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Palliative Care in Hospitals: Making the Case. Diane E. Meier, MD Director Center to Advance Palliative Care in Hospitals and Health Systems a Robert Wood Johnson Foundation - Mount Sinai School of Medicine initiative 10.10.02. Center to Advance Palliative Care

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Palliative Care in Hospitals: Making the Case


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    1. Palliative Care in Hospitals:Making the Case Diane E. Meier, MD Director Center to Advance Palliative Care in Hospitals and Health Systems a Robert Wood Johnson Foundation - Mount Sinai School of Medicine initiative 10.10.02

    2. Center to Advance Palliative Care Mount Sinai School of Medicine 1255 5th Avenue, C-2 New York, NY 10029 212-201-2670 office 212-426-1369 fax 212-201-2680 event line www.capc.org A national initiative supported by The Robert Wood Johnson Foundation at the Mount Sinai School of Medicine.

    3. Palliative Care Interdisciplinary care that aims to relieve suffering and improve quality of life for patients with advanced illness and their families. It is offered simultaneous with all other appropriate medical treatment.

    4. The Cure - Care Model: The old system D E A T H Life Prolonging Care Palliative/ Hospice Care Disease Progression

    5. Palliative Care’s Place in the Course of Illness Life Prolonging Therapy Death Diagnosis of serious illness Palliative Care Medicare Hospice Benefit

    6. “Modern Medicine” Hospice Palliative Care

    7. Hospital-based palliative care:The 5 main arguments • Clinical imperative • Concordance with patient and family preferences • Demographic imperative: meets the needs of growing aging and chronically ill population • Educational imperative • Fiscal imperative: cost avoidance, improved hospital capacity

    8. Defining and Making the Case for Palliative Care Different attributes of palliative care appeal to different audiences Alignment of messages and mission is key to making the successful case for palliative care

    9. Message alignment for palliative care: The patient perspective For patients, palliative care is a key tool to: • relieve symptom distress: pain, nausea, breathlessness, anxiety, depression, fatigue, weakness • 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

    10. Message alignment for palliative care: The clinician perspective For clinicians, palliative care is a key tool to: • handle repeated, intensive patient-family communications, coordination of care across settings, comprehensive discharge planning • manage day-to-day 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 quality of the care provided

    11. Message alignment for palliative care: 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 • rationalize the use of hospital resources • increase capacity, reduce costs

    12. Why palliative care? 1. Clinical imperative: the quality of the care given to persons with serious and complex illnesses

    13. Why hospital-based palliative care? The clinical imperative • Hospitals are where the sickest people go and remain the site of death for many. • Patients feel a loss of control and unsafe in the medical system. • Numerous studies document unnecessary patient suffering. • Patients want and will demand better care. • Family caregiver burden • Hospitals and clinicians struggling to do better, meet JCAHO pain, quality standards

    14. Site of death: Time trends 1989 1993__1997 Hospitals: 65% 56% 53% Nursing homes: 18% 19% 24% Home: 17% 21% 23% (Teno et al, Brown Site of Death Atlas of the U.S: www.chcr.brown.edu/dying/usa_statistics.htm and 1993 National Mortality Followback Survey )

    15. 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. Dartmouth Atlas of Health Care 1999

    16. The Nature of Suffering and the Goals of Medicine - Eric J. Cassell The relief of suffering and the cure of disease must be seen as twin obligations of a medical profession that is truly dedicated to the care of the sick. Physicians’ failure to understand the nature of suffering can result in medical intervention that (though technically adequate) not only fails to relieve suffering but becomes a source of suffering itself.

    17. Death in the hospital: What do we know about it? • Physical suffering • Poor to non-existent communication about the goals of medical care • Lack of concordance of care with patient and family preferences • Huge financial, physical, and emotional burdens on family caregivers • Suffering in professional caregivers • Fiscal impact on hospitals

    18. National data on the experience of dying 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

    19. SUPPORT: Phase I Results • 46% of DNR orders were written within 2 days of death. • Of patients preferring DNR, <50% of their MDs were aware of their wishes. • 38% of those who died spent >10 days in ICU. • Half of patients had moderate-severe pain >50% of last 3 days of life.

    20. 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.

    21. Why palliative care? 2. Concordance with patient and family wishes What is the impact of serious illness on patient’s families? And what do persons with serious illness say they want from our healthcare system?

    22. Family caregivers and the SUPPORT studyJAMA 1995;272:1839 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%

    23. Family caregivers:The numbers • 1996 United States estimates: 25 million caregivers deliver care at home to a seriously ill relative • Mean hours caregiving per week: 18 • Cost equivalent of uncompensated care: 194 billion dollars (assume $8/hr) Levine C. Loneliness of the long-term caregiver N Engl J Med 1999;340:1587-90.

    24. Caregiving needs among terminally ill persons Interviews with 900 caregivers of terminally 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

    25. Caregiver characteristics 900 family caregivers of terminally ill persons at 6 sites across the U.S. • Women: 72% • Close family member: 96% • Over age 65: 33% • In poor health: 33% Emanuel et al. N Engl J Med 1999;341:956.

    26. Caregiving increases mortality Population based cohort study 400 in-home caregivers and 400 controls • Increased risk of death: RR 1.6 among caregivers reporting emotional strain • Substantial increased risk of major depression • Depression associated in multiple studies with ischemic heart disease, cancer, and all-cause mortality Schulz et al. JAMA 1999;282:2215.

