Transcript Palliative Care in the Patient

Palliative Care in MiPCT:
Extending the Continuum of Care
Phil Rodgers, MD FAAHPM
Associate Professor, Department of Family Medicine
Associate Director for Clinical Programs, Palliative Medicine Program
University of Michigan Health System
MiPCT 2013 Annual Summit
October 2013
No Potential Conflict of Interest
to Declare

Phil Rodgers, MD FAAHPM
I have no potential conflicts of interest or financial
relationships to declare related to today’s presentation.
Objectives

Understand the fundamentals of palliative
care, and its value to securing the continuum
of high quality primary care

Identify specific opportunities to provide
primary palliative care to your patients with
advanced illness
What is Palliative Care?
Palliative care means patient and family-centered
care that optimizes quality of life by anticipating,
preventing, and treating suffering. Palliative care
throughout the continuum of illness involves
addressing physical, intellectual, emotional, social,
and spiritual needs and to facilitate patient
autonomy, access to information, and choice.
73 FR 32204, June 5, 2008
Medicare Hospice Conditions of Participation – Final Rule
4
Curative Care
Presentation/
Diagnosis
Hospice
Traditional Model of Care
Death
New Model of Palliative Care
Diagnosis
HEALTH
Death
ILLNESS
Curative & Life
Prolonging Care
Prevention
DEATH
Palliative Care
Symptom
Life
Management
Closure
CURATIVE CARE
EOL/
Dying Bereavement
HOSPICE CARE
How is Palliative Care
Different than Hospice?
o
Palliative care is appropriate at any point in a serious illness.
It is provided at the same time as life-prolonging treatment.
No prognostic requirement, no need to choose between
treatment approaches.
o
Hospice is a medical benefit that supports care for those in
the last weeks to few months of life. Patients must have a 2
MD-certified prognosis of <6 months, and often must give up
insurance coverage for curative or life prolonging treatment
in order to be eligible.
(Medicare Hospice Benefit: 84% Medicare, 5% Medicaid, 3% uninsured)
Palliative care in the US Today
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75% of US hospitals >50 beds have Palliative Care programs
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85% of US medical schools have hospital-based palliative care
programs
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Palliative Care now recognized by ACGME, ABMS, NQF, and CMS
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States in the US with higher hospital palliative care penetration
have:
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Fewer Medicare hospital deaths
Fewer intensive care unit / cardiac care unit (ICU / CCU) days
Fewer admissions during the last 6 months of life
Fewer ICU / CCU admissions during terminal hospitalizations
Lower overall Medicare spending / enrollee
Goldsmith BA, Dietrich J, et al. J Palliative Med 2008; 11(8):suppl 1-9
Teno JM, Clarridge BR, Casey V et al. JAMA 2004;291(1):88-93
Why Palliative Care Now?
We’re living longer, with more illness
 Burdens of symptom management and
care needs are increasing
 Treatment options and outcomes are
more complex
 Family caregivers and supports systems
are strained, eroded or absent
 Increasing emphasis on value in health
care delivery
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Target Population for Complex Care Coordination and
Palliative Care
Distribution of Total Medicare Beneficiaries and Spending
37%
Average per capita
Medicare spending
(FFS only): $7,064
90%
63%
Average per capita
Medicare spending
among top 10%
(FFS only): $44,220
10%
Total Number of FFS
Beneficiaries:
37.5 million
Total Medicare
Spending:
$265 billion
NOTE: FFS is fee-for-service. Includes noninstitutionalized and institutionalized Medicare fee-for-service
beneficiaries, excluding Medicare managed care enrollees.
SOURCE: Kaiser Family Foundation analysis of the CMS Medicare Current Beneficiary Survey Cost & Use file, 2005.
Care Management Targeted to Needs of Patients
Patient Type
• Worried well
• Self-resolving illness
• Low grade acute illness
100
%
Claimants
Cost per
Claimant
Management
Approach
Low
Demand
Management
Medium
Disease
Management
90
80
• Chronic diseases
• Moderate to severe acute illness
70
60
Complex Patients
50
• Significant diagnosis
40
• Multiple co-morbidities
30
• Often terminal
20
• Several providers of care
• Psychological / social / financial
upheaval
Case
Management
High
Complex Care
Management
10
Palliative
Care
4
Outcomes of Palliative Care
 Improved patient and family satisfaction
 Reduction in
symptom burden
 Reduced costs
 Prolonged Survival
Improved Family Satisfaction
Mortality follow back survey palliative care vs. usual care
Casarett et al. J Am Geriatr Soc 2008;56:593-99.
