Life is pleasant. Death is peaceful. It’s the transition

that’s troublesome.

The Case forPalliative Care

The Eperc Project

How Americans died in the pastEarly 1900s

average life expectancy 50 yearschildhood mortality highadults lived into their 60s

Prior to antibiotics, people died quicklyinfectious diseaseaccidents

Medicine focused on caring, comfortSick cared for at home

with cultural variations

Medicine’s Shift in FocusMarked shift in values, focus of North American society

“death denying”value productivity, youth, independencedevalue age, family, interdependent caring

Death “the enemy”organizational promisessense of failure if patient not saved

Medicine’s Shift in FocusScience, technology, communicationPotential of medical therapies

fight aggressively against illness, deathprolong life at all cost

Improved sanitation, public health, antibiotics, other new therapiesincreasing life expectancy

2010 avg 78.7 years

We Hope toDie in my sleepDie suddenly

The Reality90% of us will die after a progressive decline from chronic

illness.

Results

More than 70% of Americans say they would prefer to die at home

25% of deaths occur at home

(Robert Wood Johnson Foundation)

From This

To This

The number of people over age 85 will double to 10 million by the year 2030

People living longer with chronic disease.

The 23% of Medicare patients with > 4 chronic conditions account for 68% of all Medicare spending

Aggressive treatment at end of life often leads to a decrease in quality of life for patients and their families

Significant association between increased cost and lower quality of death in the final week of life

The Demographic ImperativeChronically Ill, Aging Population is growing

9000 Patients with life-threatening illness, 50% died within 6 months

Half of patients had moderate-severe pain, >50% in the last 3 days of life.

38% of those who died spent >10 days in ICU, in a coma or on a ventilator

Suffering in U.S. Hospitals- National Data on the Experience of Advanced Illness in 5 Tertiary Care Teaching HospitalsJAMA 1995,274;1591-98

WhyDifficult to discuss“I’ll die in my sleep”Magical thinking “If I talk negatively, it will happen”Seen as “giving up”Family doesn’t want to discussSome would argue that in general we have lost faith in

transcendent lifeAdvance care planning consists mostly of funeral

arrangement

Most people say they want to discuss their values and wishes about end of life care with their physician—and they expect the physician to bring up the topic

Physicians feel patients will have difficulty discussing these sensitive issues

Most people are never asked about their wishes

Only 10-15% of Americans have Advance Directives

Barriers: What Research Says

Intro to Palliative Care"The relief of suffering and the cure of disease must

be seen as twin obligations of a medical profession that is truly dedicated to the care of the sick. Physicians’ failure to understand the nature of suffering can result in medical intervention that (though technically adequate) not only fails to relieve suffering but becomes a source of suffering itself."

The Nature of Suffering and the Goals of Medicine- Eric Cassell

Intro to Palliative CareMedical code of ethics and clinical guidelines explicitly indicate the importance of respecting patients’ rights, goals and values, as well as good communication, advance care planning, and recognizing when continuing treatment is more harmful than beneficial.

Patient and family centered careOptimizes quality of life by anticipating, preventing and

treating sufferingThroughout the course of illnessA holistic approach that includes physical, intellectual,

emotional, social and spiritual needs Facilitates patient autonomy, provides information and

choice

What is Palliative Care

Traditional Care Model

Curative CareHospic

eCare

<------------------Disease Process –-------------

Conceptual shift for Palliative Care – ever increasing presence

of Palliative Care throughout the disease process.

Pain and symptom control

Avoid inappropriate prolongation of the dying process

Achieve a sense of control

Relieve burdens on family

Strengthen relationships with loved ones

Closure – I love you and goodbye

What Do Patients with Serious Illness Want?Singer et al., JAMA 1999,281(2);163-68

Loved one’s wishes honored

Inclusion in decision process

Support/assistance at home

Honest information

Personal care needs met (bathing, etc.)

To be listened to

Privacy

To be remembered after the death

What do Patients and Families Want

Palliative Care Services Provides:Compassionate careManagement of distressing symptomsClarification of treatment optionsImproves communication between patients and

caregiversAssists with establishing advance directivesHelp patients to develop their goals of careTime to listen

Goals of CareFamily discussions to determine patient’s wishes – What is

important to the patient and their familyDetermine setting for careProvide information re: Hospice as appropriateEvaluate support systemsEvaluate spiritual needsProvide information regarding treatment optionsTalk about what happens at the end of lifeAssist patients and families with Advance Directives

Palliative Care Assists With

Symptom Management

PainNauseaConstipationAnxietyShortness of BreathAgitationDepression

Palliative Care Assists With

Palliative Care Assists With

I hope treatments will be explained and I will be included in treatment decisions

I hope my life has meaning

I hope I can still meet some of the goals that are important to me

I hope I can get help with the practical things I need to do before I die

Redefining Hope

Palliative Care Assists With

Healing fractured relationshipsCompleting unfinished businessTaking a tripThe Bucket ListMaintain Dignity

Redefining Healing

Relief of distressing symptomsHelp navigating a complex medical systemUnderstanding the plan of careCoordination and control of care optionsAllowing simultaneous palliation of suffering along with

continued treatmentPractical and emotional support for patients and

exhausted family caregivers

What does all this mean from the patient perspective?

Hope for the best,But make arrangements just in case.

A Jewish Proverb

Hippocratic EthosTo cure occasionally

To relieve oftenTo comfort always

Please join us:http://vote.livestrong.org/vote2012/regions/1/3-harrison-medical-center/

&

Quality of Life ForumHarrison Silverdale

May 21st at 5:30 PMpalliativecare@harrisonmedical.org or 744-5618