Defining and reforming end of life care l.jpg
This presentation is the property of its rightful owner.
Sponsored Links
1 / 24

Defining and Reforming “End of Life” Care PowerPoint PPT Presentation


  • 93 Views
  • Uploaded on
  • Presentation posted in: General

Defining and Reforming “End of Life” Care. For the Citizen’s Working Group on Health Care Reform Boston, Mass., August 17, 2005 Joanne Lynn [email protected] Why target “end of life” care to reform health care policy?.

Download Presentation

Defining and Reforming “End of Life” Care

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Defining and reforming end of life care l.jpg

Defining and Reforming “End of Life” Care

For the Citizen’s Working Group on Health Care Reform

Boston, Mass., August 17, 2005

Joanne Lynn

[email protected]


Why target end of life care to reform health care policy l.jpg

Why target “end of life” care to reform health care policy?

  • It’s big – probably about 1/3 of lifetime expenses, and most of the lifetime’s suffering with ill health

  • It’s bad – care is unreliable, often harmful

  • It’s ugly – no political leadership yet has the will to confront the challenges of frailty, dementia, caregiver burden, supportive housing, impoverishment


Slide3 l.jpg

By permission of Johnny Hart and Creators Syndicate, Inc.


How americans die a century of change l.jpg

How Americans Die: A Century of Change

19002000

Age at death46 years78 years

Top CausesInfectionCancer

AccidentOrgan system failure

ChildbirthStroke/Dementia

Disability Not much 2-4 yrs before death

Financing Private, Public and substantial- modest 83% in Medicare ~½ of women die in Medicaid


Slide5 l.jpg

Good Models to Predict Survival Time Show Remarkable Ambiguity Near Death

1.0

0.8

Congestive heartfailure

0.6

Median 2-month Survival Estimate

0.4

Lung cancer

0.2

0.0

7

6

5

4

3

2

1

Medians of Predictions Estimated from Data on These Days before Death


Severity of illness not prognosis l.jpg

Severity of Illness, not Prognosis

  • Prognosis often uncertain, right up to the end of life

    • Median patient with serious chronic heart failure has 50-50 chance to live 6 months on the day before death

  • Severity of patient condition dictates needs

  • Most patients need both disease-modifying treatments and help to live well with disease


  • Slide7 l.jpg

    Time

    Old Concept

    death

    Treatment

    Aggressive Care

    Palliative Care


    Slide8 l.jpg

    Time

    Better Concept

    death

    Disease-modifying “curative”

    Treatment

    Symptom management “palliative”

    Bereavement


    Slide9 l.jpg

    Most health care provision has been organized

    by program/site

    Hospital Doctor’s office Nursing home Hospice etc.

    The Center to Improve Care of the Dying


    Slide10 l.jpg

    Most medical knowledge has been organized by disease

    Hypertension

    Diabetes

    Stroke

    Alzheimer’s Dementia

    etc.

    The Center to Improve Care of the Dying


    Slide11 l.jpg

    Quality = performance in one setting, one disease

    Service

    category

    Medical

    category

    Hospital Doctor’s office Nursing home Hospice etc.

    Hypertension

    Diabetes

    Stroke

    Dementia

    etc.

    But people with serious chronic illness have

    multiple diagnoses and need multiple service settings

    The Center to Improve Care of the Dying


    Slide12 l.jpg

    Divisions by Health Status in the Population

    Group 2

    “Healthy,” needs acute and preventive care

    Chronic, not “serious”

    Group 1

    Group 3

    Chronic, progressive, eventually fatal illness


    Target population for better end of life care l.jpg

    Target population for better “End of Life Care”

    • Very sick (disabled, dependent, debilitated)

    • Generally getting worse

    • Will die without a period of being well again

    • Most likely will die from progression of current illness(es)


    Slide14 l.jpg

    Figure 1. Divisions by Health Status in the Population and Trajectories of Eventually Fatal Chronic Illnesses

    Divisions in the Population

    Major Trajectories near Death

    A

    Group 2

    “Healthy,” needs acute and preventive care

    Chronic, not “serious”

    Group 1

    Group 3

    B

    Chronic, progressive, eventually fatal illness

    C


    Medicare decedents l.jpg

    Sudden 7%

    Other 9%

    Cancer 22%

    Frail 46%

    Heart and Lung Failure 16%

    Medicare Decedents


    Medicaring proposal core elements l.jpg

    MediCaring Proposal – Core elements

    • Eligibility – thresholds of severity

    • Services –

      • comprehensiveness

      • continuity

      • mostly at home

  • Coverage – includes capitation or salary/budget

  • Quality - measured and reported


  • Medicare coverage of services contrasted with importance to end of life patients l.jpg

    Medicare Coverage of Services,Contrasted with Importance to “end of life” Patients

    Medicare Covers Well

    – But Less Important

    Medicare Mostly Does Not Cover

    – But Very Important

    Care Coordination

    Self-care

    Medications

    MD at home

    Nursing care at home

    Hospitalization

    ER/ambulance

    MD in office

    MD in hospital

    Diagnostic tests


    Slide21 l.jpg

    “Every system is perfectly designed

    to get the results

    it gets”

    -----from P. Bataldin

    The Center to Improve Care of the Dying


    Slide22 l.jpg

    Surprises

    Symptoms

    Gaps

    What Good Care Systems Should PROMISE

    Correct Rx

    Help to live fully

    Customize

    Family Role


    Slide23 l.jpg

    Population Characteristics

    Priority Concerns

    1. Healthy

    Stay well

    2. Chronic condition

    Prevent or delay progression

    3. Maternal and infant

    Safe start

    4. Stable, disabled

    Life opportunities

    5. Acutely ill

    Get well

    6. EOL, short decline near death (mostly cancer)

    Symptoms, Dignity, Control,

    Life closure, Reliability

    7. EOL, intermittent exacerbations with sudden dying (mostly heart/lung failure)

    Avoid episodes, Longevity, Control Rx, Support carers

    8. EOL, long dwindling course (mostly frailty and dementia)

    Carer support, Dignity, Skin integrity, Mobility, Housing


    Changing policy and practice l.jpg

    Changing Policy and Practice

    • Require continuity, 24/7, advance planning

      • Conditions of participation or enhanced payment

    • Value comfort and control

      • Reporting for quality

    • Enhance relationships, closure, spirituality

      • Reporting for quality

    • Support family and paid direct caregivers

      • Financial security, health insurance, training


  • Login