institut català d’oncologia the basics of palliative care models of care and settings of care...

Institut Català d’Oncologia

The Basics of Palliative Care Models of Care and Settings of Care

Kathleen M. Foley, MD

October 26,2011

Brasov, Romania

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2002 WHO Definition of 2002 WHO Definition of Palliative CarePalliative Care

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

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Palliative Care as a Public Health Issue

• affects all people

• need for better information on end-of-life care

• potential to prevent suffering

• potential to prevent disease

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Palliative Care as a Prevention Model

• prevents needless suffering

• provides peer education

• provides patient centered care

• incorporates self-management programs

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UNAIDS Report

• 40 million living with HIV/AIDS-28.5 million in sub-saharan Africa

• 14 million orphans worldwide-11 million in sub-saharan Africa

• 20 million have died since 1981

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Global Cancer Mortality

• 12.7 million patients diagnosed each year with cancer

• 7.6 million who die from cancer

• 29 million cancer survivors

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Global Cancer Mortality (millions/yr)

0

2

4

6

8

10

12

14

1990 2000 2010 2020

TB

Malaria

HIV

Cancer

Data Source: World Bank7


Tuberculosis Global Facts

In 2009:•9.4 million new TB cases in 2009•1.7 million people died from TB in 2009•440,000 new MDR-TB cases 150,000 deaths from MDR-TB

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Pediatric Palliative Care

• Worldwide there are 7-9 million children with life-limiting and life-threatening conditions requiring palliative care

• 80% live in resource-limited countries

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Patient Populations Requiring Palliative Care

Cancer Patients

HIV/AIDS Patients

Patients with MDR-XDR TB

Frail Elderly patients with multiple comorbidities

Patients with neurodegenerative diseases

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The continuum of palliative care

Diagnosis Death

Therapies to modify disease(curative, restorative intent)

Actively Dying

BereavementCare

Life Closure

Therapies to relieve suffering, improve quality of life

6m

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EducationEducation

ImplementationImplementation

DrugAvailability

DrugAvailability

WHO Public Health ModelWHO Public Health Model

PolicyPolicyPolicyPolicy

Context

Context

Outcomes

Outcomes

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Settings of Palliative Care

• Hospital

• Home

• Nursing Home/Rehabilitation Unit

• Pediatric Home

• Hospice Home

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Models of Care

• Hospital- based palliative care

• ICU

• Cancer unit

• Neurologic unit

• Neonatal unit

• Home-based palliative care

• Nursing home palliative care

• Free standing hospice 18


Specific Resources / settings

Units

Support teams

Outp’s / Day care

Acute Hospitals

Nursing homes

Mid term and long term, RHB, (Sociohealth Centers)

Hospices

Community / home

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Types of services and Levels of complexity

General measures in conventional Services (Hospitals, Primary care, Nursing homes, Emergencies, etc)

Basic suport teams (home, hospitals, comprehensive)

Reference:

complexity+ training+ research

Complete teams Units

Transitional measures: individual Specialist nurses or consultants

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Standards of specific resources

• 1 support team at home / 100.000 h• 80-100 beds/milion habitants (10-20% acute, 40-60% mid term, 20-30% nursing

homes)

• 20-25 full time doctors / milion habitants

• 1 team available in every hospital (units in teaching)

• Models of organization adapted to demographic scenarios: metropolitans, intermediate, or small sectors < 100.000

• Models in specific resources (cancer institutes, nursing homes, etc)

XGB 2005, WHOCC, 2008

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Regional variationsCountry Services*

(n)

Ratio of services to population 1:000s

UK 1478 40

Iceland 6 49

Ireland 50 83

Poland 406 95

France 471 128

Hungary 50 202

Denmark 18 302

Belarus 12 813

Portugal 10 1,050

Russia 125 1,146

Croatia 3 1,517

Ukraine 18 2,582

*A service here is defined as a service type: number of services courtesy of EAPC Task Force22


Implementation strategies of services:

initial phases• To create a nucleus of solid

experiences• Combine different types: home,

hospital, cancer, geriatric,….• Based in feasibility: active leaders,

institutional comittment, …. • Cathalitic measures: support teams,

transitional, …• Define services before starting

implementation-23-


Models of organisation in

demographic and geographic scenarios

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Sectorized Planning

Needs:Demography

urban, rural, mixed

Resources

Type

cancer, geriatrics, AIDS, other

Complexity

low/high

Mortality / Prevalence

low/high

Specialist Services

+ General

Measures in conventional services

Direct coverage for complex diseases

Good care for non-complex diseases

• Criteria intervention

• Continuing / emergency care

• Coordination

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Demographic and setting scenarios• Demographic• Rural• Urban• Rural-urban• Metropolitan

• Settings• Primary/community care• Nursing homes• Longterm / intermediate• Hospitals: district

general, university• Cancer Institutes

Adapt the organisation to needs and contexts

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.

The ‘Qualy’ End of Life Care Observatory WHO Collaborating Centre for Public Health Palliative Care Programmes

[email protected]+34 93 260 77 36

ICO l’HospitaletHospital Duran i ReynalsGran Via de l’Hospitalet, 199-20308908 l’Hospitalet de Llobregat


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institut català d’oncologia the basics of palliative care models of care and settings of care...

Documents

complex diseasesgood

emergency care coordination

advance care planning

integration of palliative

public healthpalliative

district general

mixed resourcestype

trusting relationship