What Is a Palliative Care Consult Service?

More importantly – What can it do for you?

Palliative Care Consulting

• Making the Case

• Services Rendered

• Staffing

• A Note of Caution

• The Role Of Acute Care Hospitals In Caring For the Dying

Why Palliative Care?

• The sickest people congregate in hospitals• These people often feel a loss of control in

their medical travails• Often they experience profound suffering• The people who care for them often

experience tremendous burden, burnout• Hospitals and accreditation organizations

recognize these struggles, want to do better

What Do Patients with Serious Illness Want?

• 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

Singer et al. JAMA 1999;281(2):163-168.

National Data on the Experience of Advanced Illness in 5 Tertiary Care

Teaching HospitalsThe SUPPORT Study

• Controlled trial to improve care of seriously ill patients

• Multi-center study funded by RWJ• 9000 patients with life threatening illness,

50% died within 6 months of entry

JAMA 1995;274:1591-98

SUPPORT: Suffering and Costs, Phase I Results

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

• 38% of those who died spent >10 days in ICU.

Self-Reported Symptom Experience of Critically Ill Cancer Patients Receiving Intensive Care

Nelson JE, Meier DE, Oei EI et al. Crit Care Med 2001;29:277-282

0

10

20

30

40

50

60

70

80

90

100

Perc

ent

of pati

ents

wit

h s

ympto

ms

at

modera

te o

r se

vere

leve

l

Discom

fort

Thirs

t

Slee

ping

Anxiet

y

Pain

Hunge

r

Depre

ssion

SOB

Moderate Severe

75%75%71%71% 68%68%

63%63%56%56% 55%55%

39%39%34%34%

Pain Data from SUPPORT

% of 5176 patients reporting moderate to severe pain between days 8-12 of hospitalization:

colon cancer 60%liver failure 60%lung cancer 57%MOSF + cancer 53%MOSF + sepsis 52%COPD 44%CHF 43%

Desbiens & Wu. JAGS 2000;48:S183-186.

Physician Training in Pain Management

Oncologists self-report:– 86% of their patients undermedicated– 50% rated pain management in their own

practice as fair to very poor– 73% evaluated their own training in pain

management as fair to very poor

Von Roenn et al. Ann Intern Med 1993;Jul 15;119(2):121-6.

Caregiving Needs Among Seriously Ill Persons

Interviews with 900 caregivers of seriously ill persons at 6 U.S. sites

• need more help: 87% of families

• transportation: 62%

• homemaking: 55%

• nursing: 28%

• personal care: 26%Emanuel et al. Ann Intern Med2000;132:451

Caregiving Increases Mortality

Nurses Health Study: prospective study of 54,412 nurses

• Increased risk of MI or cardiac death: RR 1.8 if caregiving >9 hrs/wk for ill spouse Lee et al. Am J Prev Med 2003;24:113

Population based cohort study 400 in-home caregivers + 400 controls

• Increased risk of death: RR 1.6 among caregivers reporting emotional strain Schulz et al. JAMA 1999;282:2215.

Family Caregivers and the SUPPORT study

Patient needed large amount of family caregiving: 34%

Lost most family savings: 31%

Lost major source of income: 29%

Major life change in family: 20%

Other family illness from stress: 12%

At least one of the above: 55%

JAMA 1995;272:1839

What Do Family Caregivers Want?

Study of 475 family members 1-2 years after bereavement

• Loved one’s wishes honored• Inclusion in decision processes• Support/assistance at home• Practical help (transportation, medicines, equipment)• Personal care needs (bathing, feeding, toileting)• Honest information• 24/7 access• To be listened to• Privacy• To be remembered and contacted after the death

Tolle et al. Oregon report card.1999 www.ohsu.edu/ethics

Symptom Improvement for 3,707 Palliative Care Patients at Mount Sinai Hospital (6/97-

12/04)

Initial Evaluation Final Evaluation

Initial Evaluation Final Evaluation

Initial Evaluation Final Evaluation Initial Evaluation Final Evaluation

Pain Nausea

Shortness of Breath

Severe

Mod.

Mild

None

Severe

Mod.

Mild

None

Severe

Mod.

Mild

None

AnxietySevere

Mod.

Mild

None

Source: Patient Interviews, Mount Sinai Hospital, New York City

Case 1. Mount Sinai Hospital, NYC:

Improvement in Symptoms1997-2002: 2219 palliative care consult

service patients

Initial Evaluation Final Evaluation

Moderate

Severe

Mild

None

Pain

Nausea

Dyspnea

High Satisfaction -Mount Sinai Hospital DataPercent of Palliative Care Families Satisfied or

Very Satisfied with:

• Control of pain - 95%• Control of non-pain symptoms - 92%• Support of patient’s quality of life - 89%• Support for family stress/anxiety - 84%• Manner in which you were told of patient’s

terminal illness - 88%• Overall care provided by palliative care program-

95%

Source: Post-Discharge/Death Family Satisfaction Interviews, Mount Sinai Hospital, New York City

What Does All this Mean from the Patient Perspective?

For patients, palliative care is a key to:– relieve symptom distress – navigate a complex and confusing medical system– understand the plan of care– help coordinate and control care options– allow simultaneous palliation of suffering along with

continued disease modifying treatments (no requirement to give up curative care)

– provide practical and emotional support for exhausted family caregivers

The Clinician Perspective

For clinicians, palliative care is a key tool to:

• Save time by helping to handle repeated, intensive patient-family communications, coordination of care across settings, comprehensive discharge planning

• Bedside management of pain and distress of highly symptomatic and complex cases, 24/7, thus supporting the treatment plan of the primary physician

• Promote patient and family satisfaction with the clinician’s quality of care

The Hospital Perspective

For hospitals, palliative care is a key tool to:

– effectively treat the growing number of people with complex advanced illness

– provide service excellence, patient-centered care– increase patient and family satisfaction– improve staff satisfaction and retention – meet JCAHO quality standards– ration the use of hospital resources– increase bed/ICU capacity, reduce costs

Summary

• Palliative care improves quality of care for our sickest and most vulnerable patients and families.

• Palliative care improves the ability of physicians to deliver high quality care to this difficult patient population

• Palliative care saves the hospital time and money while improving overall patient satisfaction

This is My Job

Palliative Care Specialist at CPMC– Pain Management (Terminal or non-terminal)– End Of Life Counseling

• Code Status Discussion• Prolonged ICU stays• Introduction to Hospice

– Symptom Management• Dyspnea (CHF, COPD, malignancy)• Nausea/Vomiting• Pruritis (ESRD, ESLD)

– Physician/House Staff Education

My Colleagues

• 1 Geriatrician

• 1 Fellowship-trained Nurse Practitioner

• 2 Oncology Clinical Nurse Specialists

• Psychology Service

• Health and Wellness– Massage Therapy– Acupuncture– Herbal Medicine

In My Dreams

• Dedicated Social Worker

• Dedicated Case Manager

• Trained Psychologist in End Of Life Issues

• 0.5 FTE Massage Therapist

• Annual Retreats at Pebble Beach– All Expenses Paid

The Pitfalls and Perils

• Stepping On Toes– Disrupting long-held notions– Attending/House Staff Miscommunication– Answer the Question! (and only the question)

• “Spoiling the Movie”

• Commandeering