Transcript Goals and Decisions in Palliative Care

Clinical Review for the Generalist
Hospice and Palliative Nurse
Goals and Decisions
in Palliative Care
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Objectives
1. Describe methods of establishing care goals
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for hospice and palliative care settings
Define the components of treatment
decisions
Describe the concept of futile treatment
Give examples of burdensome interventions
Provide an overview of quality
improvement
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Hospice History
 Late 1960’s modern programs to care for the
dying were organized
 St. Christopher’s (London) Dame Cecily
Saunders
 Life as a ‘journey’
 Our culture does not deal well with death
……..therefore the use of another term
Palliative Care
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Palliative Care History
 First United States hospital-based
palliative care program – late 1980’s
 63% of Hospitals have Palliative Care
Programs
 85% of larger hospitals with >300 beds
 Palliative care is a dynamic field and is
now recognized as a specialty
(CAPC 2011)
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Payment for Services
Hospice
 Medicare
 Medicaid
 Most Private Health Insurers
Palliative Care
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Philanthropy
Home Care
Fee-for-service
Direct hospital Service
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Hospice Medicare
Eligibility Criteria
 The life expectancy, if the disease runs its
normal course, is six months or less
 Certificate of Terminal Illness with the
narrative and attestation
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World Health Organization
Palliative Care is an approach which improves
quality of life of patients and their families facing
life-threatening illness, through the prevention and
relief of suffering by means of early identification
and impeccable assessment and treatment of
pain, and other, physical, psychosocial, and
spiritual problems.
WHO, 2008
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World Health Organization
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Pain and symptom relief
Affirms life
Neither hasten nor postpone death
Integrate psychological and spiritual
Support system for patient & family
Team approach
Enhance quality of life
www.WHO.int
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National Consensus Project for
Quality Palliative Care (NCP)
The goal of palliative care is 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 the need for other therapies.
Palliative Care is both a philosophy of care and an
organized, highly structured system for delivering
care. Palliative care expands traditional disease-model
medical treatments to include the goals of enhancing
quality of life for patient and family, optimizing
function, helping with decision making and providing
opportunities for personal growth.
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National Consensus Project
Established Clinical Practice Guidelines
 To promote consistent, high quality care
 To guide the development and structure of
new and existing clinical palliative care
programs
References offer evidence-based practices
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National Consensus Project
Domains essential for quality care
 Structure and processes of care
 Physical aspects of care
 Psychological and psychiatric aspects of care
 Social aspects of care
 Spiritual, religious, and existential aspects
 Cultural aspects of care
 Care of the imminently dying patient
 Ethical and legal aspects of care
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National Consensus Project
Integrate palliative care into all healthcare
 Guidelines ensure
Pain/symptom control throughout continuum of
care
 Patients/families obtain information they need
 Coordination of care across settings
 Patient/family prepared for the dying process –
hospice explored
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Centers for Medicare and
Medicaid Services (CMS)
 Continue to propose new rules to improve
the quality of care to Medicare
beneficiaries receiving hospice care
 Conditions of Participation (CoPs)
 Combination of healthcare services
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Centers for Medicare and
Medicaid Services (CMS)
 Definition
 Establishes quality standards for the
vulnerable population
 www.cms.hhs.gov
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What is Palliative Care?
 Specialized Medical Care focused on providing
relief from the symptoms, pain and stress of a
serious illness
 Optimizing quality of life by anticipating,
preventing, and treating suffering
 Address physical, social, spiritual needs facilitates
patients autonomy
 Goal – improve quality of life for both the patient
and the family
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CAPC 2011
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Who Needs Palliative Care
Palliative care is appropriate for all patients from
the time of diagnosis with a life-threatening or
debilitating condition, regardless age, and can be
provided together with curative treatment.
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Prognosis Considerations
 Prognostic indicators
 Outcomes of treatment
 Consider life expectancy
 Benefits vs. burdens
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General Criteria for
Poor Prognosis
 Metastatic or advanced cancer
 Unintended weight loss
 Dependence in 3 or more ADLs
 (FAST scale, PPS,KPS)
 Progressive disease
 Competent patient with serious illness refusing or
wishing to stop treatment
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Hepatic Disease Criteria
 Not a candidate for liver transplant
 Refractory ascites
 Cirrhosis and hepatic encephalopathy
 Spontaneous bacterial peritonitis
 Recurrent variceal bleeding
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Pulmonary Disease Criteria
 Poor response to bronchodilators
 Dyspnea at rest
 FEV1 after bronchodilator of < 30%
 Cor Pulmonale
 Resting tachycardia > 100/min with COPD
 Hypoxemia at rest while on oxygen
 Hypercapnia - pCO2 > 50mm Hg
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Cardiac Disease Criteria
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CHF with optimal diuretics and vasodilator
Ejection fraction of < 20%
Symptoms of recurrent CHF at rest
History of cardiac arrest
Symptomatic supraventricular or ventricular
arrhythmias resistant to treatment
 Cardiogenic brain embolism
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Dementia Criteria
 One or more of the following in the previous year
Aspiration pneumonia
 Septicemia
 Decubitus ulcers, multiple, stages 3 or 4
 Recurrent fever after antibiotics
 Insufficient oral food to sustain life
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Decision Making
 Who makes decisions
 Surrogate law in your state
 Advance directives
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Treatment Decisions
Advance Directives
 Determine if completed
 Review existing
 Ensure visible in medical records
 Use for care planning
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Treatment Decisions
Futile Treatment
 That which fails to improve prognosis, comfort,
well-being or general state of health
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Treatment Decisions
Determining Benefit vs. Burden
 What do you enjoy doing now?
