Transcript PALLIATIVE CARE AT STANFORD James Hallenbeck, MD Medical Director, Stanford Hospice,

PALLIATIVE CARE AT
STANFORD
James Hallenbeck, MD
Medical Director, Stanford Hospice,
VA Hospice Care Center
Definitions
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Palliative Care
Palliative Medicine
Hospice
Supportive Care
The Need
• SUPPORT Study
• Studies on Communication
• Stanford Study
SUPPORT STUDY 1995
N= 9105
• 46% of DNR orders written with 2 days of death
• 40% of patients/surrogates had discussed CPR
with physician
– Of 60% who had not done so, 41% wanted to
• ~ 50% wanted a DNR status, but did have it
• 50% of patients reported as being in 7/10 or
greater pain in last three days of life
SUPPORT JAMA 1995; 274:1591-1598.
Tulsky Study on Advance Directive
Discussions
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Conversations averaged 5.6 minutes
Physicians spoke 66% of the time
Used vague language
Patients values rarely explored
Tulsky JA et. al. Opening the black box: how do physicians
communicate about advance directives? Ann Intern Med 1998 Sep
15;129(6):441-9.
Stanford Survey 1998
617 Stanford Clinicians, 35 families
• Staff and families identified communication as the
area most needing improvement
– 35% of staff felt inexperienced communicating with
dying patients and families (residents 64%)
• Broad support for a consultation team
– 61% of physicians surveyed felt that a consultation team would
be moderately or extremely helpful
– 47% of attendings, 64% of residents stated that they would
often or always use a consultation team in care of dying pts
Stanford- What We Do Not
Know...
Site-specific data
• Annual # of hospital deaths by age, insurance
status
• COD and LOS by DRG, Location of death
– In most hospitals LOS for patients who die in hospital
2-3 X for those discharged alive
• Cost per case by DRG for deceased vs. alive
• Audits of quality of symptom relief,
documentation of patient preferences
The Context
New Policy and Regulatory Mandates...
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JCAHO
ABIM
AAMC
ACGME
Palliative Medicine Evolving as a Medical
Subspecialty
• American Board of Hospice and Palliative
Medicine- > 600 physicians boarded since 1996
• A Push for ACGME Accreditation
• Currently approximately 16 fellowships
nationwide
– VA Palo Alto HCS has 2 one-year fellows
Palliative Care Services being
Integrated into Healthcare Systems
• Consultation teams and/or dedicated beds more
common
– ~ 50% of California hospitals surveyed have or are
planning dedicated services
– VA Palo Alto HCS: 30 dedicated beds, consult team
– UCSF: Comfort Care Suites, consult team
– Santa Clara Valley Med: 2 dedicated beds, evolving
consult team
Growing Public Demand
for Expert Palliative Care
• Bill Moyer’s September Public Television Special
on Death and Dying in America Sept. 10-13
• Numerous associated events:
– KQED f/u special on associated issues in the Bay Area
– Community Action Groups
• Community meeting at VA Palo Alto HCS on September 27,
sponsored by community hospices
Models for Success
• McGill University- Consult Service
– Demonstrated average length of stay halved for
terminally
• Northwestern Memorial Hospital
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Consult and inptatient service since 1994
Average 55 consults a month
Followed for an average of 2 days (range 2-10)
Revenue 1.5 million in 1996, excluding donations
exceeded direct costs of ~ 1 million
Models for Success
• Oregon Health Sciences University Consult
Service
(of 67 serial consults)
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66% Cancer, 34% Non-cancer
59% receiving life-prolonging treatment
41% hospice/palliative care only
20% died during hospitalization
Symptoms addressed: pain, nausea, constipation,
delirium…
– 65% received assistance in EOL care decision making
Bascom PB. A hospital-based comfort care team: consultation for seriously ill and
dying patients. Am J Hosp and Palliat Care. 1997
Models for Success
• Philadelphia VA: Consult team for Cancer
Patients
(of 75 patients studied)
– 164 medical problems identified
– 31 patients inadequate pain relief
– Other problems: skin care, oral care, nutrition nausea,
constipation mental status
– 15 patients referred for hospice- no documentation of
wishes regarding resuscitation
– 36 patients required psychosocial counseling
Philadephia VA Study
• Of 22 patients followed in Medical Oncology
Clinics:
– 21 had one or more problems identified by consult
team
• Principally financial, social or spritual
• 11 patients reported inadequate pain relief
Abrahm JL et al. The impact of a hospice consultation
team on the care of veterans with advanced cancer. J.
Pain Symptom Manage. 1996; 12:23-31.
What are Our Choices?
• Status Quo
• Palliative Care geared to meet JCAHO minimum
standards- a process of ‘quality improvement’
• A minimalist Palliative Care service
• A comprehensive interdisciplinary palliative care
consult team
• A comprehensive Palliative Care service, bridging
venues of care
From Consult Team
to Palliative Care Service
• Establish an interdisciplinary consult team
– Attendings, fellow, elective resident/students, nurse,
social worker, chaplain
• Coordinate with others working in related areas
– Stanford Hospice, Pain Service, Pediatrics, Ethics
Center, VA Hospice Care Center
• Consider identifying dedicated beds, outpatient
clinic in later years