Capital Region Family Medicine Conference September 8, 2012

1. Capital Region Family Medicine ConferenceSeptember 8, 2012 Primary Palliative Care

2. Diagnosis ------- Chronic Illness ---- Death Curative Efforts --------------------- Life Prolonging Measures ---------------------------------------- Palliative Care (Hospice) ---------------------------------------------------------------- Russell Portnoy, MD

3. All of hospice is palliative care, but not all of palliative care is hospice Palliative Care Hospice

4. “ The American College of Chest Physicians strongly supports the position that palliative and end-of-life care of the patient with an acute devastating or chronically progressive pulmonary or cardiac disease and his/her family should be an integral part of cardiopulmonary medicine.” Chest 2005 / VJ Vanston AAHPM 2010

5. Newly dx’d ambulatory metastatic non-small cell lung cancer MGH Standard treatment vs. Standard treatment + palliative care Intervention group • better QOL scores • lower rates of depression • 2.7 month survival benefit • less chemotherapy Temel, et al NEJM Aug. 2010

6. 40% report acute and chronic pain at levels similar to patients with cancer • 23% report neuropathy, fatigue, depression, sleep disturbance “Diabetes care management should include not only good cardiometabolic control, but also symptom palliation across the disease course.” J General Internal Medicine Aug 2012

7. Palliative Care Skill Set Advance care planning Addressing Suffering Establishing patient-centered / realistic goals of care Appropriate level (setting) of care Coordination of care

8. Hospital based interdisciplinary teams – physician, NP, nurse, social worker, pastoral care

9. Case Study #1 88 year old female Dementia, HBP, osteoporosis, hyperlipidemia, anemia, arthritis, impaired nutrition Assisted living facility June 2008 sent to ER for increased confusion MRI/Neuro consult/ EEG/ carotid US Iron, Nexium, Norvasc, Fosamax, Zocor, Folic Acid, Levaquin, Aricept, Aspirin

10. Sept 2008 returns to ER for lethargy vomited digested blood and aspiration pneumonia GI consult EGD – severe esophagitis Pulmonary consult CT, thoracentesis IV antibiotics Zocor, Aricept, Nexium, Cardiezem, Norvasc, Fosamax

11. November 2008 Sent to ER for lethargy and anemia Contracted, minimal verbalization 4 large pressures sores Urinary tract infection

12. Family contacted HC Proxy and Living Will Comfort and Returning to Community Stopped Fosamax, Zocor Started RTC pain medicine, Wound care Allowed to eat as tolerated NonHospital DNR Hospice referral

14. Medicine used to be simple, inexpensive, and relatively safe. Now its complex, effective, and potentially dangerous. Sir Cyril Chantler

15. Hospitalization-Associated Disability Covinsky, Pierluissi, Johnston JAMA October 2011 “occurs in approximately one-third of patients older than 70 years of age and may be triggered even when the illness that necessitated the hospitalization is successfully treated.”

16. Patient vulnerability and capacity to recover Age Poor mobility Cognitive function ADLs Social functioning Depression Geriatric syndromes (falls, incontinence) Severity of Illness Hospitalization Factors Environment Restricted mobility Enforced dependence Undernutrition Polypharmacy Little encouragement of independence Covinsky, Pierluissi, Johnston JAMA October 2011

17. Hospitalizations During Last 6 months of Life Medicare Patients 2007

18. The 4 Stages of Man

20. Percent of Decedents Admitted to ICU/CCU During the Hospitalization in Which Death Occurred 2007 Medicare Patients

21. Quality in healthcare is defined as: Patient-centered Timely Beneficial Equitable Safe Efficient National Quality Forum www.qualityforum.org Institute for Healthcare Improvement www.ihi.org

22. Don’t underestimate your role Let the patient set the agenda Encourage discussion and completion of advance directives “Hope for the best but be prepared for the worst”

23. Goals of Care Shift COPD 43% 1 year mortality rate after hospitalization for AECOPD with pCO2 > 50 CHF 17-20% 1 year mortality from dx Hip Fracture 25-30% 1 year Mortality rate, steady at over 50 years

24. For All Adults Health Care Proxy Form Living Will Organ Donation (optional) For Those Who Are Chronically Ill or Near the End of Their Lives Nonhospital Do Not Resuscitate (DNR) Order Medical Orders for Life Sustaining Treatment (MOLST) form Advance Care Directives

25. POLST/MOLST Communication Documentation System Responsiveness

26. Core Elements of MOLST Actionable medical orders Advanced, chronic progressive illness Limit or request all medically treatments Direction about resuscitation status Other types of intervention – future hospitalizations, tube feedings

27. POLST Research findings Oregon Effectively communicates requests for DNR, comfort measures Frail elderly make reasonable choices Not all or none (JAGS, J Gerontol Nurs 2000-2004) Oregon, W Virginia, Wisconsin Less likely to receive unwanted hospitalization and medical interventions (Hickman, JAGS July 2010)

28. POLST 2006 Paradigm of communication, documentation, and system responsiveness Paradigm of communication, documentation, and system responsiveness POLST Paradigm Program 2006POLST.org

29. POLST 2012 http://www.ohsu.edu/polst/programs/state+programs.htm accessed 4/2012

30. Slide courtesy of P Bomba, MD April 2012

33. Accepted in outpt settings but… Does NOT include DNI Does not cover additional Rx’s

34. Family Health Care Decisions Act 6/2010 • Extends family’s ability to make health care decisions for individuals without capacity who have not completed a Health Care Proxy • Applies for ALL treatments. . . not just DNR • Decisions are based on patient’s known wishes – if not known, then based on best interest of patient. • Hospital, long term care facilities, hospice patients (all locations)

35. FHCDA – Surrogate Hierarchy • Court-appointed guardian • Spouse (if not legally separated) or domestic partner • Son or daughter 18 or older • Parent • Adult Sibling • Close friend

36. shares a mutual intent to be a domestic partner with the patient such as: • They live together. • They depend on each other for support. • They share ownership (or a lease) of their home or other property. • Enrolled in a registry maintained by employer • They share income or expenses. • They are raising children together. • They plan on getting married or becoming formal domestic partners.

37. Palliative Care Information Act Public Health Law section 2997-c requires the "attending health care practitioner" to offer to provide patients with a terminal illness with information and counseling regarding palliative care and end-of-life options appropriate to the patient, including: Prognosis; Range of options appropriate to the patient; Risks and benefits of various options; Patient's "legal rights to comprehensive pain and symptom management at the end of life." http://www.health.ny.gov

38. Resources compassionandsupport.org MOLST, advance directives, patient/family friendly eperc.mcw.edu/EPERC/FastFactsandConcepts pain and symptom management, ethics, communication skills