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Suffering at End of Life: Michigan Status Report & Recommendations. Kay Presby MPH RN Pain & Symptom Management Committee 02.08.07. Data Sources. 2004 EOL Needs Assessment 50 Stakeholder & 57 hospice mgr interviews 2002 Michigan Resident Death File

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Suffering at End of Life: Michigan Status Report & Recommendations

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Suffering at end of life michigan status report recommendations l.jpg

Suffering at End of Life:Michigan Status Report& Recommendations

Kay Presby MPH RN

Pain & Symptom Management Committee 02.08.07


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Data Sources

  • 2004 EOL Needs Assessment

    • 50 Stakeholder & 57 hospice mgr interviews

    • 2002 Michigan Resident Death File

  • 2004 Special Cancer Behavioral Risk Factor Survey, EOL Module

    • Even years, phone, MPHI & MSU IPPSR

  • 2006 Census of Hospital-Based Palliative Care Programs

Pain & Sx Mgt Commiittee 02.08.07


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Project Sponsors

  • Michigan Dept of Community Health

  • Michigan Public Health Institute

  • Michigan Hospice & Palliative Care Organization

  • Michigan Cancer Consortium

Pain & Sx Mgt Commiittee 02.08.07


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Good News

Infrastructure

  • Expert professionals

  • Model programs

  • Palliative care teams

A

EOL Pain Policy

Pain & Sx Mgt Commiittee 02.08.07


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Location of Hospital-Based PC Teams

Pain & Sx Mgt Commiittee 02.08.07


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Good News

Infrastructure

  • Expert professionals

  • Model programs

  • Palliative care teams

    Public Awareness

  • 90% aware of hospice

  • 60% use hospice

A

EOL Pain Policy

Pain & Sx Mgt Commiittee 02.08.07


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Disappointing News

  • Policy has had little impact on practice.

  • Hospice length of service is dropping.

    • 1/3 die before one week

    • Median LOS is 18 days

      Needless suffering still is widespread in Michigan.

Pain & Sx Mgt Commiittee 02.08.07


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Michigan Commission on EOL Care, 2002

Stakeholders, 2004(n=50)

“The lack of effective pain and symptom management is a public health issue that requires the highest level of professional and regulatory attention.”

80% named eliminating unnecessary suffering as the top end of life priority.

Who says so?

Pain & Sx Mgt Commiittee 02.08.07


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Hospice managers, 2004

Patients & families, 2004

90% ~ Pain management is a problem in their service area.

48% ~ At least half of patients admitted in severe pain (6+).

Why not before?

Why doesn’t anyone else know?

How could you do this so quickly?

Who says so?

Pain & Sx Mgt Commiittee 02.08.07


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Place of Death by Age, Michigan 2002

Michigan Resident Death File, 2002

Pain & Sx Mgt Commiittee 02.08.07


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Distribution of Decedents, Any Terminal Illness, by Site & Avg Pain Level for Final 3 Months,MI 2004 BRFS

Pain & Sx Mgt Commiittee 02.08.07


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87,500

61,250

23,275

Average annual count of deaths in Michigan

70% die of chronic disease

38% live their final 3 months with severe to excruciating pain, as reported by caregivers

Back of the envelope…

Pain & Sx Mgt Commiittee 02.08.07


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Pain & Sx Mgt Commiittee 02.08.07


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Pain & Sx Mgt Commiittee 02.08.07


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The person in pain today

does not have to wait

for a better drug

to be developed ~

he just needs someone

to prescribe correctly

what we already know.”

(Joanne Lynn, MD, 2000)

Goldie ~ Detroit metro

Tom ~ western Mich

Henry ~ mid Michigan

James ~ northern MI

Colleen ~ thumb

Put a face on the suffering…

Pain & Sx Mgt Commiittee 02.08.07


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Invisible to Health Care System?

  • Not according to Wennberg study of intensity of services during final 6 mos for Michigan Medicare decedents in 1995-96:

    • 15% to 45% were admitted to ICU

    • Average no. of physician visits: 16 to 34

    • Up to 33% saw 10+ physicians

      Dartmouth Atlas of Health Care in Michigan, 2000; http://www.bcbsm.org

Pain & Sx Mgt Commiittee 02.08.07


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Then why the suffering?

Input from interviewed hospice managers (n=57):

90%Protocol doesn’t fit type or intensity of pain ~ wrong drug, dose, frequency

70%Lack of clinician knowledge re: opioid drugs

& dosing, atypical pain; RN reluctance

30%Pain med not taken as directed

10%Side effects, fear of addiction

End of Life in Michigan, Needs Assessment Report, 2005

Pain & Sx Mgt Commiittee 02.08.07


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Critical Issues to Address

  • Undertreatment of pain has not been embraced as an urgent problem in Michigan.

  • Clinicians can’t do what they don’t know.

  • Hospitals are slow to embrace palliative care as a clinical and business priority.

  • Nursing homes struggle with pain mgt and hospice is not often used.

  • Consumers expect to suffer. They don’t know that pain is optional at the end of life.

Pain & Sx Mgt Commiittee 02.08.07


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Key Recommendations

  • Public Health Administration

    • Establish an end-of-life unit within the Division of Chronic Disease and Injury Control to:

      • Monitor population needs

      • Foster alliances and convene partners for coordinated action

      • Organize and galvanize statewide action

      • Coordinate action among state units

Pain & Sx Mgt Commiittee 02.08.07


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Key Recommendations

  • Bureau of Health Professions:

    • Require CME in pain mgt for license renewal.

    • Adopt the 2004 FSMB model pain policy.

  • Bureau of Health Systems:

    • Require access to hospice services in all nursing homes.

    • Establish an M-tag for pain management.

Pain & Sx Mgt Commiittee 02.08.07


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Key Recommendations

  • Medical Services Administration:

    • Assure coverage and reimbursement for hospice and palliative care services by all health plans.

    • Require access to palliative care consults in network hospitals; board-certified physicians (ABHPM) and nurses preferred (CHPN, BCPCM).

  • Division of Chronic Disease & Injury Control

    • Wage a sustained community organization campaign to prepare consumers to expect and demand effective pain control.

Pain & Sx Mgt Commiittee 02.08.07


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Essential Strategies

  • Make it easy to do the right thing

    • Systems

  • Give the policy teeth

    • Consequences

  • Make a plan and assure action

    • Communicate, implement, sustain, monitor

Pain & Sx Mgt Commiittee 02.08.07


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End-of-Life Needs Assessment Report

Available online at the Michigan Cancer Consortium website ~

http://www.michigancancer.org/OurPriorities/EndOfLifeCare_InformationForProviders.cfm

Pain & Sx Mgt Commiittee 02.08.07


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