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

Choosing Wisely : Five Things Physicians and Patients Should Question About Palliative Care. Gregg VandeKieft, MD, MA HOPE of Wisconsin Annual Conference November 13, 2013. Disclosure. Dr. VandeKieft does not have any conflicts of interest to disclose. Public Service Announcement.

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

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  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.

  13. 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

  14. 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

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

  16. 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

  17. 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

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

  19. 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.

  20. 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

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

  22. 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

  23. 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

  24. 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

  25. 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)

  26. 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)

  27. 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

  28. 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)

  29. 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)

  30. 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)

  31. 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)

  32. 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)

  33. 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)

  34. 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)

  35. 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

  36. 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

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