ira r. byock, md director of palliative medicine dartmouth-hitchcock medical center
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Dying in America A Generation’s Crisis and Opportunity. Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005. Reasonable Expectations . Routine assessment and competent treatment of pain & physical distress - PowerPoint PPT PresentationTRANSCRIPT
Ira R. Byock, Ira R. Byock, MDMD Director of Palliative Medicine
Dartmouth-Hitchcock Medical CenterAugust 17, 2005
Dying in America
A Generation’s Crisis and Opportunity
Reasonable Expectations
• Routine assessment and competent treatment of pain & physical distress• Clear, complete & honest communication• Respect for people’s stated preferences• Coordination of care • Crisis prevention and management • Safe & prudent staffing ratios for nurses and CNAs • Support for family caregivers • Support for families in grief
Jan Hoffman New York Times, August 14, 2005
Awash in Information, Patients Face a Lonely, Uncertain Road
Photo: Nicole Bengiveno
Institute of Medicine Institute of Medicine Dimensions and DeficienciesDimensions and Deficiencies
I. Too many people suffer needlessly at the end I. Too many people suffer needlessly at the end of life, both from errors of omission and of life, both from errors of omission and from errors in commissionfrom errors in commission
II. Legal, organizational, and economic II. Legal, organizational, and economic obstacles conspire to obstruct reliably obstacles conspire to obstruct reliably excellent care at the end of life.excellent care at the end of life.
Approaching DeathApproaching Death Nat’l Academy Press, 1997
III. The education and training of physicians III. The education and training of physicians and other health care professionals fail and other health care professionals fail to provide them the attitudes, to provide them the attitudes, knowledge, and skills required to care knowledge, and skills required to care well for the dying patient.well for the dying patient.
IV. Current knowledge and understanding are IV. Current knowledge and understanding are insufficient to guide and support the insufficient to guide and support the consistent practice of evidence-based consistent practice of evidence-based medicine at the end of life. medicine at the end of life.
Approaching DeathApproaching Death Nat’l Academy Press, 1997
Institute of Medicine Dimensions and Deficiencies
Robin Marantz Henig
New York Times Magazine, August 7, 2005
Will We Ever Arrive At the Good Death?
Photo: Nicholas Nixon
These may be the “Good Old Days”
The Graying of AmericaChanging U.S. Age Distribution
SOURCE: AMARA et. al., SOURCE: AMARA et. al., Looking Ahead at American Health CareLooking Ahead at American Health Care (1988) (1988)
10 5 0 5 10 10 5 0 5 10
Millions of Persons
1020304050607080
1020304050607080
1980 1990 2000
Indicates the Baby-Boom Group
10 5 0 5 10
2050
4 to 1
20306 to 1
2010
10 to 1
1990
11 to 1
The Shrinking Pool of Caregivers
www.dyingwell.org
USA Today December 13, 2000
Where We Die
Zerzan J, Stearns S, Hanson LAccess to Palliative Care and Hospice in Nursing Homes
JAMA 2000 Nov 15, 284(19) 2489-2494
“Nearly half of Americans who live to 65 years of age will enter a nursing home
before they die.”
The Washington Post MagazineJune 9, 2002
“More than 90 percent of the nation's nursing homes have too few workers to
take proper care of patients, a new federal study has found.”
9 of 10 Nursing Homes Lack Adequate Staff, Study Findsby Robert Pear, New York Times February 18, 2002 A1 Deidre Scherer
collection
The Coming Crisis in Nursing
Source: Projections by Division of Nursing BHPr, HRSA, USDHHS, 1996
1.92
2.12.22.32.42.52.62.7
2000 2005 2010 2015 2020
FTE RN Requirements FTE RN Supply
Millions
USA Today
““Eighty-three percent of elderly Americans Eighty-three percent of elderly Americans would stay in their homes until the end if they would stay in their homes until the end if they
could. Thirty percent say they’d rather die than could. Thirty percent say they’d rather die than go into a nursing home.” go into a nursing home.”
