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What Is a Palliative Care Consult Service?

What Is a Palliative Care Consult Service?. More importantly – What can it do for you ?. Palliative Care Consulting. Making the Case Services Rendered Staffing A Note of Caution The Role Of Acute Care Hospitals In Caring For the Dying. Why Palliative Care?.

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What Is a Palliative Care Consult Service?

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  1. What Is a Palliative Care Consult Service? More importantly – What can it do for you?

  2. Palliative Care Consulting • Making the Case • Services Rendered • Staffing • A Note of Caution • The Role Of Acute Care Hospitals In Caring For the Dying

  3. Why Palliative Care? • The sickest people congregate in hospitals • These people often feel a loss of control in their medical travails • Often they experience profound suffering • The people who care for them often experience tremendous burden, burnout • Hospitals and accreditation organizations recognize these struggles, want to do better

  4. What Do Patients with Serious Illness Want? • Pain and symptom control • Avoid inappropriate prolongation of the dying process • Achieve a sense of control • Relieve burdens on family • Strengthen relationships with loved ones Singer et al. JAMA 1999;281(2):163-168.

  5. National Data on the Experience of Advanced Illness in 5 Tertiary Care Teaching Hospitals The SUPPORT Study • Controlled trial to improve care of seriously ill patients • Multi-center study funded by RWJ • 9000 patients with life threatening illness, 50% died within 6 months of entry JAMA 1995;274:1591-98

  6. SUPPORT: Suffering and Costs, Phase I Results • Half of patients had moderate-severe pain >50% of last 3 days of life. • 38% of those who died spent >10 days in ICU.

  7. Self-Reported Symptom Experience of Critically Ill Cancer Patients Receiving Intensive Care Nelson JE, Meier DE, Oei EI et al. Crit Care Med 2001;29:277-282 75% 71% 68% 63% 56% 55% 39% 34%

  8. Pain Data from SUPPORT % of 5176 patients reporting moderate to severe pain between days 8-12 of hospitalization: colon cancer 60% liver failure 60% lung cancer 57% MOSF + cancer 53% MOSF + sepsis 52% COPD 44% CHF 43% Desbiens & Wu. JAGS 2000;48:S183-186.

  9. Physician Training in Pain Management Oncologists self-report: • 86% of their patients undermedicated • 50% rated pain management in their own practice as fair to very poor • 73% evaluated their own training in pain management as fair to very poor Von Roenn et al. Ann Intern Med 1993;Jul 15;119(2):121-6.

  10. Caregiving Needs Among Seriously Ill Persons Interviews with 900 caregivers of seriously ill persons at 6 U.S. sites • need more help: 87% of families • transportation: 62% • homemaking: 55% • nursing: 28% • personal care: 26% Emanuel et al. Ann Intern Med2000;132:451

  11. Caregiving Increases Mortality Nurses Health Study: prospective study of 54,412 nurses • Increased risk of MI or cardiac death: RR 1.8 if caregiving >9 hrs/wk for ill spouse Lee et al. Am J Prev Med 2003;24:113 Population based cohort study 400 in-home caregivers + 400 controls • Increased risk of death: RR 1.6 among caregivers reporting emotional strain Schulz et al. JAMA 1999;282:2215.

  12. Family Caregivers and the SUPPORT study Patient needed large amount of family caregiving: 34% Lost most family savings: 31% Lost major source of income: 29% Major life change in family: 20% Other family illness from stress: 12% At least one of the above: 55% JAMA 1995;272:1839

  13. What Do Family Caregivers Want? Study of 475 family members 1-2 years after bereavement • Loved one’s wishes honored • Inclusion in decision processes • Support/assistance at home • Practical help (transportation, medicines, equipment) • Personal care needs (bathing, feeding, toileting) • Honest information • 24/7 access • To be listened to • Privacy • To be remembered and contacted after the death Tolle et al. Oregon report card.1999 www.ohsu.edu/ethics

  14. Symptom Improvement for 3,707 Palliative Care Patients at Mount Sinai Hospital (6/97-12/04) Pain Nausea Severe Severe Mod. Mod. Mild Mild None None Shortness of Breath Anxiety Severe Severe Mod. Mod. Mild Mild None None Source: Patient Interviews, Mount Sinai Hospital, New York City

  15. Case 1. Mount Sinai Hospital, NYC:Improvement in Symptoms1997-2002: 2219 palliative care consult service patients Severe Pain Nausea Moderate Dyspnea Mild None

  16. High Satisfaction -Mount Sinai Hospital DataPercent of Palliative Care Families Satisfied or Very Satisfied with: • Control of pain - 95% • Control of non-pain symptoms - 92% • Support of patient’s quality of life - 89% • Support for family stress/anxiety - 84% • Manner in which you were told of patient’s terminal illness - 88% • Overall care provided by palliative care program- 95% Source: Post-Discharge/Death Family Satisfaction Interviews, Mount Sinai Hospital, New York City

  17. What Does All this Mean from the Patient Perspective? For patients, palliative care is a key to: • relieve symptom distress • navigate a complex and confusing medical system • understand the plan of care • help coordinate and control care options • allow simultaneous palliation of suffering along with continued disease modifying treatments (no requirement to give up curative care) • provide practical and emotional support for exhausted family caregivers

  18. The Clinician Perspective For clinicians, palliative care is a key tool to: • Save time by helping to handle repeated, intensive patient-family communications, coordination of care across settings, comprehensive discharge planning • Bedside management of pain and distress of highly symptomatic and complex cases, 24/7, thus supporting the treatment plan of the primary physician • Promote patient and family satisfaction with the clinician’s quality of care

  19. The Hospital Perspective For hospitals, palliative care is a key tool to: • effectively treat the growing number of people with complex advanced illness • provide service excellence, patient-centered care • increase patient and family satisfaction • improve staff satisfaction and retention • meet JCAHO quality standards • ration the use of hospital resources • increase bed/ICU capacity, reduce costs

  20. Summary • Palliative care improves quality of care for our sickest and most vulnerable patients and families. • Palliative care improves the ability of physicians to deliver high quality care to this difficult patient population • Palliative care saves the hospital time and money while improving overall patient satisfaction

  21. This is My Job Palliative Care Specialist at CPMC • Pain Management (Terminal or non-terminal) • End Of Life Counseling • Code Status Discussion • Prolonged ICU stays • Introduction to Hospice • Symptom Management • Dyspnea (CHF, COPD, malignancy) • Nausea/Vomiting • Pruritis (ESRD, ESLD) • Physician/House Staff Education

  22. My Colleagues • 1 Geriatrician • 1 Fellowship-trained Nurse Practitioner • 2 Oncology Clinical Nurse Specialists • Psychology Service • Health and Wellness • Massage Therapy • Acupuncture • Herbal Medicine

  23. In My Dreams • Dedicated Social Worker • Dedicated Case Manager • Trained Psychologist in End Of Life Issues • 0.5 FTE Massage Therapist • Annual Retreats at Pebble Beach • All Expenses Paid

  24. The Pitfalls and Perils • Stepping On Toes • Disrupting long-held notions • Attending/House Staff Miscommunication • Answer the Question! (and only the question) • “Spoiling the Movie” • Commandeering

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