foundations of palliative care j. cameron muir, md, faahpm evp, quality and access, capital caring...
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Foundations of Palliative Care
J. Cameron Muir, MD, FAAHPM
EVP, Quality and Access, Capital Caring
Clinical Scholar, Georgetown Center for Bioethics
Assistant Clinical Professor, Johns Hopkins Oncology
Past President, Am. Academy of Hospice and Palliative Medicine
J. Cameron Muir, MD, FAAHPM
EVP, Quality and Access, Capital Caring
Clinical Scholar, Georgetown Center for Bioethics
Assistant Clinical Professor, Johns Hopkins Oncology
Past President, Am. Academy of Hospice and Palliative Medicine
Presentation Outline:
National Framework(s)
Hospice AND Palliative Care – Unique Solutions
Quality OutcomesCare Transitions across the ContinuumPositive Impact on Bottom Line
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ASCO - 1Cancer Care During the Last Phase of
Life JCO 5:1986-1996, 1998Longstanding & continuous relationship –
training and interest in end-of-life careResponsive to patient’s wishesTruthful, sensitive, empathic communication
with patient and familyOptimizes QOL throughout the course of the
illness
ASCO - 2
Palliative Cancer Care a Decade Later: Accomplishments, the Need, Next Steps JCO 27: 3052-3058, 2009
Changes are needed in current policy, drug availability, education, quality improvement, and research for integration of PC throughout the experience of cancer
The need for palliative cancer care is greater than ever
Vision: PC integrated into CCC by 2020
National Priorities PartnershipConvened by the National Quality Forum (NQF)
Engage patients and families in managing their health and making decisions about their care
Improve the health of the populationImprove the safety and reliability of America’s healthcare
systemEnsure patients receive well-coordinated care within and
across all healthcare organizations, settings, and levels of care
Guarantee appropriate and compassionate care for patients with life-limiting illnesses
Eliminate overuse while ensuring the delivery of appropriate care
http://www.nationalprioritiespartnership.org/uploadedFiles/NPP/About_NPP/ExecSum_no_ticks.pdf 5
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NQF Framework for Quality Palliative Care Eight Domains
1. Structure and Process of Care2. Physical Aspects of Care3. Psychological and Psychiatric Aspects of
Care4. Social Aspects of Care5. Spiritual, Religious and Existential Aspects
of Care6. Cultural Aspects of Care7. Care of the Imminently Dying Patient8. Ethical and Legal Aspects of Care
http://www.nationalconsensusproject.org/AboutGuidelines.asp
NQF: Core Elements of Palliative CareDebilitating chronic or life-threatening illness,
condition or injury Patient- and family-centered care Begins at the time of diagnosis of a life-
threatening or debilitating condition Comprehensive care Interdisciplinary teamAttention to relief of suffering Communication skills Skill in care of the dying and the bereaved Continuity of care across settings
http://www.nationalconsensusproject.org/Guidelines_Download.asp 7
ASCO - 3ASCO Statement: Toward
Individualized Care for Patients with Advanced Cancer JCO 28:1-
6, 2011 Individualized approach to discussing and
providing disease-directed and supportive care throughout the continuum of care
Discussion of patient’s goals and preferences improves patient care
Oncologists should curtail the use of ineffective therapy and ensure a focus on palliative care
The “problem”90% of us will die from a chronic, progressive
illness
85% of us want to be at “home”
75% of us will die in an institution50% die in hospitals25% die in a nursing facility
Will not die “well”SUPPORT studyCancer and AIDS symptom burden studies
Sites of Death
Death in the USCensus:
19902000
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Historically (400 BC-1950 AD) - At home with family
Framework for Continuum of Care
Palliative Care
Disease Modifying Treatments
Hospice
DiagnosisTreatments to Relieve Suffering/Improve QOL
6Mo Death
Bereavement
Mean survival: “advanced” diseaseDementia: years (x = 11 years)CHF: 3 years (x from EF <20%)COPD: yearsBreast CA (bone mets only): 3 yearsLung CA (IIIb/IV): 12-14 months
Multiple hospitalizations
Symptom = first indication of advanced disease
Hospice is “Gold Standard”Utilization increasing dramatically:
158,000 (1985)1,360,000 (2008)
NHPCO (2008)Average: 57 daysMedian: 22 days
Primary site = home
#1 feedback: “if only I’d known about your services earlier”
Palliative CareAcross continuum: 3 years across 57 days through
deathPhysicalPracticalEmotional Spiritual
Reduce sufferingImprove Quality of Life
Setting:Acute CareOutpatient
Who Does Palliative Care???Primary PC
What all of us should know – AND do…
Secondary PCWhen I need an extra set of eyes and hands…
can you give me some advice?
