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Caring for Seriously Ill People

Kyle P. Edmonds, MD

Assistant Clinical ProfessorDoris A. Howell Palliative Care ServiceDirector, SOMI 421, Subinternship in Palliative Medicine

Medicine 401UCSD School of Medicine

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Free-range

Millennial

Zone

Caring for Seriously Ill People

#HPM #MedEd with @kpedmonds

From @UCSDPalliative @UCSDHealth

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Specialist Palliative Care

• A team that can help your patients and families manage the pain, symptoms, and stress of serious illness.

• Available at any age and at any stage in a serious illness and can be provided along with curative treatment.

• Expert communication for challenging situations.

• Partnering with you for better outcomes by helping your patients tolerate curative treatment.

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Generalist / Specialist Palliative Care

Hospice

•Symptom management•Whole person plan of care•No relation to prognosis•Not a philosophy of care

•Funding mechanism•Strictly <6mo prognosis•Home-based•Teaches caregivers

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Forget the line in the sand

Time

Palliative

Care

Routine Medical Care:

antibiotics, dialysis, chemotherapy, surgery

“Dying”?

“Nothing more to do”?

“Pt / family request”?

“Really sick”?

“Really, really sick”?

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Time

General OR Specialty Palliative

Care

Routine Medical Care

The Course of Illness

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General OR Specialty Palliative

Care

Routine Medical Care

Hospice Bereavement

Decision

Maker

Goals of

Care

Nausea

Mgmt

Psychosocial

Needs

Care

coordination

Prognostication

Bowel

Obstruction

Mgmt

Legacy

Work

Family

Meetings

Hospice

Education

POLST

Spiritual

SupportMgmt: Vomiting,

Pain, Ascites,

Delirium,

Anxiety

Care

Transitions

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2 3

4

5

7

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Equipment

Teaching

Medications

Home Aides

Volunteers

Prognosis

Symptoms

24/7 Access

Preparing

Children

Support

Groups

Counseling

Resources

Dx

Death

Adapted from Landzaat, 2013.

The Course of Illness

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Routine Medical Care

Generalist Palliative Care

Specialist Palliative Care

•Fluids•Antibiotics•Etc.

•ACP/GoC•opioids•Ondansetron•Routine MDM •Complex pain

•High dose opioids•Limit setting•Hope & Prognostication•Complex MDM

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Palliative principles are appropriate for all patients with serious illness

Principle

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Hospice

• Historical evolution

• US Medicare Hospice Benefit

• ~40% of all deaths

• Median enrollment 18.5 days

• 34.5% of patients die within 7 days

NHPCO. 2014.

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The Many Meanings of “Hospice”

• A system of reimbursement

• An organization or program

• A place

• An approach to or philosophy of care

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Choosing Hospice

• Prognosis < 6 months according to two providers

• Elect to use hospice benefit

• Consent to treatment

• Maybe forego some dz-directed therapies

• Can sign on & off at will

Table adapted from NHPCO. 2014.

Location of Death 2013

Place of residence 66.6%

Private residence 41.7%

Nursing home 17.9%

Residential facility 7%

Hospice inpt facility 26.4%

Acute care hospital 7%

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Structure of Hospice

• Capitated, per diem payment

• Medicare/Medicaid

• Private insurance

• Charity• Out of pocket

• Levels of care

• Routine care

• General inpatient care

• Continuous care

• Respite care

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What Patients & Families Get

• Interdisciplinary care

• Chaplaincy, nursing, medical social services, counseling, volunteers

• Primary care physician

• Hospice medical director

• Medical equipment, supplies

• Medications and therapies related to the terminal diagnosis

• Bereavement counseling

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Hospice is an underutilized way to deliver patient-centered & family oriented care

Principle

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Assessing Symptoms

• 58yo mother of three with metastatic colorectal CA

• Admitted with recurrent SBO (being medically managed), nausea and pain out of control

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Pt/Fam

Disease Mgmt

Physical

Psych

SocialSpiritual

Practical

End of Life Worries

Whole-person Assessment…

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Pt / Fam

Chaplain

Clinical Social Work

Nursing

Pharmacy

Physician

Many others

…Whole-person Approach

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Symptoms exist in the context of a person’s life

