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Francis A. Komara, D.O. Michigan State University College of Osteopathic Medicine Define Palliative Care. Identify indications for palliative care services. services Describe Guidelines for delivery of palliative care and quality outcomes. Identify types of palliative care services and their utilization.
What Is Palliative Care?
Medical treatment that aims to relieve suffering and improve quality of life simultaneously with all other appropriate treatment for patients with advanced illness, and their families.
What is Hospice Care?
Support and care for persons in the last phase of an incurable disease so that they may live as fully and comfortably as possible. NHPCO Hospice is a program designed to care for the dying and their special needs:
Control of pain and other symptoms Psychosocial support for patient and family Medical services with needs of patient Interdisciplinary Team approach AAFP
Palliative Care and ICU Care?
Critical care is the sophisticated, state-ofthe-art and technologically-oriented medical and nursing care provided to patients facing life-threatening illness or injury with the goal of reversing illness or injury and restoring health
Greater than half of hospital deaths in U.S. occur in ICU. 20% of Americans receive ICU care near the end of life. 10-20% of ICU patients will die. 70 - 90% of ICU deaths occur in the context of withholding or withdrawing life support. Many ICU patients Live with significant reduction in quality of life after the ICU Return to the ICU
Angus, Crit Care Med, 2004; 32:638; SUPPORT, JAMA 1996;274:1591
2 . Assist in Medical Decision Making Team members informed of patient and family needs. Care given by Interdisciplinary team Diagnosis Palliative Care Hospice Death & Bereavement Physical Psychological Spiritual Social NHWG.A New Vision of Palliative Care Definition: Palliative care Disease Modifying Therapy Curative. The Care Unit made of: Patient Family Caregiver g Should be Integrated into daily clinical practice (Not just specialty care). Promote communication and continuity of care across settings. Adapted from work of the Canadian Palliative Care Association & Frank Ferris. explore hospice option. Primary Care Physician expected to provide basic palliative care. Enable the best quality of life. or restorative intent Life Closure Serves patients of all ages with chronic illness or injury that affects daily functioning or reduces life expectancy. Address physical. Prepare patient and family of dying process and death. Provided in multiple settings. Physician offices Hospital and Emergency Rooms Home Nursing homes Goals of Care Care Team Prevent and relieve suffering. psychological and psychiatric. May require PC Specialists in Complex situations Can be main focus of care or given with life-prolonging treatment. Bereavement Communication Determine Goals and Preferences of patient and family. spiritual and social issues. MD Definition Definition Begins when condition is diagnosed and continues through cure or until death or family bereavement.
social. spiritual and legal aspects. psychological. delirium. Symptom control skills y p Assessment of Social and Practical needs. surrogate decision makers.Care Team Support for the Team Emotional support Education R Regular meetings l ti Specialist-level skills in physical. Psychiatric need awareness: Depression. 3 . anxiety. directives. Benefit vs Burden Need for higher intensity care near death. Support for the Family Ready access to palliative care team (24/7) Help with decision making Di Discuss goals of care and advance care l f d d planning Emotional and social support Referrals Hospice and community resources. Medical Decision Making: Advance care planning. co-morbidities of serious illness. Specialized professionals T Transportation t ti Rehabilitation services Medications Counseling Completion of unfinished business Communication Care Plan Identify goals of patient and family Review regularly!! A Assessment T l t Tools Care plan changes as patient and family needs evolve.