CBS News February 27, 2001
Nursing homes and public opinion
This is one crisis we can solve!!!
Deidre Scherer collection
…and we are already spendingenough money
Robert Pope collection
Palliative Care
Hospice Care
Hospice and Palliative Care
Palliative Care
Interdisciplinary care for persons with life-threatening illness or injury which addresses physical, emotional, social and spiritual needs and seeks to improve quality of life for the ill person and his or her family.
SocialWorker
MedicalDirector
HospiceRNs
HospitalNursingResp.
Therapy
Pharmacist
ProgramCoord.
Dietician
VolunteerCoordinator
PastoralCare
HospitalSW-Discharge
Planner
Patient &
Family
www.dyingwell.org
6 month prognosis
Hospice
Diagnosis
Curative &
Life-Prolonging Treatment
Sequential Model“Curative” followed by “Palliative” Care
Medicare Hospice Benefit
Diagnosis Death
Concurrent Care
“Curative” orDisease-modifying Treatment
Palliative Care
Promoting Excellencein End-of-Life Care
A national program of The Robert Wood Johnson Foundation
Bristol Bay Area
Health Corporation
Cardinal Glennon Children’s Hospital
Children’s Hospital and
Regional Medical Center
University of
Michigan Cancer Center
Promoting Excellence in End-of-Life
Care
Dartmouth-Hitchcock Norris
Cotton Cancer Center
Department of Veterans
Affairs; West Los Angeles
Medical Center
Henry Ford Health System
Hospice of the Valley
Case Western Reserve
Univ.
Louisiana State
University Medical Center
Mass. Mental Health
Medical U. of So. Carolina
Mount Sinai School of Medicine
UC Davis, Cancer Center
UC San Francisco
Univ of Chicago Medical Center
U. New Mex,
U. PA. School of Nursing
VNA. & Hospice of No. Calif
Volunteers of America
Baystate Medical Center
Cooper Green
Medical Center
An interdisciplinary team 24/7 availability Ongoing communication Advanced care planning Formal symptom assessment & treatment Crisis prevention & early crisis management Care coordination Spiritual care Anticipatory guidance Bereavement support
Typical Services of Palliative Care
www.PromotingExcellence.org
It is possible to
• Expand Access• Improve Quality• Control Costs
Access Quality Costs
Promoting Excellencein End-of-Life Care
www.PromotingExcellence.org
Promoting ExcellenceMonographs
www.PromotingExcellence.org
Promoting Excellence Monographs
Alleviation of symptoms and suffering are our first priorities…
Goals of Palliative Care
… but they are not the ultimate goals.
Goals of Palliative Care
Bill Bartholome
Bill Bartholome
• Communicating• Completing affairs & relationships• Resolving relationships• Grieving• Reviewing life, exploring meaning & purpose• Exploring spiritual & transcendent realms
Preserving Opportunity
www.dyingwell.org
“Please forgive me”
“I forgive you”
“Thank you”
“I love you”
Completing RelationshipsSaying “The Four Things That Matter Most”
www.dyingwell.org
Ensuring the “best care possible” Feeling that preferences were followed Knowing the person was treated in a dignified manner A chance to say and do the things
“that matter most” Honoring and celebrating the person in
his/her passing
A chance to grieve together
Dying Well – Family Perspective
www.dyingwell.org
• Ensure adequate staffing and living wages for aide-level workers in long term care
• Insist on adequate training of physicians, nurses & clinicians society employs and relies on
• Encourage innovation in health service delivery promoting a continuum of care
• Decrease barriers to effective pain management
Public policies can’t do everything, but they can…
• Eliminate the arbitrary distinction between “curative” and palliative care
• Insist on accurate accounting of costs
• Empower consumer and citizen expectations
• Encourage community-based responses
• Foster cultural maturation of a healthy conclusion to life
Public policies can’t do everything, but they can…
More information available at
www.PromotingExcellence.org
www.DyingWell.org
www.ChoicesBank.org
www.Lifes-End.org