Principle

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Managing Symptoms

• 58yo mother of three with metastatic colorectal CA

• Admitted with recurrent SBO (being medically managed) and pain out of control

• On PRN hydrocodone/APAP at home• Nausea has resolved since NGT placed

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• Constant

• Constant + Acute

• Intermittentacute

Symptom Time Course

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For constant symptoms, treat with constant (scheduled) meds

Principle

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For acute symptoms, treat with frequent, fast-acting (PRN) meds

Principle

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Example: Pain

• 58yo mother of three with metastatic colorectal CA

• Admitted with recurrent SBO (being medically managed) and pain out of control

• On PRN hydrocodone/APAP at home• You want to start morphine…

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Pla

sm

a C

on

cen

trati

on

0 Time

AbsorptionExcretion

First Order KineticsWhen biological effect

follows plasma concentration

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Pla

sm

a C

on

cen

trati

on

0 Time ( hours )

Time to Maximum Concentration ( t Cmax )

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10

1

= time it takes to get to

maximum concentration

Cmax

Morphine

PO / PR

Cmax = 1 hour

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Pla

sma C

on

cen

trati

on

0 Time

IV

PO / PR60min

Time to Maximum Concentration ( t Cmax )10min

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Pla

sma C

on

cen

trati

on

0 Time

Cmax

Treating Acute Pain

PO / PR

≈ 1 hr

IV

~10 min

Cmax

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For acute pain, dose every C-max with short-acting meds

Principle

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Goals of Care

• 58yo mother of three with metastatic colorectal CA

• Admitted with recurrent SBO (being medically managed) and pain out of control

• 3rd admission in 3 months for SBO• “I want to get back to how I was!”

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Potential Goals of Care

Restorative or Cure

Return to Baseline

Improve Survival

Improve Function

Relieve Symptoms

Allow Natural Death

Adapted from Mulkerin, 2011.

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Goals…How?

• Perception of patient/family

• Exploration of life before illness

• Relating patient story to medical situation

• Sources of worry for the future

• Outline the plan concretely

• Notify those who need to know

Edmonds, Ajayi, Cain, Yeung, & Thornberry. 2014.

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Goals of care are who the patient is and what they want

Principle

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Breaking Bad News

• 58yo mother of three with metastatic colorectal CA

• Admitted with recurrent SBO (being medically managed) and pain out of control

• PMHx of CHF

• Needs help around the house and with dressing

• Albumin 2.4 g/dL

• 3rd admission in 3 months for SBO

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Formulating Prognosis

• ePrognosis.org

• CAPC.org/Fast-facts

Covinsky et al., 2011.

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Use SPIKES Protocol to Break Bad News

• Setting

• Perception of patient / family

• Invitation (+ Warning Shot)

• Knowledge

• Empathize & Explore

• Strategy & Summary

Buckman et al., 2000.

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Use a standardized approach to breaking bad news

Principle

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• Palliative principles are appropriate for all patients with serious illness

• Hospice is an underutilized way to deliver pt-centered & family oriented care

• Symptoms exist in the context of a person’s life

• For acute symptoms, treat with frequent, fast-acting (PRN) meds

• For constant symptoms, treat with constant (scheduled) meds

• For acute pain, dose every C-max with short-acting meds

• Goals of care are who the patient is and what they want

• Use a standardized approach to breaking bad news

Principles

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Caring for Seriously Ill People

Kyle P. Edmonds, MDkpedmonds@ucsd.edu

Want more? Take SOMI 421, Subinternship in Palliative Medicine

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• Baile WF, Buckman R, Lenzi R, Glober G, Beale EA & AP Kudelka. SPIKES: A six-step protocol for delivering bad news: Application to the patient with cancer. The Oncologist. 5:302-11.

• Edmonds KP, Ajayi TA, Cain J, Yeung HN & K Thornberry (2014). Establishing goals of care at any stage of illness: The PERSON mnemonic. J Pall Med. 17(10).

• Mulkerin, C.M. (2011). Palliative care consultation. In T. Altilio & S. Otis-Green (Eds.), Oxford Textbook of Palliative Social Work (pp. 43-51). New York, Ny: Oxford University Press, Inc.

• NHPCO (2014). NHPCO’s Facts & Figures: Hospice care in America. Acessed via: http://www.nhpco.org/sites/default/files/public/Statistics_Research/2014_Facts_Figures.pdf

References