Tertiary PCWhen all of us here can’t figure it out…
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When does PC start???2 weeks before death?Last breath?6 Months or less “if the disease runs it’s usual
course”?“Would it surprise you if they died in the next year?”At Diagnosis?“Whenever I say it does?”Triggers:
Identifying Patients in Need of a Palliative Care Assessment in the Hospital Setting: A Consensus Report from the Center to Advance Palliative Care. David E. Weissman, M.D.1 and Diane E. Meier, M.D.2; J OF Pall Med, 14(1), 2011
None exist in the outpatient setting
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Best Hospitals: Best PracticeTop 100 Hospitals (US News & World
Report)Has considered the presence of Hospice and
Palliative Care services as an indicator of excellence since 2001
All of the Top Ten have Palliative Care programs
46 of the Top 50 Cancer ProgramsSince 2001: ~20%/year Growth in US Hospital-
based Palliative Care
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Trends in Hospital-based Palliative Care Consultation:
http://www.capc.org/news-and-events/releases/04-05-10
125.8% increase from 2000-2008
H/PC becoming standard…Significant growth in past 5 years:
1486 hospital-based PC Programs (2008)59% of COTHs have PC Programs (2005)90 fellowship programs/54 Accredited (2008)ACGME recognition for training (7/06)ABMS Recognition as subspecialty (9/06)
ASCO QOPI “Palliative Subset” (Core Measures)Pain Assessment
3. Pain assessed by the second office visit (%) 4. Pain intensity quantified by the second office visit (%) 5. For patients with moderate to severe pain, documentation that pain
was addressed (%) Narcotic analgesic assessment 6. Effectiveness of pain medication assessed on visit following new
narcotic prescription (%) 7. Constipation assessed at time of or at first visit following new
narcotic analgesic prescription (%) Psychosocial support (Test) 21. Chart documents patient’s emotional well-being was assessed
within one month of first visit to office (%) 22. For patients identified with a problem with emotional well-being,
the chart documents that action was taken within one month of first visit to office (%)
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ASCO QOPI “Palliative Subset” (Care at End of Life Measures)
Pain assessed and documented near the end of life 35. Pain assessed on the second to last or last visit before death (%) 36. Pain intensity quantified on second to last or last visit before death (%)
Dyspnea assessed near the end of life 37. Dyspnea assessed on second to last or last office visit before death (%) 38. Action taken to ease dyspnea on second to last or last office visit before death
(%) Timing of hospice enrollment
39. Patient enrolled in hospice before death (%) 40. Patient enrolled in hospice/referred for palliative care services before death (%) 41. Patient enrolled in hospice within 3 days of death (%) (Lower Score - Better) 42. Patient enrolled in hospice within 1 week of death (%) (Lower Score - Better) 43. For patients not referred in last 2 months of life, hospice/palliative care
discussed (%) Timing of chemotherapy administration before death
44. Chemotherapy administered within the last two weeks of life (%) (Lower Score -Better)
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Unique Opportunity
Integrate the best of: Acute careHospice CarePalliative Care
Further enhance the quality of the continuum of care“Accountable Care”“Transitions”
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Quality Outcomes of Palliative Care…
Reduction of Pain & SymptomsImproves Quality of LifePatient and Family Satisfaction Nurse SatisfactionPhysician SatisfactionReduced Provider/Caregiver burden Care plan consistent with wishesIncreased Referral/LOS to Hospice