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N=524 family survivors
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Overall satisfaction markedly superior in palliative care
group, p<.001
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Palliative care superior for:
 Emotional and spiritual support
 Information and communication
 Care at time of death
 Access to services in community
 Well-being and dignity
 Care type and setting concordant with patient preference
 Pain and symptom control
Improved Symptom Control
Bakitas M et al. JAMA 2009;302(7):741-9
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N= 322 advanced cancer patients in rural NH+VT
Improved quality of life and less depression (p=.02)
Trend towards reduced symptom intensity (p=.06)
No difference in utilization, very low in both groups
Median survival: intervention group 14 months,
control group 8.5 months, p=.14
How Palliative Care Reduces
Length of Stay and Cost
Palliative care:
 Clarifies goals of care with patients and families
 Helps families to select medical treatments and
care settings that meet their goals
 Assists with decisions to leave the hospital, or to
withhold or withdraw death-prolonging
treatments that don’t help to meet their goals
capc.org/research-and-references-for-palliative-care/citations Lilly et al, Am J Med, 2000; Dowdy et al, Crit Care Med, 1998; Carlson et al, JAMA,
1988; Campbell et al, Heart Lung, 1991; Campbell et al, Crit Care Med, 1997; Bruera et al, J Pall Med, 2000; Finn et al, ASCO, 2002; Goldstein et al,
Sup Care Cancer, 1996; Advisory Board 2002; Davis et al J Support Oncol 2005; Smeenk et al Pat Educ Couns 2000; Von Gunten JAMA 2002;
Schneiderman et al JAMA 2003; Campbell and Guzman, Chest 2003; Smith et al. JPM 2003; Smith, Hillner JCO 2002; www.capc.org; Gilmer et al.
Health Affairs 2005. Campbell et al. Ann Int Med.2004; Health Care Advisory Board. The New Medical Enterprise 2004. Elsayem et al, JPM 2006;
Fromme et al, JPM 2006; Penrod et al, JPM 2006; Gozalo and Miller, HSR 2006; White et al, JHCM 2006; Morrison RS et al Arch Int Med 2008
Palliative Care Shifts Care
Out of Hospital to Home
Service Use Among Patients Who Died from CHF, COPD, or Cancer
Palliative Home Care versus Usual Care, 1999–2000
Usual Medicare home care
Palliative care intervention
40
35.0
30
20
13.2
11.1
9.4
10
5.3
2.3
0.9
2.4
4.6
0.9
0
Home health
visits
Physician
office visits
ER visits
Brumley, R.D. et al. 2007. J Am Geriatr Soc.
Hospital days
SNF days
Hospital Palliative Care Reduces Costs
Cost and ICU Outcomes Associated with Palliative Care Consultation in 8 U.S. Hospitals
Live Discharges
Costs
Usual
Care
Hospital Deaths
Δ
Palliative
Care
Usual
Care
Palliative
Care
Δ
Per Day
$867
$684
$183*
$1,515
$1,069
$446*
Per Admission
$11,498
$9,992
$1,506*
$23,521
$16,831
$6,690*
Laboratory
$1,160
$833
$327*
$2,805
$1,772
$1,033*
ICU
$6,974
$1,726
$5,248*
$15,531
$7,755
$7,776***
Pharmacy
$2,223
$2,037
$186
$6,063
$3,622
$2,441**
Imaging
$851
$1,060
-$208***
$1,656
$1,475
$181
Died in ICU
X
X
X
18%
4%
14%*
*p<.001
**p<.01
***p<.05
Morrison, RS et al. Archives Intern Med 2008;
Palliative Care Can Improve
Survival
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Randomized controlled-trial, 151 patients with
metastatic NSCLC
Palliative care plus cancer treatment vs.
usual cancer care
Intervention group showed:
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Better QOL and symptom scores
Less ‘aggressive care’ at end-of-life
Prolonged survival (~2 months)
Temel J, et al. New Engl J Med 2010; 363(8): 733-42
What does Palliative Care Do?
