Who? What? When? Where? Why? Cecilia L. May, MD October 9, 2015

Palliative Care’s Mission “When we grow old or sick and we are tempted to lose heart, we should be surrounded by people who ask “How can we help?” We deserve to grow old in a society that views our cares and needs with a compassion grounded in respect, offering genuine support in our final days... We can help build a world in which love is stronger than death.” USCCB, To Live Each Day with Dignity: A Statement on Physician-Assisted Suicide, June 16, 2011

Newly diagnosed life limiting illness Goals of Care, Complex Decision Making Uncontrolled Pain or other Symptoms “Frequent Fliers” Prolonged LOS without progress ICU patients Transition to EOL care Psychosocial or Spiritual Care needs

Palliative medicine focuses on relief of pain, symptoms and distress of serious illness. Goal = Improve quality of life possible for patients and their families. Palliative care treats serious illness regardless of prognosis at any point in the illness, with or without curative treatment. Focuses on the physical, spiritual, psychological and social domains

(From Dame Cicely Saunders’ teachings)

“Usual” Curative Care Model

Life Prolonging Death Accepting Cure the Disease Few functional limits Promote Living More Investigation Death is failure High Tech Relieve the Symptoms Accept limits Live while dying Less Investigation Death is natural High Touch

Palliative Care Model

Relationship to Hospice Hospice is both a philosophy, and a health care reimbursement system Restrictions on eligibility (< 6 months prognosis) Restrictions on treatments (palliative intent and only treatments that are financially feasible). Palliative Care has no restrictions on eligibility or use of treatments. Hospice is a subset of Palliative Care, for patients who meet the hospice eligibility requirements.

Palliative Care Curative Care Hospice

ASAP !!! Early PC referral actually increased longevity in one study of CA patients Advance Directives are vital to care Delaying referral  “death squad myth”

Advance Directives Living Will Healthcare POA/Representative/Proxy POST form and OOH DNR Legal and Ethical Concerns Indiana Code HCPOA Following the Catholic Ethical and Religious Directives

Tasks of Dying Relieving Symptoms and Personal Care Achieving a Sense of Completion Being Treated as a Whole Person Relating to Others and God Being Prepared for Death Having Loved Ones Prepared for Your Death

Palliative Care InpatientOutpatient Emergency Room ECFHomeACO

Expertise Gift of Time Benefits Everyone Patients, Family Staff Physicians Hospitals Medicare and US

PC benefits our patients Person centered care Expert symptom management Aligns treatment plan with patient goals Increases patient and family satisfaction Improves continuity of care Decreases stress of dying process

PC benefits our staff Improves support with complex patients Increases comfort with EOL care Addresses and reduces moral distress Increases staff satisfaction and retention Decreases stress of dying process

PC benefits physicians Gift of time Expertise in symptom management Establish patient goals and code status Increases patient and family satisfaction Improves continuity of care Decreases stress of dying process

PC benefits Hospitals Lowers Costs Improves Throughput, increases hospice #s Improves Quality of EOL care Increases patient and family satisfaction Reduces readmissions Integrates care as in ACO Accreditation standards, e.g. CoC/ACS, JCAHO

PC benefits Medicare and US Lowers Costs and Improves Quality of Care By 2030, 20% of the population will be over age 65 Medicare spends 25% of total budget on patients in their last year of life By avoiding care that patients don’t want, Medicare spending will decrease dramatically

Target Population for Palliative Care Distribution of Total Medicare Beneficiaries and Spending, 2009 Total Number of FFS Beneficiaries: 37.5 million Total Medicare Spending: $265 billion Average per capita Medicare spending (FFS only): $7,064 Average per capita Medicare spending among top 10% (FFS only): $44,220 SOURCE: Kaiser Family Foundation analysis of the CMS Medicare Current Beneficiary Survey Cost & Use file, 2009.

10% of Medicare patients with >/= 5 chronic problems utilize 66% of spending 1-2 chronic conditions 10% 3 chronic conditions 10% 4 chronic conditions 13% No chronic conditions 1 % 5+ chronic conditions 66% Source: J. Anderson & G. Horvath, Making the Case for Ongoing Care. Baltimore, MD. Partnership for Solutions, December 2002

Palliative Care is the Remedy Established, evidence-based specialty Implement care plans to satisfy patient goals Increase satisfaction; measurable result Collaborative care model Decrease costs and readmissions Integrate care across multiple service lines

Thank you ! Questions??