factors

15 Outpatient Palliative Care Free standing specialty clinic full interdisciplinary services Embedded clinic providing services to distinct population within a clinic (CHF, oncology); usually staffed with one or more palliative care specialists PCP clinic typically involves placing a staff resource (RN, case manager, APRN) who can support the following: -advanced care planning -symptom management -goal setting -hospice information and referral

16 Generalist Palliative Care A lot of palliative care not provided by palliative specialists Any clinician who works directly with patients can be considered a generalist in palliative care PCP, oncology, pulmonary, hospitalist, etc. Benefit from focused training

17 Formal Education Opportunity UCOPE- Utah Certificate for Palliative Care Co-sponsored with University of Utah 4 day intensive course for Generalist Palliative Care providers. MDs, DOs, NPs, PAs, RNs, LCSW, Chaplains 2017 Dates: January May 9-12 September Awards CME credit

18 Informal Education Incorporated into medical training and board recertification CME Provided by Intermountain via updates on program Palliative Care Fast Facts

19 Specialized Palliative Care Team approach and experience Discussion of goals of care in detail with patient and family POLST Advanced Directives Symptom Management (Physical and Otherwise) Coordination of Care

20 Resources for Specialized Palliative Care Intermountain system per Dr. David Weissman report General support for palliative care program development - Widespread lack of knowledge about definition and benefit - Significantly behind peer institutions - Current programs within Intermountain understaffed, isolated - Recommended dedicated physician leadership and system strategic plan

21 South Region Palliative Care Gary Garner, MD Full time palliative care provider Inpatient consults and outpatient clinic ~80% oncology patients in clinic Looking for full-time partner Outpatient clinic / Inpatient consult Kelleen Brown, NP

22 Case Study Best way to describe Palliative Care is with a case Bridge inpatient and outpatient settings Demonstrates what Palliative Care can do for patient and family

23 Mr. K 59 y/o Male diagnosed with Stage IV Colon Cancer in April 2014 Mets to Liver, Lung, lymph nodes Underwent chemotherapy with reasonable tumor response Colon Stent for obstruction Hemi-colectomy preformed on 10/10/14 secondary to ulcerative lesions in colon Post op course complicated by development of C. Diff colitis and inability to tolerate nutrition Inpatient Palliative Care consulted by Surgeon on 10/14/14 for symptom management and goals of care discussion and planning

24 Mr. K. Palliative Care met with patient and family to establish symptom management plan Helped clarify patient and families wishes and goals of care Helped to clear up confusion regarding POLST form and care levels Prior to discharge, arranged referral to PC attending and the McKay Dee outpatient palliative care clinic Also coordinated with outpatient oncologist and outpatient oncology social work

25 Mr. K Patient followed up with PC attending in the outpatient Palliative Care Clinic on 10/30/14 P.C. attending and the outpatient team addressed: pain, GI, psychosocial, spiritual and other symptoms and issues Mr. K had good response to symptom management, and was followed on a regular basis by PC attending and the Palliative Care team This happened while the patient was still following with Surgery and Oncology for active care and goal of cure

26 Mr. K. Seen by PC outpatient attending on 4/9/15 after progression of disease Completed an updated POLST form on that date - DNR/DNI, defined trial of aggressive care, antibiotics and hospitalization Patient and family provided multiple areas of support by Palliative Care team Continued to coordinate care with PCP and subspecialists

27 Mr. K Overnight 4/11 to 4/12 increased weakness, large amount of output from ostomy, and mental status change. Evaluated in the McKay Dee ER diagnosis of dehydration with possible septic shock ED physician spoke with outpatient P.C. physician and patient s oncologist PC attending spoke with family via phone Plan admit to ICU for 24 hours aggressive attempt to reverse course short of intubation and CPR

28 Mr. K No improvement after 24 hours of aggressive therapy Discussion with Mr. K and family make me comfortable with my family around me Aggressive curative measures stopped and transferred to floor with inpatient PC team involved Comfort measures only and passed away comfortably with family present

29 Summary This case shows the power of Palliative Care Upstream Collaboration ED, outpatient PC, ICU, inpatient PC Most important: Patient and family wishes were honored Death never easy but much better when patient has some control

30 To Sum up Palliative Care proven to improve quality of life with added benefit of lower costs Many types of healthcare providers can utilize and perform Palliative Care services Misunderstood, understaffed and underutilized The work to change this has started

31 Questions? Thank You

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