Mark McIntosh, MD, MPH

Department of Emergency Medicine

Medical Director of Palliative Care UF Health/Jax

Ashley Shreves, MDDepartment of Emergency Medicine

Brookdale Department of Geriatrics and Palliative Medicine

Icahn School of Medicine at Mt. Sinai

THE EMERGENCY DEPARTMENT THE LATEST SITE FOR PALLIATIVE CARE

Palliative Care in Denver

OBJECTIVES

• Be able to explain the difference between Palliative Care and Hospice

• Appreciate Balance Between Quality and Quantity of Life

• Describe Roadmap for Discussing Goals of Care with Patients/families at EOL

• Identify Useful Phrases in Speaking to Patients/families about EOL Care

• Consider Future Implications for Palliative Care Delivery

• They’re coming

• 50% of seniors visit ED last month of life

• 1/3rd cancer patients visit ED during last 2 weeks of life

• Their needs and goals are different

• Time is precious!

WHY WE NEED TO KNOW

Smith AK. Health Affairs 2012Barbera L. CMAJ 2010

“Under the influence of the more-is-better mentality, well-intentioned clinicians and loving families can inadvertently cause people to spend precious, fleeting days at the end of a long illness in hospitals and ICUs, instead of at home or other places they would rather be…”

Ira Byock, MDFormer director of palliative care at Dartmouth-Hitchcock Medical Center

THE REALITY IN THE ED

WHAT IS PALLIATIVE CARE?

Palliative care is medical care that specializes in the relief of the pain, symptoms and stress of serious illness.

CONCEPTUAL SHIFT FOR PALLIATIVE CARE

Source: Center to Advance Palliative Care (CAPC)

Diagnosis Death

CASE SEEN MOST DAYS IN THE ED ICU

• 89 yo female

• CC: Fever and SOB

• VS

• BP 100/50 HR 130 O2 sat 90% on NRB RR 35 temp 102

• Advanced dementia (G-tube feeds)

• No advance directives

• “Please do everything”

NEXT STEPS?

• What do you usually do?

• What do you want to do?

• What’s “the right thing”?

WHAT’S MOST IMPORTANT TO PATIENTS AT EOL?

Steinhauser KE JAMA 2000

DON’T THEY WANT “EVERYTHING” DONE?

Quality of life > quantity of life

Fried TR. N Engl J Med 2002

STEPS

• Understand basic EOL trajectories

• Learn communication skills to transition care

RECOGNIZE THE EOL Spending time in bed, high sx

Infections, feeding problems

Tough, need good PMH

EMS

Lunney JR JAMA 2003

BACK TO CASE

• Was this patient dying?

• Trajectory?

NOW WHAT?

• A. ICU, admit

• B. ICU, palliative care

• C. Talk to family about goals of care

• D. No clue

WHY NOT TALK TO FAMILY?

• A. Time

• B. Legal

• C. Don’t want upset family

• D. Never taught

Smith AK. Ann Emerg Med 2009Stone SC. J Palliat Med 2011

Meo N. J Palliat Med 2011

ED APPROACH TO GOALS OF CARE

• Do you want us to intubate her?

• If she codes, should we do CPR?

• Do you want us to put in a central line?

• Would she want pressors?

WHAT HAPPENS?

• They get “everything”

• Why?

• Health literacy

• Communication

• Emotions Volandes AE J Palliat Med 2008Volandes AE J Palliat Med 2011

Volandes AE BMJ 2009Quill TE Ann Intern Med 2009

TALKING ABOUT DYING: GROUND RULES

• It will be awkward

• You will say “the wrong thing”

• It’s ok

• Use a roadmap

• Time limit

• When in doubt, prolong

GOC ROADMAP “SPIKES”

• Setting

• Perception

• Invitation

• Knowledge

• Emotion (est. Goals)

• Summarize

ASK-TELL-ASK-TELL-ASK

Buckman and Baile

SETTING AND INTRO

• Prepare for the Conversation

• Quiet room (bring a chaplain or nurse)

• Sit down

• Build trust

• “Tell me about your father…”

PERCEPTION

• Patient/family understanding of medical facts

• Patients/families

• Weren’t told

• Told poorly

• Weren’t ready to hear

• “What have the doctors told you about…?”

• “How have things been going at home?”

Mitchell SL. N Engl J Med 2009Weeks. N Engl J Med 2012

KNOWLEDGE OR MEDICAL EXPLANATION

• Big picture

• No jargon

• “It sounds like your mother’s health has really declined in the past few months. I have to tell you, she is really sick right now and I’m worried that she is dying.”

