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Palliative Care Interdisciplinary Curriculum

Palliative Care Interdisciplinary Curriculum. A Joint Initiative of the Palliative Medicine Faculty & Staff of.

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Palliative Care Interdisciplinary Curriculum

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  1. Palliative Care Interdisciplinary Curriculum A Joint Initiative of the Palliative Medicine Faculty & Staff of We gratefully acknowledge the support ofAward Number R25CA134309 from the National Cancer InstituteThe content is solely the responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute or the National Institutes of Health

  2. Palliative Care is… Hospice Care is… Frank D Ferris, MD, FAAHPM, FAACE

  3. Objectives • Modern illness experience • What are palliative & hospice care • Value of early referral

  4. Main Message Early referral to palliative & hospice care, delivers higher value & safety…

  5. Success of Modern Medicine…

  6. Illness in thePast . . .

  7. Prior to Antibiotics Health Status Sudden, Unexpected • infections • accidents • adults lived into their 60s Death Time Adapted from Lunney JR et al. JAMA, May 14, 2003—Vol 289, No. 18 2387-92

  8. 1940s - 1980s Health Status Decline Prolonged Dying • predictable decline Death Time Adapted from Lunney JR et al. JAMA, May 14, 2003—Vol 289, No. 18 2387-92

  9. Illness in2016 . . .

  10. Disease, Aging in 2016 • Sometimes cured • Most often controlled • Life expectancy 20 - 30 yr. • Canada ≈ 81.8 yr. • USA ≈ 79.7 yr. • World ≈ 68.3 yr.

  11. Cancer Health Status Decline with dependence for2 – 3 months Death Time Adapted from Lunney JR et al. JAMA, May 14, 2003—Vol 289, No. 18 2387-92

  12. Kit, 58 year oldPeripheral lung mass onroutine chest x-ray • Wants best treatment for her cancer • Wants to be comfortable, with family

  13. Kit: Surgery • Subtotal pneumonectomy • Adenocarcinoma • Metastatic workup:No evidence other cancer • Post-thoracotomy pain syndrome • Opioids + adjuvants to control pain

  14. What does Kit need ?

  15. Multiple Issues Cause Suffering Psychological • Anxiety • Depression • Distress Physical • Pain, dyspnea & other symptoms • Function, fluids, nutrition Disease Management • Diagnosis • Prognostication • Management Loss, grief • Emotional responses • Bereavement Social • Family dynamics • Financial • Legal End of life / death management • Last hours of living • When death occurs Practical • Caregiving • Teamwork • Volunteers Spiritual • Hope • Meaning, value • Existential

  16. Who is Affected

  17. Martha, 76, Pulmonary Fibrosis … What does Martha need ? What are the Clinicians thinking ? Dr. Charles von Gunten, OhioHealth

  18. Debrief… Martha… What does Martha need ? What are the Clinicians thinking ? Dr. Charles von Gunten, OhioHealth

  19. Organ Failuree.g., CHF, COPD, Renal, Liver Decline withdependence for months – years Health Status Crisis Death Time Adapted from Lunney JR et al. JAMA, May 14, 2003—Vol 289, No. 18 2387-92

  20. Dementia Health Status Decline with dependence foryears Death Time Adapted from Lunney JR et al. JAMA, May 14, 2003—Vol 289, No. 18 2387-92

  21. Why Did Kit and Martha come to the Healthcare system ? Normal path of life with an anticipated future Illness path withan uncertain future Help me fixmy broken story( Brody )

  22. Patients & Families Want… • Live life the way they want to • ‘ Fix ’ disease, or not • Prevent and relieve suffering, or not • Don’t do treatments they don’t want • Negotiate goals for • Life • Medical care

  23. Death in North America • 90% want to die at home ( NHO Gallup survey ) • 25 % die at home • 75 % die in institutions( Teno et al, 1997 ) • 2 / 3 in hospitals • 1 / 3 in nursing homes • 90% believe it is a family responsibility to provide care to a loved one

