Choosing Wisely : Five Things Physicians and Patients Should Question About Palliative Care

1. Choosing Wisely:Five Things Physicians and Patients Should Question About Palliative Care Gregg VandeKieft, MD, MA HOPE of Wisconsin Annual Conference November 13, 2013

2. Disclosure • Dr. VandeKieft does not have any conflicts of interest to disclose.

3. Public Service Announcement • Hospice Medical Director Certification Board • First exam window: May 8-23, 2013 • Applications open: Dec 16, 2013 • Information at: • http://www.hmdcb.org/ • Or contact Sally Weir at 847.375.4810

4. Learning Objectives • At the conclusion of this presentation, participants should be able to: • Describe the Choosing Wisely campaign • Name 5 practices in hospice and palliative medicine (HPM) that should be questioned • Identify relevant Choosing Wisely recommendations from other specialties

5. History of Choosing Wisely campaign • 2010: Howard Brody, MD, PhD, NEJMcommentary • “Medicine’s Ethical Responsibility for Health Care Reform—The Top Five List” • 2011: Family Medicine, Internal Medicine, and Pediatrics “Top Five” lists published • 2012: ABIM Foundation launches Choosing Wisely • 9 specialty societies in first cohort, AAHPM in 2nd cohort • now 54 participating specialty societies • some have already released their 2nd or 3rd “Top 5” list

6. General principles of Choosing Wisely campaign • Goal: enhance communication, quality, choice • The right care at the right time in the right place • All Choosing Wisely recommendations have solid evidence base • More isn’t always better - excess may cause harm • Estimated 30% of healthcare expenditures go to overuse or inappropriate use • Helping “avoid inappropriate tests or procedures that provide little to no benefit”

7. Taking Choosing Wisely to the public • 17 consumer group partners • Consumers Union (Consumer Reports publisher), AARP, NHPCO, Leapfrog Group, Wikipedia, others • Grants to state and regional organizations • Includes Wisconsin Collaborative for Healthcare Quality, in conjunction with Wisconsin Medical Society

8. 1. Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead, offer oral assisted feeding.

9. Evidence base • In advanced dementia, feeding tubes do NOT improve survival, decrease risk of aspiration pneumonia, or improve healing of pressure ulcers • G- or J-tubes have complications, increase symptom and caregiving burden, distress • Increased fluid overload, diarrhea, feeling bloated • “Weissman’s triad”: advanced dementia, feeding tube, and restraints

10. Consider in context • Recommendation is specific to dementia • There are other situations when FT should be offered • Families frame medical evidence within personal, social, cultural, and religious values • Focus on what CAN be done • Withholding feeding tubes does NOT mean no feeding or hydration – careful hand feeding key • At end of life, feeding is more about human contact, personal engagement than nutrition – feed for comfort

11. Educational resources http://hankdunn.com/choosing-wisely-once-again-no-feeding-tube/

12. 2. Don’t delay palliative care for a patient with serious illness who has physical, psychological, social or spiritual distress because they are pursuing disease-directed treatment.

14. Evidence base • Palliative care concurrent with active cancer care • Improves pain and symptom control, quality of life • Improves patient and family satisfaction with care • End-of-life care more likely aligned with preferences • Does not hasten death – often prolongs survival • Reduces costs

15. Consider in context • Variations on this recommendation included in lists from SGO, and ACEP (see later slides) • Greatest barriers are cultural • Lack of distinction between palliative care and hospice • Association of palliative care with end of life • Struggle to balance hopes for the best outcome with confronting reminders of the seriousness of the illness

17. 3. Don’t leave an implantable cardioverter-defibrillator (ICD) activated when it is inconsistent with the patient/family goals of care.

18. Evidence base • About ¼ of ICDs fire in the last weeks of life • No benefit in actively dying patients • Painful, distressing to patients and families • No widely accepted standard practice protocols • <10% of hospices have a policy in place • Hospices with a policy twice as likely to deactivate ICDs • Sample policy: http://annals.org/article.aspx?articleid=745635

19. Consider in context • Biggest barriers • Cultural: many cardiologists oppose or do not see the necessity of deactivating an ICD • Also need to distinguish ICD from pacer • Awareness: too often we don’t know patient has an ICD • Heart Rhythm Society guidelines • http://www.hrsonline.org/Practice-Guidance/Clinical-Guidelines-Documents/Expert-Consensus-Statement-on-the-Management-of-CIEDs#axzz2k2dqo5h8

20. 4. Don’t recommend more than a single fraction of palliative radiation for an uncomplicated painful bone metastasis.

