Transcript What Is a Palliative Care Consult Service?

What Is a Palliative Care
Consult Service?
More importantly – What can it do
for you?
Palliative Care Consulting
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Making the Case
Services Rendered
Staffing
A Note of Caution
The Role Of Acute Care Hospitals In
Caring For the Dying
Why Palliative Care?
• The sickest people congregate in hospitals
• These people often feel a loss of control in
their medical travails
• Often they experience profound suffering
• The people who care for them often
experience tremendous burden, burnout
• Hospitals and accreditation organizations
recognize these struggles, want to do
better
What Do Patients with
Serious Illness Want?
• Pain and symptom control
• Avoid inappropriate prolongation of the
dying process
• Achieve a sense of control
• Relieve burdens on family
• Strengthen relationships with loved ones
Singer et al. JAMA 1999;281(2):163-168.
National Data on the Experience
of Advanced Illness in 5 Tertiary
Care Teaching Hospitals
The SUPPORT Study
• Controlled trial to improve care of
seriously ill patients
• Multi-center study funded by RWJ
• 9000 patients with life threatening illness,
50% died within 6 months of entry
JAMA 1995;274:1591-98
SUPPORT: Suffering and
Costs, Phase I Results
• Half of patients had moderate-severe
pain >50% of last 3 days of life.
• 38% of those who died spent >10
days in ICU.
Self-Reported Symptom Experience of
Critically Ill Cancer Patients Receiving Intensive Care
Nelson JE, Meier DE, Oei EI et al. Crit Care Med 2001;29:277-282
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Moderate
Percent of patients with symptoms at
moderate or severe level
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75%
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71%
68%
63%
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Severe
56% 55%
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39%
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10
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34%
Pain Data from SUPPORT
% of 5176 patients reporting moderate to
severe pain between days 8-12 of
hospitalization:
colon cancer
liver failure
lung cancer
MOSF + cancer
MOSF + sepsis
COPD
CHF
60%
60%
57%
53%
52%
44%
43%
Desbiens & Wu. JAGS 2000;48:S183-186.
Physician Training in Pain
Management
Oncologists self-report:
– 86% of their patients undermedicated
– 50% rated pain management in their own
practice as fair to very poor
– 73% evaluated their own training in pain
management as fair to very poor
Von Roenn et al. Ann Intern Med 1993;Jul 15;119(2):121-6.
Caregiving Needs Among Seriously
Ill Persons
Interviews with 900 caregivers of seriously ill
persons at 6 U.S. sites
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need more help: 87% of families
transportation:
62%
homemaking:
55%
nursing:
28%
personal care:
26%
Emanuel et al. Ann Intern Med2000;132:451
Caregiving Increases
Mortality
Nurses Health Study: prospective study of 54,412 nurses
• Increased risk of MI or cardiac death: RR
1.8 if caregiving >9 hrs/wk for ill spouse
Lee et
al. Am J Prev Med 2003;24:113
Population based cohort study 400 in-home caregivers +
400 controls
• Increased risk of death: RR 1.6 among
caregivers reporting emotional strain
Schulz et al. JAMA 1999;282:2215.
Family Caregivers and the
SUPPORT study
Patient needed large amount of family
caregiving:
34%
Lost most family savings:
31%
Lost major source of income:
29%
Major life change in family:
20%
Other family illness from stress:
12%
At least one of the above:
55%
JAMA 1995;272:1839
What Do Family Caregivers
Want?
Study of 475 family members 1-2 years after bereavement
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Loved one’s wishes honored
Inclusion in decision processes
Support/assistance at home
Practical help (transportation, medicines, equipment)
Personal care needs (bathing, feeding, toileting)
Honest information
24/7 access
To be listened to
Privacy
To be remembered and contacted after the death
Tolle et al. Oregon report card.1999 www.ohsu.edu/ethics
Symptom Improvement for 3,707 Palliative Care
Patients at Mount Sinai Hospital (6/97-12/04)
Pain
Nausea
Severe
Severe
Mod.
Mod.
Mild
Mild
None
Initial Evaluation
Final Evaluation
None
Initial Evaluation
Severe
Shortness of Breath
Final Evaluation
Anxiety
Severe
Mod.
Mod.
Mild
Mild
None
None
Initial Evaluation
Final Evaluation
Initial Evaluation
Final Evaluation
Source: Patient Interviews, Mount Sinai Hospital, New York City
Case 1. Mount Sinai Hospital, NYC:
Improvement in Symptoms
1997-2002: 2219 palliative care consult
service patients
Severe
Pain
Nausea
Moderate
Dyspnea
Mild
None
Initial Evaluation
Final Evaluation
High Satisfaction -Mount Sinai Hospital Data
Percent of Palliative Care Families Satisfied or Very
Satisfied with:
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Control of pain - 95%
Control of non-pain symptoms - 92%
Support of patient’s quality of life - 89%
Support for family stress/anxiety - 84%
Manner in which you were told of patient’s
terminal illness - 88%
• Overall care provided by palliative care program95%
Source: Post-Discharge/Death Family Satisfaction
Interviews, Mount Sinai Hospital, New York City
What Does All this Mean from the
Patient Perspective?
For patients, palliative care is a key to:
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relieve symptom distress
navigate a complex and confusing medical system
understand the plan of care
help coordinate and control care options
allow simultaneous palliation of suffering along with
continued disease modifying treatments (no requirement
to give up curative care)
– provide practical and emotional support for exhausted
family caregivers
The Clinician Perspective
For clinicians, palliative care is a key tool to:
• Save time by helping to handle repeated, intensive
patient-family communications, coordination of care
across settings, comprehensive discharge planning
• Bedside management of pain and distress of highly
symptomatic and complex cases, 24/7, thus supporting
the treatment plan of the primary physician
• Promote patient and family satisfaction with the
clinician’s quality of care
The Hospital Perspective
For hospitals, palliative care is a key tool to:
– effectively treat the growing number of people
with complex advanced illness
– provide service excellence, patient-centered care
– increase patient and family satisfaction
– improve staff satisfaction and retention
– meet JCAHO quality standards
– ration the use of hospital resources
– increase bed/ICU capacity, reduce costs
Summary
• Palliative care improves quality of care for
our sickest and most vulnerable patients
and families.
• Palliative care improves the ability of
physicians to deliver high quality care to
this difficult patient population
• Palliative care saves the hospital time and
money while improving overall patient
satisfaction
This is My Job
Palliative Care Specialist at CPMC
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Pain Management (Terminal or non-terminal)
End Of Life Counseling
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Symptom Management
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Code Status Discussion
Prolonged ICU stays
Introduction to Hospice
Dyspnea (CHF, COPD, malignancy)
Nausea/Vomiting
Pruritis (ESRD, ESLD)
Physician/House Staff Education
My Colleagues
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1 Geriatrician
1 Fellowship-trained Nurse Practitioner
2 Oncology Clinical Nurse Specialists
Psychology Service
Health and Wellness
– Massage Therapy
– Acupuncture
– Herbal Medicine
In My Dreams
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Dedicated Social Worker
Dedicated Case Manager
Trained Psychologist in End Of Life Issues
0.5 FTE Massage Therapist
Annual Retreats at Pebble Beach
– All Expenses Paid
The Pitfalls and Perils
• Stepping On Toes
– Disrupting long-held notions
– Attending/House Staff Miscommunication
– Answer the Question! (and only the question)
• “Spoiling the Movie”
• Commandeering