Palliative Care Solomon Liao, MD Associate Clinical Professor University of California, Irvine Director of Palliative Care Service
Objectives By the end of this session, participants will be able to: Define palliative care & hospice Educate patients & families on the benefits of palliative care Utilize palliative care services
How Do You Help? 78 year-old brought in for seizure Admitted for a left MCA infarct o Got tpa Lethargic but improving Dysphagia No advance directive Family debating about PEG Not ready for hospice
Palliative Care What does it mean to you? Comfort care (quality of life) o Symptom management Not curative (quantity of life) o Concomitant Comprehensive o Person & family = treatment unit o Physical, Psychosocial, Spiritual 4
Interdisciplinary MD Primary and consultant Nurse/case manager Social worker (case manager) Chaplain Pharmacist Volunteer (coordinator) Nursing aide Dietician Therapist physical, occupational, speech 5
Levels of Palliative Care Tertiary: Academic Referral Secondary: Local Consult Primary: Everyone
Conceptual Shift for Palliative Care Hospice
Difficult Family 58 year-old admit for large right MCA hemorrhagic infarct Atrial fibrillation o Inconsistently taking Coumadin Intubated for 10 days o Aspiration pneumonia o ARDS Large family o Different opinions o Unable to decide tracheostomy & PEG What would you do?
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Intractable Service We are the most helpful with Most difficult, most intractable cases Intractable pain or symptoms Difficult patients & families Challenging situations Difficult discharges
Satisfaction with PC Consults Author Year Location Satisfaction Brumley et al 2007 US Pt Engelhardt et al 2006 US Pt Rabow et al 2004 US Pt Moore et al 2002 UK Pt Hankes et al 2002 UK Pt & Caregiver Jordhoy et al 2001 UK Caregiver Hughes et al 2000 US Pt Support 1995 US Caregiver Hughes et al 1992 US Pt & Caregiver Zimmer et al 1984 US Caregiver JAMA 2008; 299:1698-1709
Family Meeting Phases Preparatory most important o Who s the decision maker(s)? o What s the decision making process? Advance directive? o Interpreter needed? o Consultants opinions o Purpose or goal of meeting Introduction o Introduce everyone in the room o Update or summarize everyone on the same page What s their understanding of the patient s condition
Analysis Phases (Continued) o Best and worse case scenarios Acceptable state o Spectrum of options Most aggressive to most comfortable o Pros and cons o Time limited trial Conclusion o Summarize o Action items Debriefing o Formal or informal can be short o Feelings as well as thoughts o Others observations
Systems Improvement CNO returns from national conference o Palliative care improves LOC & reported mortality ratio She wants you to o Increase palliative care involvement in stroke patients o Reduce cost of stroke patients in the ICU And measure it o Improved mortality ratio for stroke patients How do you do all that?
Nursing Palliative Care ICU Trigger Stage 4 CA Cardiopulm arrest Trach/PEG considered Intra-cerebral bleed on Vent Complex decision making ICU readmit Dementia w/dysphagia > 2 organ failure Was on hospice 2 or more: o Recurrent systemic infection o Alb <2.5 o Uncontrolled pain or symptom o Lives in SNF o Readmit in 30 days
UCI ICU Deaths Oct 2010 to Sept 2011 Cases ALOS Total Cost Gain Pall Care per case 123 13.6 $80,498 $7,601 per day $5,929 $560 w/o PC per case 141 10.9 $76,424 -$5,223 per day $6,988 -$478
Helping O/E Mortality Observed o Move death out of the hospital o Trach & PEG early o Identify outliers 2 SD out Expected o Documentation: Coma o DNR o Comfort care, V66.7
Pain All Over 69 year-old admitted for a small thalamic infarct Recovering well Complains of severe diffuse generalized pain throughout her body Morphine does not help Anxious & depressed What is the problem?
Central Pain Treatments Lamotrigine (Lamictal) Tricyclics o Not for older patients Gabapentin (Neurontin) o Small studies Venlafaxine o Also treats depression or anxiety Ketamine o If all else fails
Conclusion Early Palliative Care helps o The Patient o The Family o The Physician o The Staff o The Hospital o The Health System Win-Win o Quality of Life o Quantity of Life o Cost savings