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Palliative Care . Cardinale B. Smith, MD, MSCR Assistant Professor Division of Hematology/ Medical Oncology Tisch Cancer Institute Brookdale Department of Geriatrics & Palliative Medicine Hertzberg Palliative Care Institute Icahn School of Medicine at Mount Sinai. Palliative Care.

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palliative care

Palliative Care

Cardinale B. Smith, MD, MSCR

Assistant Professor Division of Hematology/ Medical Oncology Tisch Cancer Institute

Brookdale Department of Geriatrics & Palliative Medicine Hertzberg Palliative Care Institute

Icahn School of Medicine at Mount Sinai

palliative care1
Palliative Care
  • Specialized medical care for people with serious illnesses.
    • Focused on providing patients with relief from the symptoms, pain, and stress of a serious illness - whatever the diagnosis.
    • The goal is to improve quality of life for both the patient and the family.
  • Provided by a team of doctors, nurses, and other specialists who work with a patient's other doctors to provide an extra layer of support.
  • Appropriate at any age and at any stage of a serious illness, and can be provided together with curative or disease directed treatments.
palliative care in practice
Palliative Care in Practice
  • Expert control of pain and symptoms
  • Uses the crisis of the hospitalization to facilitate communication and decisions about goals of care with patient and family
  • Coordinates care and transitions across fragmented medical system
  • Provides practical support for family and other caregivers (+ clinicians)
old model two types of care

Palliative /Hospice Care

Old Model: Two types of care

Disease-focused Care

(“Aggressive Care”)

the cure care model the old system
The Cure - Care Model: The Old System


Life Prolonging Care




Disease Progression


A New Vision of Care

Disease Modifying Therapy

curative or restorative intent



Death &



Palliative Care


palliative care is
Palliative Care Is

Palliative Care Is NOT

  • Not “giving up” on a patient
  • Not in place of curative or life-prolonging care
  • Not the same as hospice or end-of-life care
  • Excellent, evidence-based medical treatment
  • Vigorous care of pain and symptoms throughout illness
  • Care that patientswant at the same time as efforts to cure or prolong life
consumer knowledge of palliative care
Consumer Knowledge of Palliative Care

95% of respondents agree that it is important that patients with serious illness and their families be educated about palliative care.

92% of respondents say they would be likely to consider palliative care for a loved one if they had a serious illness.

92% of respondents say it is important that palliative care services be made available at all hospitals for patients with serious illness and their families.

CAPC/ACS Public Opinion Survey, 2011

significance of palliative care
Significance of Palliative Care
  • More patients with serious illness not imminently dying, but living with chronic and debilitating conditions
  • Surveys of patients and families have identified top needs:
    • Relief of suffering
    • Practical support needs
    • Open communication
    • Opportunities to relieve burdens and strengthen relationships with families
palliative care relevance in context
Palliative Care – Relevance In Context

Heart disease: 1:2 men; 1:3 women (age 40+)

Cancer: > 1:3

Alzheimer's: 1:2.5 – 1:5 by age 85

Diabetes: 1:5

Parkinson’s: 1:40

Lifetime Risk of:

the reality of the last years of life death is not predictable
The Reality of the Last Years of Life: Death Is Not Predictable


(slide adapted from Joanne Lynn, MD, Rand Health/CMS)

hospital palliative care the 5 main principles
Hospital Palliative Care:The 5 Main Principles
  • Clinical Quality
  • Patient and Family Preferences
  • Demographics
  • Education
  • Finances
why palliative care
Why palliative care?

1. The Clinical Imperative

The need for better quality of care for people with serious and complex illnesses.

everybody with serious illness spends at least some time in a hospital
Everybody with serious illness spends at least some time in a hospital...
  • 98% of Medicare decedents spent at least some time in a hospital in the year before death.
  • 15-55% of decedents had at least one stay in an ICU in the 6 months before death. Average length of stay in the ICU is 2-11 days.

Dartmouth Atlas of Health Care 1999 & 2006

symptom burden of patients hospitalized with serious illness at 5 u s academic medical centers
Symptom Burden of Patients Hospitalized With Serious Illness at 5 U.S. Academic Medical Centers

% of 5176 patients reporting moderate to severe pain between days 8-12 of admission

Colon Cancer 60%

Liver Failure 60%

Lung Cancer 57%

COPD 44%

CHF 43%

Desbiens & Wu. JAGS 2000;48:S183-186.

why palliative care1
Why palliative care?

2. Concordance with patient and family wishes

What is the impact of serious illness on patients’ families?

What do persons with serious illness say they want from our healthcare system?

what do patients with serious illness want
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.

difficult conversations improve outcomes
“Difficult” Conversations Improve Outcomes
  • Multisite, longitudinal study of 332 patient-family dyads
  • 37% of patients reported having prognosis discussion at baseline
  • These patients had lower use of aggressive treatments, better quality of life, and longer hospice stays
  • Family after-death interviews showed better psychological coping for those with conversations as compared to those without

Wright et al. JAMA 2008 300(14):1665-1673

what do family caregivers want
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

families want to talk about prognosis
Families Want to Talk About Prognosis
  • Qualitative interviews with 179 surrogate decision makers of ICU patients
  • 93% of surrogates felt that avoiding discussions about prognosis is an unacceptable way to maintain hope
  • Information is essential to allow family members to prepare emotionally and logistically for the possibility of a patient's death
  • Other themes:
    • moral aversion to the idea of false hope
    • physicians have an obligation to discuss prognosis
    • surrogates look to physicians primarily for truth and seek hope elsewhere

Apatira et al. Ann Intern Med. 2008;149(12):861-8

why palliative care2
Why palliative care?