 What is your illness preventing you from doing?
 What is most important to you right now?
 What is the hardest part of this for you and your family?
 When you think about the future, what concerns do you have?
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Treatment Decisions
Withholding and Withdrawing
 Withdrawing = withholding
Don’t say we are “Withdrawing care”
 Withholding is an easier decision
 Consider interventions difficult to withdraw
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Goals of Care
 Goals: general outcomes or health states that a
patient would like to achieve (e.g. living
independently at home, walking to the mailbox,
avoiding hospitalization)
 Preferences: patients’ wishes about treatments
(e.g. radiation therapy, surgery, chemotherapy)
Casarett, D.J., and Quill, T. E. (2007).
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Factors that Affect Decisions
 Uncertainty & ambivalence
 Complex medical language
 Emotions (fear, anxiety, anger)
 Family systems/cultural background
 Patient-healthcare provider relationship
 Past experiences with healthcare providers
Reassessment of
Goals of Care
 Changes in prognosis or treatments
 Decision-maker
 Durable Power of Attorney
 Reclaim own decision-making
 Patient self-determined goals
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Considerations
Providers (Physicians, Nurses, NPs, Social Workers)
Time pressure
Their comfort level regarding end of life care
Patients
Conflicted about benefits and burdens
Lack of understanding regarding disease trajectory
Family members
Conflicting views
Lack of understanding regarding disease trajectory
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Quality Improvement (QI)
Description
 An approach to continuously improve every
process in the organization
 A way of doing business
 Begins and ends with the customer,
determining their needs and creating changes to
meet their needs
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Quality Improvement (QI)
Factors influencing
 Consumers
 More aware
 Demand higher quality
 Regulations
 Cost
 Reimbursement
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Quality Improvement
Models
 QAPI
Comprehensive quality assessment and
performance improvement
 Models
 PDCA
 Six Sigma
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DMAIC
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Cultural Considerations
End-of-Life
 Increasing diversity within American society
 Broad meaning of culture – a way of life
 An interdisciplinary team approach is vital to
culturally competent care
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Cultural Considerations
End-of-Life
 Recognize differences
 Provide individualized care
 Great variations within cultural or ethnic groups
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Conclusion
 Scope of palliative care
 Determine goals
 Reassessment at intervals for optimal care
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References
1. World Health Organization. Palliative Care. Available at
www.who.int/cancer/palliative/en/. Accessed December 6, 2011.
2. Center to Advance Palliative Care. Report Card.2011
Available at www.capc.org/reportcard/pdf Accessed October 10,2011.
3. National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines
for Quality Palliative Care. 2nd ed. Pittsburgh, PA: National Consensus Project
for Quality Palliative Care; 2009. Available at
www.nationalconsensusproject.org. Accessed May 23, 2010.
4. National Consensus Steering Committee. The National Consensus Project for
Quality Palliative Care: The Development of Clinical Practice Guidelines. 2009.
5. Stuart B, Alexander C, Arenella C, et. al. Medical guidelines for determining
Prognosis in selected non-cancer diseases. South Deerfield, MA: National Hospice
and Palliative Care Organization, 1996.
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Additional References
 Bednash G, Ferrell B. End-of-Life Nursing Education Consortium
(ELNEC-CORE). Washington, DC: Association of Colleges of
Nursing. 2010.
 Serman D. Spirituality and culture as domains of quality palliative
care. In: LaPorte Matzo, M, and Witt Sherman, D, Eds. Palliative
Care Nursing, Quality Care to the End of Life. New York, NY:
Springer; 2006: 3-49.
 Bookbinder G, Ferrell B. Death and society. In: LaPorte Matzo M.
and Witt Sherman D. Eds. Palliative Care Nursing, Quality Care to
the End of Life. New York, NY: Springer; 2006: 89-115.
 Casarett D, Quill T. “I’m Not Ready for Hospice”:Strategies for
Timely and Effective Hospice Discussions. Annals of Internal
Medicine. 2007;146:443-449.
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Additional References
 Emanuel L, von Gunten CF, Ferris FD, eds. The Education for
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Physicians on End-of-Life Care (EPEC) Curriculum. The EPEC Project.
The Robert Wood Johnson, Foundation, 2003.
Glass E, Cluxton D, Rancour P. Principles of patient and family
assessment. In: Ferrell B, Coyle, N. Textbook of Palliative Nursing.
New York, NY: Oxford University Press; 2006: 13-46.
Berry P. An Overview of Hospice and Palliative Care. In Berry P, ed.
Core Curriculum for the Generalist Hospice and Palliative Nurse. 3rd.
2nd ed. Dubuque, IA: Kendal/Hunt; 2010:1-9.
National Hospice Organization, Guidelines for Prognosis for NonCancer Diagnoses. Arlington, VA: NHP; 1993.
Super A. The Context of Palliative Care in Progressive Illness. In:
Ferrell B, Coyle, N. Textbook of Palliative Nursing. New York, NY:
Oxford University Press; 2001: 27-36.
Task Force on Palliative Care. Precepts of Palliative Care, Chicago, IL:
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Last Acts; 1997.