21. Evidence base • Single-fraction radiation to previously un-irradiated bone metastases provides comparable pain relief as multiple-fraction regimens • Higher likelihood retreatment will be needed, but decreased treatment burden outweighs risk when life expectancy is limited • “Skeletal events” a poor prognostic marker • Single-fraction regimen the norm everywhere but U.S.

22. Consider in context • Weights on the balance • Life expectancy, functional status, severity of pain, treatment burden, response to initial treatment • Consider alternatives • Analgesics, bisphosphanates, radionuclides, vertebroplasty/kyphoplasty • Endorsed by 2011 ASTRO guideline • https://www.astro.org/Clinical-Practice/Guidelines/Bone-Metastases.aspx

23. 5. Don’t use topical lorazepam (Ativan), diphenhydramine (Benadryl), haloperidol (Haldol) (“ABH”) gel for nausea.

24. Evidence base • No well designed studies confirming efficacy • Best study to date showed active agents either • had blood levels insufficient for therapeutic effect, or • were absorbed too unreliably to achieved desired effect in a timely manner

25. Consider in context • Commonly used in hospice • Just as we question others’ practices, we need to be willing to question or own • Use alternate routes or alternate agents • Use topical agents with evidence of efficacy • e.g., NSAIDs for local arthritis, lidocaine for post-herpetic neuralgia

26. Relevant examples from other specialties: AMDA • Don’t insert percutaneous feeding tubes in individuals with advanced dementia. Instead, offer oral assisted feedings. • Don’t routinely prescribe lipid-lowering medications in individuals with a limited life expectancy. • American Medical Directors Association (AMDA) – nursing home medical directors’ professional society

27. Relevant examples from other specialties: ASCO • Don’t use cancer-directed therapy for patients with solid tumors with the following characteristics: low performance status (3 or 4), no benefit from prior evidence-based interventions, not eligible for a clinical trial, and no strong evidence supporting the clinical value of further anticancer treatment. • American Society for Clinical Oncology (ASCO)

28. Relevant examples from other specialties: ACEP • Don’t delay engaging available palliative and hospice care services in the emergency department for patients likely to benefit. • American College of Emergency Physicians (ACEP)

29. Relevant examples from other specialties: ACS • Avoid colorectal cancer screening tests on asymptomatic patients with a life expectancy of less than 10 years and no family or personal history of colorectal neoplasia. • American College of Surgeons

30. Relevant examples from other specialties: AGS • Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead offer oral assisted feeding. • Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation or delirium. • American Geriatrics Society (AGS)

31. Relevant examples from other specialties: ASTRO • Don’t routinely use extended fractionation schemes (>10 fractions) for palliation of bone metastases. • Don’t routinely recommend proton beam therapy for prostate cancer outside of a prospective clinical trial or registry. • American Society for [Therapeutic] Radiation Oncology (ASTRO)

32. Relevant examples from other specialties: ASN • Don’t perform routine cancer screening for dialysis patients with limited life expectancies without signs or symptoms. • Don’t initiate chronic dialysis without ensuring a shared decision-making process between patients, their families, and their physicians. • American Society of Nephrology (ASN)

33. Relevant examples from other specialties: CoC • Don’t initiate cancer treatment without defining the extent of the cancer (through clinical staging) and discussing with the patient the intent of treatment. • Commission on Cancer (CoC)

34. Relevant examples from other specialties: SGIM • Don’t recommend cancer screening in adults with life expectancy of less than 10 years. • Don’t place, or leave in place, peripherally inserted central catheters for patient or provider convenience. • Society of General Internal Medicine (SGIM)

35. Relevant examples from other specialties: SGO • Don’t delay basic level palliative care for women with advanced or relapsed gynecologic cancer, and when appropriate, refer to specialty level palliative medicine. • Society for Gynecologic Oncology (SGO)

36. Relevant examples from other specialties: SHM • Don’t place, or leave in place, urinary catheters for incontinence or convenience or monitoring of output for non-critically ill patients (acceptable indications: critical illness, obstruction, hospice, perioperatively for <2 days for urologic procedures; use weights instead to monitor diuresis). • Society of Hospital Medicine (SHM)

37. Summary: Choosing Wisely helps providers fulfill their ethical obligation to: • Offer therapies with evidence supporting their effectiveness in helping patients achieve their goals • Recommend against therapies with evidence demonstrating a lack of effectiveness

38. Online References • Choosing Wisely site • http://www.choosingwisely.org/ • AAHPM’s Choosing Wisely page • http://www.aahpm.org/advocacy/default/choosing-wisely.html • NHPCO Choosing Wisely page • http://www.nhpco.org/press-room/press-releases/choosing-wisely%C2%AE-campaign