  24. What do Youwant your illness experience to be ?

  25. Patterns of Functional Declineat the End of Life 1 – Organ Failure 2 – Dementia 4 – Sudden Death 3 – Cancer Lunney JR et al. JAMA, May 14, 2003—Vol 289, No. 18 2387-92

  26. Where Would You Like to Receive Your CareWhen You are Dependent ? • Acute care • Long-term care • Home

  27. Palliative Care is…

  28. Palliative Care is… • Prevent & relieve suffering • Promote quality of life and death • Any diagnosis • Any time there is need Adapted From: Ferris FD, Balfour HM, Bowen K, Farley J, Hardwick M, Lamontagne C, Lundy M, Syme A, West P. A Model to Guide Hospice Palliative Care. Ottawa, ON: Canadian Hospice Palliative Care Association, 2002.

  29. Historical Perspective End-of-LifeCare Anti-disease Therapy Presentation 6m Death BereavementCare

  30. Palliative Care 2016  2026 End-of-Life Care Anti-disease Therapy Palliative Care Presentation 6m Death Therapies to relieve suffering and / or improve quality of life BereavementCare

  31. Domains of Care Diseasemanagement Physical Psychological Loss, grief Social End of life / death management Practical Spiritual

  32. Interdisciplinary Care Nurse Spiritualcounselor Volunteers Family Psychologist Doctor Patient Pharmacist Community Socialworker Physiotherapist Bereavementcounselor

  33. H OS P I T AL ICUs Office DAY AcuteCare Home InpatientUnit Other, eg, Jails Long-TermCare SpecializedUnits InpatientUnit

  34. Fact Our ability to relieve the pain, symptoms and the distress of serious illness has never been greater

  35. Goals of Palliative Care Help to • Eat well • Sleep well • Maintain function • Reducestress • Live better • Live longer “ Add life to daysand days to life ”

  36. Hospice Care is…

  37. Hospice Care is… End-of-Life / Hospice Care =Enhanced Palliative Care Anti-disease Therapy Hospice Care Presentation 6m Death Therapies to relieve suffering and / or improve quality of life BereavementCare

  38. In the USA Since 1982, Hospice Care is • Medicare insurance benefit • Carved out of Medicare Part A • Adopted by • Medicaid • Commercial insurers

  39. Eligibility • 2 physicians certify • Referring physician • Hospice medical director “ I believe the patient has a prognosis of ≤ 6 months if the illness runs its normal course ” ‘ More likely than not ’= 51 % probabililty

  40. Benefit Periods Initial Certification2 physiciansReferringHospice Medical Director F2F F2F F2F F2F Unlimited60 d 60 d 90 d 60 d 60 d 90 d Recertification1 physicianHospice Medical Director

  41. Medicare Hospice Benefit includes… • Patients & their families • Treat & prevent issues that cause suffering • Promote quality of life during illness & bereavement • Facilitate transitions • Achieve full potential – finish life story • Rebuild lives

  42. Medicare Hospice Benefit includes… • Services • Skilled nursing • Medical counseling • Chaplaincy • Healthcare Aides • Volunteers • 24 hr Triage • Bereavement support ≥ 13 months • Medications / therapies • Medical equipment • Supplies • Palliative Medicine physicians

  43. …Medicare Hospice Benefit in Central Ohio • Routine care ~ $150 / day • Respite care ( 5 days ) ~ $150 / day • Continuous care ( crises ) ~ $800 / day • Home • Extended care facility • General Inpatient Care ( GIP ) ~ $800 / day • Hospice • Hospital

  44. Value of early Palliative Care…

  45. Quality Value = Cost Safety = minimize risk of harm& don’t Rx without benefit

  46. Key Elements of Palliative Care • Communication & negotiation ofgoals of life & care • Symptom management • Distress

  47. How Much Palliative Care ? Acute Last Daysof Life Recurrence IncreasedDebility Chronic Death Presentation Respite

  48. Impact of COPD Pilot Program39 % Reduction in Re-hospitalizations

  49. 2010

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