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Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center

Dying in America A Generation’s Crisis and Opportunity. Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005. Reasonable Expectations . Routine assessment and competent treatment of pain & physical distress

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Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center

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  1. Dying in America A Generation’s Crisis and Opportunity Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005

  2. Reasonable Expectations • Routine assessment and competent treatment of pain & physical distress • Clear, complete & honest communication • Respect for people’s stated preferences • Coordination of care • Crisis prevention and management • Safe & prudent staffing ratios for nurses and CNAs • Support for family caregivers • Support for families in grief

  3. Awash in Information, Patients Face a Lonely, Uncertain Road Jan Hoffman New York Times, August 14, 2005 Photo: Nicole Bengiveno

  4. Institute of Medicine Dimensions and Deficiencies I. Too many people suffer needlessly at the end of life, both from errors of omission and from errors in commission II. Legal, organizational, and economic obstacles conspire to obstruct reliably excellent care at the end of life. Approaching Death Nat’l Academy Press, 1997

  5. Institute of Medicine Dimensions and Deficiencies III. The education and training of physicians and other health care professionals fail to provide them the attitudes, knowledge, and skills required to care well for the dying patient. IV. Current knowledge and understanding are insufficient to guide and support the consistent practice of evidence-based medicine at the end of life. Approaching Death Nat’l Academy Press, 1997

  6. Will We Ever Arrive At the Good Death? Robin Marantz Henig New York Times Magazine, August 7, 2005 Photo: Nicholas Nixon

  7. These may be the “Good Old Days”

  8. Indicates the Baby-Boom Group 1980 1990 2000 80 80 70 70 60 60 50 50 40 40 30 30 20 20 10 10 10 5 0 5 10 10 5 0 5 10 10 5 0 5 10 Millions of Persons The Graying of America Changing U.S. Age Distribution SOURCE: AMARA et. al., Looking Ahead at American Health Care (1988)

  9. The Shrinking Pool of Caregivers 1990 11 to 1 2010 10 to 1 2030 6 to 1 2050 4 to 1 www.dyingwell.org

  10. USA Today December 13, 2000

  11. Where We Die “Nearly half of Americans who live to 65 years of age will enter a nursing home before they die.” Zerzan J, Stearns S, Hanson L Access to Palliative Care and Hospice in Nursing Homes JAMA 2000 Nov 15, 284(19) 2489-2494

  12. The Washington Post Magazine June 9, 2002

  13. “More than 90 percent of the nation's nursing homes have too few workers to take proper care of patients, a new federal study has found.” 9 of 10 Nursing Homes Lack Adequate Staff, Study Finds by Robert Pear, New York Times February 18, 2002 A1 Deidre Scherer collection

  14. The Coming Crisis in Nursing Millions Source: Projections by Division of Nursing BHPr, HRSA, USDHHS, 1996

  15. USA Today

  16. Nursing homes and public opinion • “Eighty-three percent of elderly Americans would stay in their homes until the end if they could. Thirty percent say they’d rather die than go into a nursing home.” CBS News February 27, 2001

  17. This is one crisis we can solve!!! Deidre Scherer collection

  18. …and we are already spending enough money Robert Pope collection

  19. Hospice and Palliative Care Palliative Care Hospice Care

  20. Program Coord. Hospice RNs Medical Director Volunteer Coordinator Pharmacist Patient & Family Hospital Nursing Resp. Therapy Hospital SW-Discharge Planner Pastoral Care Social Worker Dietician Palliative Care Interdisciplinary care for persons with life-threatening illness or injury which addresses physical, emotional, social and spiritual needs and seeks to improve quality of life for the ill person and his or her family. www.dyingwell.org

  21. Sequential Model “Curative” followed by “Palliative” Care Curative & Life-Prolonging Treatment Hospice Medicare Hospice Benefit Diagnosis 6 month prognosis

  22. Concurrent Care “Curative” or Disease-modifying Treatment Diagnosis Death Palliative Care

  23. Promoting Excellence in End-of-Life Care A national program of The Robert Wood Johnson Foundation

  24. University of Michigan Cancer Center Henry Ford Health System Dartmouth-Hitchcock Norris Cotton Cancer Center Univ of Chicago Medical Center Children’s Hospital and Regional Medical Center Mass. Mental Health Case Western Reserve Univ. Promoting Excellence in End-of-Life Care UC Davis, Cancer Center Baystate Medical Center VNA. & Hospice of No. Calif Mount Sinai School of Medicine U. PA. School of Nursing UC San Francisco Volunteers of America Department of Veterans Affairs; West Los Angeles Medical Center Hospice of the Valley Medical U. of So. Carolina Cardinal Glennon Children’s Hospital U. New Mex, Louisiana State University Medical Center Cooper Green Medical Center Bristol Bay Area Health Corporation

  25. Typical Services of Palliative Care • An interdisciplinary team • 24/7 availability • Ongoing communication • Advanced care planning • Formal symptom assessment & treatment • Crisis prevention & early crisis management • Care coordination • Spiritual care • Anticipatory guidance • Bereavement support

  26. Access Costs Quality Promoting Excellence in End-of-Life Care • It is possible to • ExpandAccess • ImproveQuality • ControlCosts www.PromotingExcellence.org

  27. Promoting Excellence Monographs www.PromotingExcellence.org

  28. Promoting Excellence Monographs www.PromotingExcellence.org

  29. Goals of Palliative Care Alleviation of symptoms and suffering are our first priorities…

  30. Goals of Palliative Care … but they are not the ultimate goals.

  31. Bill Bartholome

  32. Bill Bartholome

  33. Preserving Opportunity • Communicating • Completing affairs & relationships • Resolving relationships • Grieving • Reviewing life, exploring meaning & purpose • Exploring spiritual & transcendent realms www.dyingwell.org

  34. Completing Relationships Saying “TheFour Things That Matter Most” “Please forgive me” “I forgive you” “Thank you” “I love you” www.dyingwell.org

  35. Dying Well – Family Perspective •  Ensuring the “best care possible” •  Feeling that preferences were followed •  Knowing the person was treated in a dignified manner • A chance to say and do the things “that matter most” •  Honoring and celebrating the person in his/her passing •  A chance to grieve together www.dyingwell.org

  36. Public policies can’t do everything, but they can… • Ensure adequate staffing and living wages for aide-level workers in long term care • Insist on adequate training of physicians, nurses & clinicians society employs and relies on • Encourage innovation in health service delivery promoting a continuum of care • Decrease barriers to effective pain management

  37. Public policies can’t do everything, but they can… • Eliminate the arbitrary distinction between “curative” and palliative care • Insist on accurate accounting of costs • Empower consumer and citizen expectations • Encourage community-based responses • Foster cultural maturation of a healthy conclusion to life

  38. More information available at www.PromotingExcellence.org www.DyingWell.org www.ChoicesBank.org www.Lifes-End.org

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