TIME-LIMITED TRIALS: Currently Receiving: Ventilator: Dialysis Feeding Tube Antibiotics IV Fluids Other: Other: Re-Evaluation Date: ________________ Re-evaluat ion Dat e Date Stopped: ________________ Dat e Comments ________________ Re-evaluat ion Dat e ________________ Dat e ________________ Re-evaluat ion Dat e ________________ Dat e ________________ Re-evaluat ion Dat e ________________ Dat e Palliative Care Assessment ________________ Re-evaluat ion Dat e ________________ Dat e ________________ Re-evaluat ion Dat e ________________ Dat e ________________ Re-evaluat ion Dat e ________________ Dat e NURSE PRACTITIONER ASSESSMENT: ___________________________________________________________ Review of admission to unit triggers Palliative Care Screen ICU Admission following a current hospital g p stay of at least 10 days Age>80 in presence of 2 or more lifethreatening co-morbidities Diagnosis of active Stage IV malignancy S/P cardiac arrest Intra-cerebral hemorrhage requiring ventilator Full Consult Now Await Result of Time-limited Tria ls SIGNATURE: NP: ______________________________________________________ Date: _____________________________ PALLIATIVE CARE ATTENDING REVIEW : ________________________________________________________ SIGNATURE: Attending: ___________________________________________________ Date: ___________________________ FINAL DISPOSITION: Trans ferred to: _____________ Died in Unit Coded Treatment Withdrawal No treatment / No code Com m e nts : Date: Date: Date: Date: Date: ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ Palliative Care Assessment Brief HPI Physical exam Symptoms: Palliative Care Assessment Patient and family support needs addressed: Yes/No Health care proxy identified Living will identified Goals of care identified End of life issues identified Addressed: Yes/No Pain Nausea/vomiting Dyspnea Agitation anxiety Palliative Care Assessment Palliative Care Assessment Limitations set on: No CPR DNI No Dialysis No Feeding tube No antibiotics No pressors No IV fluids Time-Limited trials? Ventilator Dialysis Feeding tube Antibiotics IV Fluids 4 .
Quality Measures for Palliative Care: Robert Wood Johnson Critical Care Workgroup Quality Measures Patient and family-centered decision making Assessment of patient s decisional capacity patient’s Documentation of surrogate decision maker within 24 hrs of admission Documentation of presence and contents of advance directives Documentation of goals of care Communication within the team and with patients and family Documentation of timely physician communication with family and interdisciplinary clinician-family conference Transmission of key information with transfer of patient out of ICU Continuity of care Quality Measures Quality Measures Emotional and practical support for patients and family Open visitation Documentation that psychosocial support has been offered Symptom management and comfort care Documentation of pain assessment and management Documentation of respiratory distress assessment and management Protocol for analgesia/sedation in terminal withdrawal of mechanical ventilation Quality Measures Documentation that spiritual support was offered Emotional and organizational support for clinicians Care Plan Identify Alternative settings and treatment. 5 . Communicate regularly. C ll b Collaborate between palliative and hospice t b t lli ti dh i programs and community providers to assure continuity of care.
Advance care planning. complementary therapies. hopes. Assist Surrogate decision makers. substituted judgment and best-interest criteria. Withholding and withdrawing treatments Do not resuscitate orders Ethical Aspects Beneficience Self-determination C Capacity assessment it t Informed consent Quality Improvement Be attentive to: Safety Error reduction Timeliness Patient preferences Benefit and effectiveness Equity of access Efficiency 6 . Barriers: Fear of addiction. Honoring patient’s preferences. Ethical and Legal aspects Creating or updating wills. End of life and Bereavement Introduce hospice referral Address end of life concerns. side-effects. management Timely reduction of pain and symptoms that is acceptable to the patient. advance care directives. Address safety Fl ibl visiting hours Flexible i iti h Space for families Privacy According to goals of care. non-pharmacologic. Pharmacologic. Guardianship agreements. Bereavement services for at least 12 months after death. respiratory depression.Treatment Care Setting By patient and family preference. Pain and Symptom management. Assessment of Risk vs Benefit. fears P t Pastoral care to facilitate religious or l t f ilit t li i spiritual/cultural rituals.
