Applications for Palliative Care Program and Consults for Symptom Management June 2013

1. Applications for Palliative Care Program and Consults for Symptom Management June 2013 Lori Embleton, Program Director WRHA Palliative Care Program

2. Palliative Care Program Two streams of service delivery: • Registration on Program • Consultative Services

3. Registration on Program Once accepted/registered with the program, patients are eligible for: Case management through Palliative Care Coordinator Access to Community Palliative Care Team Nurses, Physicians, Psycho-social support Admission to Palliative Care Units (PCU) and Hospice – if bed available Enrollment on Provincial Palliative Care Drug Access Program

4. Registration on Program Criteria for application and registration on Palliative Care Program: Prognosis of less than 6 months No longer receiving aggressive treatment which requires on-going monitoring for and treatment of serious complications Have chosen a comfort-focused approach including a decision to decline attempted resuscitation

5. Consider Application for Registration on Palliative Care Program when: • Discharge home is being considered for palliative patient • Discharge to LTC setting is being considered for palliative patient: • PCH vs Hospice as discharge options • Palliative patient has care needs that may necessitate transfer to Palliative Care Unit

6. How to Register a Patient on Palliative Care Program • Complete the “Application for Registration” form • 2 page form • “Completed” forms can be processed more quickly • Completed application forms do not mean that a member of the Palliative Care team will come to see the patient • Completed forms are reviewed by PC coordinator • May ask for PC team assessment re eligibility • Accepts on to Program – letter of acceptance sent to unit • Rejects application – all reviewed by Manager, Program Director or Medical Director

7. Consultative Services Available to any patient with a life limiting illness (even if still pursuing active Tx) in any care setting for: symptom management psycho-social support discussions regarding goals of care assistance with discharge planning **If you wish Palliative care team to assess patient/meet with family – a consult must be initiated

8. Consultative Services Consultation services are provided by inter-professional team members (individually or as a team, depending on need): Palliative Care Physician Palliative Care Clinical Nurse Specialist Psycho-social Support Specialist

9. Consider consulting palliative care for: • Assistance with symptom issues • MD to MD consults for advice 24/7 • Assistance with care planning • What might care team expect as patient nears end of life? • Could symptoms escalate? • Will oral route be available? • What plans need to be made to address symptom needs

10. Consider consulting palliative care when: • Clarifying goals of care: • Discrepancy between patient, family and/or members of care team with plan of care • Discharge to community or LTC is anticipated • Does patient need to be or are they currently “registered” on Palliative Care program? • Would it be appropriate for Palliative Care nurse to see the patient in the community?

11. When should Palliative Care NOT be consulted? • Patients with chronic or acute pain issues outside of the context of a life-limiting illness • Patient and/or family not in agreement with palliative consult

12. What information is needed on consult? • Main reason for consult • What is the main symptom issue? • Urgency of consult • Is the physician aware of the consult?

13. How to Contact Palliative Care • All consults should be directed to Palliative Care Program (Staff available during business hours) 204-237-2400 • After business hours MD to MD consults available 24 hours a day – access Palliative Care physician on call through SB paging 204-237- 2053

14. Case studies

15. Mrs. Jones is 84 years old. She presented at SOGH ED with rectal bleeding related to a known carcinoma. Since admission, the bleeding has resolved. It has been determined during hospitalization, that no further treatment options are available. The patient feels she has good quality of life but realizes her condition is not treatable. Her condition has now stabilized and discharge options are being considered. Prior to admission, she had been living alone at home but she and her family do not believe that she will be able to return home. A family meeting has been arranged to discuss discharge options. Should Palliative Care be consulted?

16. Palliative Care could be consulted to: • Attend family meeting to discuss discharge options in keeping with patient’s current condition and expected prognosis • Stay in facility • Home • Hospice • PCH

17. Once discharge plan is confirmed, palliative care team would be involved in planning for care • If discharge is not possible, could assist with EOL planning • If discharge home is possible, patient would need to be registered on Palliative Care program and home care services in place to support patient and family • If hospice is possible, patient would need to be registered on Palliative care program and the palliative care team would assist in transition to hospice • If discharge to LTC is possible, patient would need to be registered on Palliative Care Program and the palliative care team would assist in the transition to PCH

18. Mr. Smith is a 56 year old man who presented to emergency with ascites that has been causing shortness of breath and interfering with mobilization. He states he has a “growth on his liver” but has not seen the “cancer” doctor yet. He lives alone and his family (daughter) is very concerned about his ability to manage at home as he has been progressively getting weaker. Both patient and family want active treatment (chemo) if possible. In ED, a paracentesis is performed and the patient wants to go home. Should palliative care be consulted?

19. Palliative care could be consulted for this patient • The patient has not been seen by oncology and treatment options have not been reviewed so application for program is not appropriate at this time. • Home care should be consulted for this patient as family has concerns about his ability to manage at home • Palliative Care nurse can be requested to see patient at home as part of the home care plan to assist with symptom issues and facilitate transition to Palliative Care when appropriate.

20. Mrs. Doe is a 75 year old woman who was admitted from ED with pain. She has a multiple chronic disease conditions including hypertension, mild COPD, diabetes and osteoarthritis. She has been seen previously in the Pain Clinic for pain related to her arthritis. She lives at home with her husband who also has health issues. The family has been receiving services from home care but Mrs. Doe frequently presents to ED because of health concerns. Since admission, her pain has not been well controlled. Should Palliative Care be consulted?

21. Palliative Care should not be consulted in this case: • Mrs. Doe’s pain is chronic in nature • The family is known to home care, but continues to present to ED. Prior to discharge, home care should be consulted to review the care plan and augment services and case management as needed.

22. Consult Service Community Palliative Nursing • Case Coordinator • Admission Eligibility • Medication Coverage • comfort-focused • prognosis “6 mo. or less” • some treatment limitations(DNAR, no TPN, no chemoTx with high adverse effects • aggressive, often toxic treatment focused on cure or life-prolonging disease modification Diagnosis of Life-Limiting Illness Transitioning to Palliative Palliative

23. Questions?