• Silence

RESPOND TO THE EMOTION

• Give some Space and use Silence

• Name the emotion (its “shocking” to me too)

• “Is it OK if I move forward to talk about the plan and the options?”

ED: HAVE TO GET THE GOALS

• Hopes and worries, given new info

• Ask what patient would tell us if in the room

• Error: Asking family members to decide on life-sustaining treatment for a patient, rather than asking them to assess what their loved one would want

• “What’s most important?”

SUMMARIZE AND GIVE MEDICAL RECOMMENDATION• Be a doctor !!!

“Based on what we know about your mother’s condition and our discussion here, I’m going to make some recommendations. Is that ok?”

• Need to know your options

• “Re-focus our efforts” BUT NEVER “Withdraw care”

• “Maximize comfort”

“I think we should focus our efforts on maximizing her comfort/QOL.”

“I do not think that we should use machines and other tools to try to artificially prolong her life. I’m worried that would add to her suffering.”

INTUBATION AND “CODE STATUS”

• Meaningless discussion out of context – don’t use DNR order to introduce dying

• Patients don’t want to be “full code”

• They want an outcome

• If intubation can’t meet goals, recommend against

• “Allow natural death”

Blinderman CD. JAMA 2012

CPR SUCCESS: ALIVE AT DISCHARGE• Rule of thumb

• 17% = Hospitalized Patients with Cardiac Arrest

• -5% = For each significant diseased organ system

OK do the calculation: Patient with heart failure + dementia + pneumonia .

NEGOTIATION/CARE PLAN

• Suggest limits, where appropriate

• Summarize your understanding

• “Hope for the Best, Prepare for the Worst” – underlying principle

Palliative Care Referral Tool

A-B-C-D-E CHECKLIST

BACK TO CASE

• Family room discussion 15 minutes with 4 children

• “We want everything”

• “It’s time to let her go”

• Family at bedside, crying, laughing

PALLIATIVE CARE PREDICTIONS

• Palliative Care Trained Staff in the ED

• Advance Directive Registries

• Reimbursement changes (pay for the discussion, PC reimbursement, end of life reimbursement, PC for ACO )

Patient Enters Triage Area

Palliative CareLiaison

Triage algorithm: Just a few questions (1-2) the triage nurse can ask the patients/families for early identification

Referral to Palliative Care Team

Symptom Management (pain, nausea, vomiting, etc.)

Hospice Referral

ED algorithm:Series of questionsand observation that will result in appropriate ED management or triage

PC NURSE NAVIGATOR ED PILOT PROJECT

ADVANCED DIRECTIVES

• 181 Established previously

• 167 HCS/Proxy/DPOA/Guardian

• 18 DNR

• 514 Addressed in ED

• 491 HCS/Proxy/ DPOA/Guardian

• 35 DNR

• 445 Not Addressed

CONSULTS:

10/12-2/13 3/13-8/13 3/13-3/14

Hospice 20 48 33

Palliative Care 68 199 304

Both - 37 74

DISPOSITION:

• 1140 Patients and families served from 03/2013-03/2014

n %

Admitted 776 68

Home 42 4

Hospice 62 5

Died 33 2.9

LTC/SNF 2 .2

Others 224 20

Advance Directive Registries

• 1/3 of Health Care Surrogates suffer negative effects of making decisions for months to years

Ann Intern Med. 2011 Mar 1;154(5):336-46

• States to connect advance directive registries to

health information exchanges.

EPIC HINTS

GO TO “MEDIA TAB” TO FIND: ADVANCE DIRECTIVES/HEALTH CARE SURROGATE

LIVING WILL

HEALTHCARE SURROGATE

• Pay for the discussion

• PC and End of Life reimbursement

• PC for ACO: Hospice of Michigan Model

REIMBURSEMENT IS CHANGING

REFERENCES

• Communication skills

• Mastering Communication with Seriously Ill Patients

• Bedside info

• EPERC Fast Facts

• ED-Pal Care initiative

• IPAL-EM (CAPC)

• EM-Pal Care course

• EPEC-EM

SUMMARY

• Quality > quantity at EOL

• EOL communication is a procedure

• Roadmap and key phrases should empower you to start talking

• Palliative care = health care’s future and salvation…

• Join the movement now!

CONSULTS TO PALLIATIVE CARE AND HOSPICE

• 107 Hospice

• 33 Hospice only

• 74 hospice and palliative care

• 378 Palliative Care

• 304 Palliative Care only

• 74 both PC and hospice