ibl lit f lif f ti t f ll d th i f ili Palliative care is a both a philosophy of care and an organized program for delivering care to persons of all ages with life threatening conditions. optimizing function.decouple palliative care from end of life carecall it non hospice palliative care. families. National Quality Forum: Palliative care refers to patient. practical help. intellectual. dying. evidencebased medical treatment Vigorous care of pain and symptoms throughout illness Care that patients want at the same time as efforts to cure or prolong life Expert control of pain and symptoms Uses the crisis of the hospitalization to facilitate communication and decision-making about goals of care with patient and family Coordinates care and transitions across fragmented medical system Provides practical support for family and other caregivers Cultural competency 7 . Use the language of the National Consensus Project for Quality Palliative Care. helping with decision-making. and CAPC. and spiritual needs and facilitating patient autonomy. families. and bereavement language renders our services immediately irrelevant to 95% of our audience. access to information.and family-centered care that optimizes quality of life by anticipating. Even among the subset that are. and treating suffering. efficiency Use of end of life. If we want to reach the patients and families who need us we cannot force them to 1st agree that they are dying. emotional. Solution. and colleagues using language that focuses on the needs of the audience as they perceive them. As such. Definitions CAPC: Palliative care is an Interdisciplinary specialty that aims to relieve suffering and improve quality of life for patients with advanced illness. and choice. Palliative care throughout the continuum of illness involves addressing physical. Watch our language.for patients+families: relief. Specifically: Palliative Care Is Palliative Care in Practice Palliative Care Is NOT Not “giving up” on a patient. NCP: The goal of palliative care is to prevent and relieve suffering and support the best th b t possible quality of life for patients of all ages and their families. Language matters Communicate who we are and what we do to patients. withdrawing life support Not in place of curative or lifeprolonging care Not the same as hospice Not Comfort care Excellent. and their families. For hospitals: quality and efficiency. and providing opportunities for personal growth. health tf ti t f ili h lth professionals Focus on meeting needs of those receiving the care.it drives our audience away If our goal is to provide a patient-centered approach to improving care of seriously ill…the major barrier we face is self-imposed. This care focuses on enhancing quality of life for patient and family. It is provided simultaneously with all other appropriate medical treatment. no-one wants to die. Many people who need palliative care are not dying. it can be delivered concurrently with life prolonging care or as the main focus of care.Quality Improvement Collaborative Regular assessment I Input from patients. social. For referring docs: time and assistance. preventing. and very few are able to accept that they are dying until death is imminent. National Quality Forum.
The Nature of Suffering and the Goals of Medicine The relief of suffering and the cure of disease must be seen as twin obligations of a medical profession that is truly dedicated to the care of the sick.aspx?prodid=Q014 EPEC-O Learn by doing! 8 . 2006. AHA Survey 2002. The demographic imperative: Chronically ill. Pan CX et al J Pall Med. No. Cassell.73 15.gov/ncipubs/detail. et al.com/cgibin/fulltext/122486445/PDFSTART https://cissecure.palliativedrugs. American Family Physician.org www. Proposed quality measures for palliative care in the critically ill: A consensus from the Robert Wood Johnson Critical Care Workgroup. Physicians’ f il Ph i i ’ failure to understand the nature of t d t d th t f suffering can result in medical intervention that (though technically adequate) not only fails to relieve suffering but becomes a source of suffering itself.73.stoppain. aging population is growing The 63% of Medicare patients with 2 or more chronic conditions account for 95% of Medicare spending (CDC) The number of people over age 85 will double to 9 million by the year 2030 (CDC) More and more physicians are providing palliative care But… Number of palliative care programs. Eric NEJM 1982.nci.com www. 11 (Suppl) Other Web Sites www. Critical Care Medicine 2006 Vol 34.org AGS GUIDELINE Management of Persistent Pain in GUIDELINE: M t fP i t tP i i Older Persons http://www3.wiley. Mularski RA. physicians need basic PC clinical skills Number of hospital-based palliative care programs has doubled in recent years to more than 800 One in five hospitals now offers palliative care US News & World Report includes palliative care in its criteria for “America’s Best Hospitals” ABHPM certifying more and more physicians Referral rates at established programs are growing each year Billings JA et al J Pall Med.nih.interscience. 2001 References Smith L.306:639-45.growthhouse. specialists not sufficient to meet patient need In absence of comprehensive palliative care programs and PC specialists. Guidelines for Delivering Quality Palliative Care. Physician March 15 2006. 2001.
Palliative Care: Making the Case. DE.capc. June 21.org Meier. 2005.capc. www capc org Meier. 2004 www.org Care 2004.org Meier.org 9 .capc. www. www.capc. 2007. Clinical Essentials of Palliative Care. DE.Presentation adapted from: www. DE. Palliative Care Comes of Age.
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