3. The demographic imperative

Hospitals need palliative care to effectively treat the growing number of persons with serious, advanced and complex illnesses.

chronically ill aging population is growing
Chronically Ill, Aging Population Is Growing
  • The number of people over age 85 will double to 10 million by the year 2030.
  • The 23% of Medicare patients with >4 chronic conditions account for 68% of all Medicare spending.

US Census Bureau, CDC, 2003

Anderson GF. NEJM 2005;353:305

CBO High Cost Medicare Beneficiaries May 2005

hospital based palliative care programs in the united states
Hospital Based Palliative Care Programs in the United States

63% of all hospitals and 85% of mid-large size hospitals report a palliative care team

100% of cancer centers report a palliative care team

why palliative care3
Why palliative care?

4. The educational imperative

Every doctor and nurse-in-training learns in the hospital.

deficiencies in medical education
Deficiencies in Medical Education

improvements in education
Improvements in Education
  • 2007 Board Certification in Palliative Care
  • Medical school licensing requirement:

“Clinical instruction must include important aspects of … end of life care (average 14 hours).”

why palliative care4
Why palliative care?

4. The fiscal imperative

Hospital and insurers of the future will have to efficiently and effectively treat serious and complex illness in order to survive.


Healthcare Spending and Quality

U.S. leads the world in per capita spending

27thin life expectancy

37thin overall quality of healthcare system (WHO)

national health expenditure growth 1970 2003
National Health Expenditure Growth 1970-2003

HCFA, Office of the Actuary, National Health Statistics Group, 2003

costs and outcomes associated with hospital palliative care consultation 8 hospital study
Costs and Outcomes Associated with Hospital Palliative Care Consultation 8-hospital study

Adjusted results, n>20,000 patients

Morrison et al. Arch Internal Med. 2008. 168 (16)

8 Hospital Study:Costs/day for patients who died with palliative care vs. matched usual care patients
cost savings medicaid in ny state
Cost Savings – Medicaid in NY State

Cost savings/Day for Live Discharges

Morrison et al. Health Affairs 2011 30:454-63


U. Michigan- Hospice of MichiganPalliative Care Reduces Hospital Costs (patients with complete data as of July 1, 2002, at Medicare prices, excludes Rx)

how palliative care reduces length of stay and cost
How Palliative Care Reduces Length of Stay and Cost

Palliative care:

  • Clarifies goals of care with patients and families
  • Helps families to select medical treatments and care settings that meet their goals
  • Assists with decisions to leave the hospital, or to withhold or withdraw treatments that don’t help to meet their goals
what does all this mean from the patient perspective
What Does All this Mean from the Patient Perspective?

For patients, palliative care is a key to:

  • relieve symptom distress
  • navigate a complex medical system
  • understand the plan of care
  • help coordinate and control care options
  • allow simultaneous palliation of suffering along with continued disease treatments (no requirement to give up life prolonging care)
  • provide practical and emotional support for exhausted family caregivers
what does all this mean from the clinician perspective
What Does All this Mean from the Clinician Perspective?

For clinicians, palliative care is a key tool to:

  • Save time

help to handle repeated, intensive patient-family communications, coordination of care across

settings, comprehensive discharge planning

  • Provide Symptom Control

assists with controlling pain and distress for highly

symptomatic and complex patients, 24/7 -thus supporting clinician’s treatment plan

  • Promote Satisfaction

increases patients’ and families’ satisfaction with the quality of care provided by the clinician

what does all this mean from the hospital perspective
What Does All this Mean from the Hospital Perspective?

For hospitals, palliative care is a key tool to:

  • effectively treat the growing number of people with complex advanced illness
  • provide excellent patient-centered care
  • increase patient and family satisfaction
  • improve staff satisfaction and retention
  • meet accreditation and quality standards
  • rationalize the use of scarce hospital resources
  • increase bed/ICU capacity, reduce costs
  • Disparities in access to palliative care
  • Lack of a solid evidence base to guide clinical care and care delivery
  • Lack of research funding to support needed research
  • Need for public advocacy and public and professional education
research publications oncology and palliative care 2003 2005
Research Publications: Oncology and Palliative Care (2003-2005)

Gelfman LP, Morrison RS. J Palliat Med, 2008

  • Palliative care improves quality of care for our sickest and most vulnerable patients and families.
  • Serious illness is a universal human experience and palliation is a universal health professional obligation.
‎"When we honestly ask ourselves which people in our lives mean the most to us, we often find that it is those who, instead of giving advice, solutions, or cures, have chosen rather to share our pain and touch our wounds with a warm heart and tender hand. The person who can be silent with us in a moment of despair or confusion, who can stay with us in an hour of grief and bereavement, who can tolerate not knowing, not curing, and face with us the reality of our powerlessness, that is a person who cares.”

-Henri Nouwen