    27. What Do Patients With Serious Illnesses 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

    28. 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

    29. 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.

    30. The demographic imperative:Chronically ill, aging population is growing • The 63% of Medicare patients with 2 or more chronic conditions account for 95% of Medicare spending (CDC) • The number of people over age 85 will double to 9 million by the year 2030 (CDC) • Aging baby boomers will demand better care for their parents, then for themselves • Data show caregivers are severely burdened financially, emotionally, and physically (JAMA) • System patterns, silo payment incentives promote acute episodic care, but patients will need a continuum of care over years of illness

    31. Average Life Expectancy

    32. Who is dying in the U.S. in 2002? • Median age of death is 78 years, and rising • Among survivors to age 65, median age at death is 82 years • Among survivors to age 80, median age at death is 88 years

    33. The demographic imperative: Is this patient ‘terminally ill’? • 94 y/o with moderate dementia, congestive heart failure, and recurrent infections. She is treated with spoon feeding, antipsychotic medications, an ACE inhibitor, a beta blocker, and judicious use of diuretics. Is this patient terminally ill? (slide courtesy of Joan Teno MD, Brown University)

    34. The Demographic ImperativeThe Reality of the Last Years of Life: Death Is Not Predictable(slide courtesy of Joanne Lynn, MD Rand Corp.)

    35. Leading Causes of Death in 1997: 77% are not due to cancer Heart disease: 33% Malignant neoplasm: 23% Cerebrovascular disease: 7% COPD: 5% Accidents: 4% Pneumonia: 4% Account for 75% of all deaths Natl. Ctr. Health Statistics, CDC, 1998

    36. Bettercare needed from the day of diagnosis of any serious illness • People need better care throughout the multi-year course of advanced illness • Medicare Hospice Benefit developed to care for the dying: regulations require 6 month prognosis and decision to forego coverage for life prolonging care. • Additional approaches are needed for much larger numbers of persons with chronic, progressive illness.

    37. Why palliative care? 4. The educational imperative Every doctor and nurse-in-training learns in the hospital.

    38. The educational imperative • Teaching hospitals are the site of training for most clinicians. • Acknowledged deficits in skills/knowledge and attitudinal barriers abound. • Medical school and residency curricula offer little to no teaching in palliative care. Meier, Morrison & Cassel. Ann Intern Med 1997;127:225-30.

    39. Deficiencies in medical education • 74% of residencies in U.S. offer no training in end of life care. • 83% of residencies offer no hospice rotation. • 41% of medical students never witnessed an attending talking with a dying person or his family, and 35% never discussed the care of a dying patient with a teaching attending.Billings & Block JAMA 1997;278:733.

    40. 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

    41. Palliative care not part of medical training, but this is changing LCME undergraduate medical education requirement as of 2000 ACGME residency training recommendation JCAHO recommendations on educating staff Message: Palliative care = best quality care for the seriously ill, not less care, not cheaper care, and not instead of life-prolonging care The Educational Imperative

    42. Palliative care education • LCME requirement (2000): • “Clinical instruction must include important aspects of … end of life care.” • ACGME requirements for internal medicine and internal medicine subspecialties (2000): “Each resident should receive instruction in the principles of palliative care…it is desirable that residents participate in hospice and home care…The program must evaluate residents’ technical proficiency,…communication, humanistic qualities, and professional attitudes and behavior…”

    43. Why palliative care? 5. The fiscal imperative Population aging, growth in effective technologies, and antiquated payment system= financial crisis for healthcare

    44. Exponentially rising costs with effective new technologies, aging population 9.2% growth in hospital payments in 2001 76% of projected 2002 Medicare budget will be spent on hospital care ($198 billion) Under DRG system long, high intensity hospital stays = fiscal crisis for hospitals Hospital and insurer of the future will have to efficiently and effectively treat serious and complex illness in order to survive Why Palliative Care? The Fiscal Imperative

    45. Medical Spending and Care of the Seriously Ill: $1.3 trillion in 2001 • 11% of U.S. health care dollar spent in last year of life, much of it on hospital services • 30% of Medicare costs to the 5% of enrollees with most serious and complex illness (Emanuel et al. N Engl J Med 1994;330:540.)

    46. Summary: Care for serious illness at the turn of this century • Unprecedented gains in life expectancy: exponential rise in number and needs of the frail elderly • Cause of death shifted from acute sudden illness to chronic episodic disease • Untreated physical symptoms • Unmet patient/family needs • Future doctors and nurses untrained • Fragmentation, poor coordination and an unresponsive health care and payment system

    47. How do we make it better? Starting with first principles… • Does our healthcare system respond to the needs of our sickest patients and their families? • What are the goals of medical care? • What should they be?

    48. A different kind of care Palliative care in hospitals aims to: • Relieve physical and emotional suffering • Support family caregivers • Train future health professionals • Meet the needs of the growing population of elderly with complex and advanced illness • Coordinate and rationalize care- the right care for the right patient at the right time in the right place • Begin to make the system responsive to the patients it intends to serve

    49. Palliative Care... To relieve suffering, improve quality of life • Affirms life, sees death as a personal and natural process • Many diagnoses • “serious or life threatening illness” • Appropriate early in course of illness • Patient and family preferences sought and respected • Should be combined with life prolonging therapies or may become the focus of care near the end of life • Interdisciplinary • Psychological, spiritual, social, bereavement support