“Right Care, Right Place, Right Time”
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Pain and physical symptom management
Clear communication
Difficult or complex treatment decisions
Managing care transitions
Detailed and practical help at all stages of care
Emotional and spiritual support
Palliative Care Delivery
Tertiary Palliative Care
Delivered by subspecialty
Palliative Care Teams
Secondary Palliative Care
Delivered by clinicians frequently caring
for seriously ill patients
Primary Palliative Care
Delivered by all interdisciplinary clinicians to
patients with serious illness, and their families
Primary Palliative Care
Many patients die in the care of their PCP
 Effective palliative care is high-quality primary
care through the end of life
 Primary care providers are uniquely situated to
provide comprehensive care to patients and
families facing life-limiting illness
 Our growing challenge is to provide this care in a
coordinated, sustainable way
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Primary Palliative Care ‘Tasks’
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Prognosis – help communicate prognosis to inform
patient/family decision-making
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Planning – establish goals of care consistent with
patient/family desires and values
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Palliation – carefully assess and address physical, emotional,
interpersonal and spiritual symptoms
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Prescribe Hospice – discuss when/if hospice care is an
appropriate option
Smucker D. Clin Fam Prac; Elsevier, June 2004
Tasks of Primary
Palliative Care
Prescribing Hospice:
Understand eligibility
criteria and explain
options for care
Prognosis:
Consider and
communicate
Palliation:
Integrate Palliative
and DiseaseOriented Measures
Planning:
Clarify Patient’s
Values and
Goals of Care
Smucker D. Clin Fam Prac, June 2004
Why is Prognosis Assessment
Important?
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Important to medical teams
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Assist clinicians in their decision making
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Avoid costly interventions that may cause
suffering
Guides recommendations for interventions likely
to be beneficial
Optimization of resource allocation and
utilization of support services
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Why is Prognosis Assessment
Important?
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Important to patients and their families:
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Information helps patients and families in
choosing therapeutic options
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Planning for emotional and financial
management through advancing illness and
end-of-life
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Not receiving a prognosis is the most common
reason families say they are dissatisfied with
end-of-life care
Karnofsky Performance Scale
100%
90
80
70
60
50
40
30
20
10
0
Normal, no complaints, no evidence of disease
Able to carry on normal activity: minor symptoms of disease
Normal activity with effort: some symptoms of disease
Cares for self: unable to carry on normal activity or active work
Requires occasional assistance but is able to care for needs
Requires considerable assistance and frequent medical care
Disabled: requires special care and assistance
Severely disabled: hospitalization indicated, death not imminent
Very sick, hospitalization necessary: active treatment necessary
Moribund, fatal processes progressing rapidly
Death
DA Karnofsky, JS Burchenal, 1949
Predictions of survival
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Time predictions: “How long do you expect this person
to live”?
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Outcome predictions: “ What is the probability you
think this person will be alive in 6-12 months”?
or
“Would I be surprised if this patient died
within the next 12 months”?
Outcome predictions more accurate than time predictions
Br J Cancer 1990;62:685-689
Planning: Outcomes
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Advanced Directives
Living Wills
 Durable Power of Attorney for Health
Care (DPOA-HC)
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“Do-not-resuscitate orders”
Prolonged mechanical ventilation
 Artificial nutrition (tube feeding)
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Starting the Conversation
“What are you hoping for?”
 “What are you afraid of?”
 “What is most important to you in your life?”
 “Have you thought about what it might be
like if we can’t help you live the way you
want to live?”
 “Have you thought about dying? Have you
talked to anyone about it?”
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When to Start: Clinician Cues
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At time of serious diagnosis
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Advanced CHF, cancer, dementia, etc.
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At time of functional change
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At time of crisis or disease progression
Hospitalizations, ICU stays
 Initiation of advanced therapies
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• Artificial nutrition/hydration
• Dialysis, LVAD, tracheostomy, etc.
. . .Patient and Family Cues
“I don’t know if I can do this much longer”
 “I don’t want to come back to the hospital
again”
 “We can’t stand to see Mom like this”
 “What happens if this (procedure/
medicine/treatment) doesn’t work?”
 “I’m so tired, I just want to die”
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Shared Decision-Making
Patient/Family
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Goals
Values
Hopes
Resources
Medical Providers
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Clear information
Prognosis
Recommend plans
to meet goals, be
consistent w/values
Commitment to
always provide care
Words that Work
“We want to help you live as well as you
can, for as long as you can”.
 “You’re sick and it’s serious, but we’ll be
with you no matter what happens”.
 “What can I do for you now?”
 “We will do all we can to get you the best
care possible”.
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Resources
Hospice Finder (www.mihospice.org)
 Palliative Care Programs and Resources
(www.capc.org)
 Educational Tools (www.eperc.mcw.edu)
 Patient and Family Resources
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www.theconversationproject.org
 www.fivewishes.org
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