Disclosures. Objectives 3/12/2015. Carpenter For personal use only; may not be reproduced, represented, or otherwise disseminated.

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1 AN EVIDENCE BASED APPROACH TO IMPROVE ACCESS TO PALLIATIVE CARE: THE EXPERIENCE OF A COMMUNITY CANCER CENTER JOAN CARPENTER, MN, CRNP, ACHPN NURSE PRACTITIONER, COASTAL HOSPICE AND PALLIATIVE CARE Disclosures None Objectives Discuss the challenges and opportunities integrating early palliative care in the treatment of patients with cancer. Describe the benefits (outcomes) of early referral to palliative care for patients with cancer. Identify one actionable strategy to integrate early palliative care in cancer treatment. 1

2 Palliative Care to prevent and relieve suffering and to support the best possible quality of life for patients and their families, regardless of the stage of the disease or need for other therapies. (National Consensus Project for Quality Palliative Care, 2013) Defining the Difference What is hospice Patient decides against life-sustaining, lifeprolonging therapies Last 6 months of life Home : includes longterm care facility or a personal home Inpatient: is for limited time (hospice is not a place ) What is palliative care No treatments are specifically excluded from the plan of care Throughout the course of serious and/or complex illness Any setting will see more in hospitals Symptom management and supportive care The Quality Improvement Project Phase I: Evidence Phase II: Interventions Phase III: Follow-up 2

3 The Evidence- Phase 1, Part1 Summary: What We Know Part I 4 areas performed poorer than the benchmark ICU last month of life Hospital death < 3 days hospice > 1 hospital stay in the last month of life The Evidence - Phase 1, Part II 3

4 The Evidence: Part II Strong evidence from a phase III RCT, patients with metastatic non small-cell lung cancer should have concurrent PC and standard oncologic care at initial diagnosis. Seven RCT s show palliative care can be provided alongside standard/usual oncology care No harm Evidence of benefit Higher physical and functional QOL related to improved survival 79% of lung cancer patients report symptom cluster Need for comprehensive symptom management strategies Irwin, et al., 2013 Smith et al., 2012 Summary: What We Know Part II Studies of concurrent palliative care in advanced cancer have demonstrated: Better patient outcomes Improved symptoms Improved quality of life Improved satisfaction Diminished caregiver burden Reduced cost Smith et al., 2012, Zimmermann et al., 2014 National Consensus Project for Quality Palliative Care, 2009, p. 6 4

5 Phase II Interventions Structure Formed a cooperate structure to support the growth and development of the palliative care program through practice and education. Palliative Care Advisory (PAC) committee meets quarterly and oversees activity. Integrating Palliative Care into Practice Implementation of advance directive question with follow-up discussion with patient and family. Goal- All patients will be offered advance directive education to support their end-of life decisions by their fifth visit. A copy of a completed advance directive will be place in the record. Oncology Outpatient Palliative Care Assist in identifying patients and their families who may benefit from palliative care at diagnosis. Primary goals: a) increase awareness of available palliative care services and b) meet palliative care needs of patients earlier in the illness/disease trajectory c) provide education about palliative and the services available. All outpatients diagnosed with stage III and IV cancer will have a one-time no-charge visit with a palliative care team member. The palliative care team member providing the visit is certified in palliative care. 5

6 Components of Palliative Care Average time= 55 minutes (range ) Symptom management Patient and family coping Illness understanding and education Establish rapport Discussion about coping Explore prognosis and trajectory Transition to more serious discussions Jacobsen, et al., 2011 Palliative Care Education Mandatory net learning module completed annually by all clinicians. Palliative Care integrated into orientation education for both clinicians and medical staff. Palliative Care and Hospice information/education provided in both the inpatient welcome brochure and the oncology journal. Re-educated medical staff End of Life Nursing Education Consortium (ELNEC) Presentation of the 9 modules with continuing ed. credits. Outcomes Inpatient Palliative Care Statistics: FY 12 FY 13 FY 14 Inpatient Referrals: Average Time - Admission to Palliative Care Referral: 5.8 Days 5.3 Days 5.2 Days Referred Day 1-3 of Hospitalization 46% 47% 52% Referred Day % 29% 28% Referred Day % 19% 15% > Day 14 of Hospitalization 6% 5% 5% Completed Advanced Directive Symptom Management Outpatient Visits Palliative Care Statistics

7 Questions Contact Information References Irwin, K. E., Greer, J. A., Khatib, J., Temel, J. S., & Pirl, W. (2013). Early palliative care and metastatic non-small cell lung cancer: potential mechanisms of prolonged survival. Chronic respiratory disease, 10(1), 35. Jacobsen, J., Jackson, V., Dahlin, C., Greer, J., Perez-Cruz, P., Billings, J. A.,... Temel, J. (2011). Components of Early Outpatient Palliative Care Consultation in Patients with Metastatic Nonsmall Cell Lung Cancer. Journal of Palliative Medicine, 14(4), Levy, M. H., Smith, T., Alvarez-Perez, A., Back, A., Baker, J.N., Block, S., Codada, S.N., Dalal, S., Dans, M, Kutner, J., Kvale, E., Misra, S., Mitchell, W., Sauer, T., Spiegel, D., Sutton, L., Taylor, R.M., Temel. J., Tickoo, R., Urba, S.G., Van Syl, C., Weinstein, S.M., Bergamn, M.A., Scavone, J.L. (2014). Palliative Care, Version Journal of the National Comprehensive Cancer Network(12), National Consensus Project for Quality Palliative Care. (2013). Clinical Practice Guidelines for Quality Palliative Care (3nd ed.). National Consensus Project for Quality Palliative Care. (2009). Clinical Practice Guideline for Quality Palliative Care, 2nd Edition. Pittsburgh: National Consensus Project for Quality Palliative Care. Smith, T. J., Temin, S., Alesi, E. R., Abernethy, A. P., Balboni, T. A., Basch, E. M.,... Von Roenn, J. H. (2012). American Society of Clinical Oncology Provisional Clinical Opinion: The Integration of Palliative Care Into Standard Oncology Care. Journal of Clinical Oncology, 30(8), Zimmermann, C., Swami, N., Krzyzanowska, M., Hannon, B., Leighl, N., Oza, A.,... Lo, C. (2014). Early palliative care for patients with advanced cancer: A cluster-randomised controlled trial. The Lancet. Retrieved from 7