Identifying patients who may benefit from palliative care:

Introducing iPall

Romayne Gallagher MD, CCFP, FCFPKate McNamee-Clark RN, MSN (candidate),

CHPCN (c)Providence Health Care

Objectives

• Define palliative care• Provide background to iPALL• Identify those who might benefit from palliative

care• Show evidence on benefits of earlier palliative

care involvement• Highlight harm associated with late referral• Show how iPALL can be used to improve care• Present next steps

WHO definition 2005

Palliative care is an approach that improves the quality of life of patients & their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification, impeccable assessment & treatment of pain and other problems, physical, psychosocial and spiritual

http://www.who.int/cancer/palliative/definition/en/

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Palliative CarePalliative Care

Palliative Care

End-of-Life Care

Terminal Care

Symptom management

Introduction to palliative care

Living with a life-limiting illness – any prognosis

Hospice Care

Weeks to months to live

Days to hours of life

Ongoing medical treatments as appropriate

Maximizing community supports

Symptom Control

Psychosocial support of patient/family

Maximizing quality of life

Palliative Care vs End-of-Life Care vs Terminal Care

Background to iPALL

• Heart Failure clinic team

• Interdisciplinary moral distress

• MSJ EOL council

• PHC consult team experience

• Literature Reviews & Statistics

Background to iPALL

By 2020, there will be 40% more deaths annually than in 2003 (Stats Canada)

• ~ 90% of Canadians die of prolonged illness

Canadian Strategy on Palliative and End-of-Life Care: Final Report, 2007. Retrieved from http://www.hc-sc.gc.ca/hcs-sss/pubs/palliat/2007-soin_fin-end_life/index-eng.php

Background to iPALLHealth Care Use at the End of Life in Western

CanadaB.C.• Health service use peaked in the last three to six months

of lifeOlder population• Chronic illness and co-morbid conditions are common• End-of-Life care is needed well before the last three to

six months.• Leading causes of death in western Canada are

circulatory & respiratory diseases; cancer

Canadian Institute for Health Information (2007) Retrieved from https://secure.cihi.ca/free_products/end_of_life_report_aug07_e.pdf

Background to iPALL

Only 16-30% of those in need receiving palliative care

http://pcpcc-cpspsc.com/wp-content/uploads/2011/11/ReportEN.pdf

Carstairs (2010) report: Palliative care for patients late if at all even with available palliative care specialist

Pan Canadian study - SUPPORT: Heyland,et al, (2004) about increase aggressive interventions prior to death

Does palliative care improve outcomes in hospital?

Results of systematic reviews

Compared to conventional care, palliative care teams were associated with significant improvements in:– Pain– Non-pain symptoms– Patient/family satisfaction – Hospital length of stay– Reduces in-hospital deaths

* Jordhay et al Lancet 2000*Higginson et al, JPSM, 2003; †Finlay et al, Ann Oncol 2002; Higginson et al, JPSM 2002.

Incorporating palliative care into oncology -

• 1409 patients with lung cancer – 1095 on pathway that incorporates early goals of care discussion into the pathway

• Costs 35% less over 12 months• No difference in survival Neubauer et al. (2010) J Clinical Oncology

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NEJM 2010

• 151 patients newly diagnosed with metastatic lung cancer, randomized to early palliative care v.s. usual care

• Outcomes: length of life, quality of life, mood• The two groups had the same amount of

chemotherapy• Early palliative care group:

– Quality of life better p=0.03– Fewer depressive symptoms p=0.01

• Temel et al NEJM 2010

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Length of life was 2.7 months longer p=0.02

Improved survival

Average 2.7 months

Late referral decreases quality

• 237 bereaved family members of hospice patients asked about timing of the referral

• 13.7% reported referral “too late”• Compared to family members referred early or at the

right time, these respondents reportedLower satisfactionMore unmet needsLower confidence More concerns about coordination

Schockett, Teno, Miller, Stuart. (2005) JPSM

Incorporating palliative care into oncology -

• 1409 patients with lung cancer – 1095 on pathway that incorporates early goals of care discussion into the pathway

• Costs 35% less over 12 months• No difference in survival

• Neubauer et al. J Clinical Oncology 2010

iPall

• Cancer• COPD• Congestive Heart Failure• Dementia• Frailty• HIV/AIDS• Liver• Renal failure on hemodialysis

Next Steps

• Quantitative study to measure utility of iPALL with GPs in Interior Health

• Roll out use of iPALL throughout PHC acute and residential care sites

• Ongoing: sharing iPALL with colleagues at every health authority in BC and Yukon