CAPC http://www.capc.org/research-and-references-for-palliative-care/citations/index_html#2
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PC = Improved SurvivalThe New England Journal of Medicine - original
articleEarly Palliative Care for Patients with Metastatic
Non–Small-Cell Lung CancerRCT – standard care vs standard plus PCImproved QOLDecreased resource utilization (33% vs. 54%, P = 0.05)Lived 3 months longer (11.6 months vs. 8.9 months,
P = 0.02)
J. Temel, et al., n engl j med 363(8): 733-742 (august 19, 2010)
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60 Minutes Nov. 22, 2009
The Cost of Dying: Patients' Last Two Months of Life Cost Medicare $50 Billion Last Year; Is There a Better Way?More than the budget of the
Department of Homeland Security or the Department of Education
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Palliative Care = Quality
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Integrating Palliative Care into an Outpatient Private Practice Oncology Setting Private practice with 5 offices:
Primary office – 7 Medical Oncologists/4 NPs* Integrated PC consultation ½ day/week in April 2005
Secondary office – 2 Medical Oncologists Integrated PC consultation ½ day/week in August
2008Three additional offices begin summer 2011
3 Medical Oncologists /1 NP 2 Medical Oncologists 2 Medical Oncologists
Integrating Palliative Care into an Outpatient Private Practice Oncology Setting JC Muir, F Daly, M Davis, et al, JPSM 40(1):126-135, 2010
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Clinical Quality Outcomes
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Pain (152 patients)
0
1
2
3
Initial Final
Moderate
Mild
None
Severe
Dyspnea (274 patients)
0
1
2
3
Initial Final
Severe
Moderate
Mild
None
Initial Consultation Symptoms
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96% = 3-5 Symptoms
JC Muir, F Daly, M Davis, et al, Integrating Palliative Care into the Outpatient, Private Practice Oncology Setting. JPSM 40(1):126-135, 2010
Symptom Relief
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ESAS: Edmonton Symptom Assessment Scale/90 www.palliative.org
JC Muir, F Daly, M Davis, et al, Integrating Palliative Care into the Outpatient, Private Practice Oncology Setting. JPSM 40(1):126-135, 2010
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Mean Median
Availability of Palliative Care Services:9.3 9
Accessibility of Palliative Care Services:9.3 9
Acceptability Of Palliative Care Services:8.4 8.5
Continuity of Palliative Care Services:8.4 9
Quality of Palliative Care Services:8.4 9
Cost Impact of Palliative Care Services:7.9 8.5
Physician Satisfaction
JC Muir, F Daly, M Davis, et al, Integrating Palliative Care into the Outpatient, Private Practice Oncology Setting. JPSM 40(1):126-135, 2010
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Impact of Comprehensive Palliative Oncology in Partnered versus Non-Partnered Practices
JC Muir, F Daly, M Davis, et al, Integrating Palliative Care into the Outpatient, Private Practice Oncology Setting. JPSM 40(1):126-135, 2010
Averag e P C R eferrals per P hys ic ian in Group
0
2
4
6
8
10
12
14
16
18
2003 2004 2005 2006 2007 A NNL
F NV HO/F (8)
F NV HO/O (17)
Other MedOnc (75)
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600
3600
0 720 840
3960
9720
0
2000
4000
6000
8000
10000
Estimated Time (min) Saved 2006 EstimatedTime (min) Saved 2007
Estimated FNVHO/F MD* Productive Time Expanded Using Outpatient Palliative Care Services
Referring Physician
Min
ute
s
Average of 170 minutes of provider time saved per referral to PC
SummaryUnprecedented opportunity:
High quality care
Care across an enhanced continuum
Reduce health care expenditures
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