Palliative Care Education Module

Objectives Understand the definition of Palliative Care. Recognize the difference between hospice and palliative care Recognize patients that are appropriate for palliative care consultation

Hospice Care and Palliative Care There is a relationship between hospice and palliative care, but they are not same thing.

Hospice Care and Palliative Care Hospice – focus is on care, not cure, and on the quality and value of life, not duration. Hospice emphasizes the use of palliative care. Typically occurs at end of life. Palliative Care – goal is to prevent and relieve suffering and support best possible quality of life for patients and their families, regardless of the stage of the disease or need for other therapies. May be provided at any time, along with curative or life-prolonging treatment.

Hospice Care Patients with a prognosis of ≤ 6 months Focus changes from Curing to Caring Attempts to cure or delay the progression of the disease will stop Comfort Care is always provided Focus on Quality of Life Covered by Medicare Part A benefit Interdisciplinary care provided by a Medicare Certified Hospice Provider

Palliative Care Specialized, interdisciplinary care Aims to relieve suffering and improve quality of life for patients with advanced illness and their families. Control of pain, of other symptoms, and of psychological, social and spiritual problems, is paramount. It is offered simultaneously with all other appropriate medical treatment. Should be provided throughout the patient’s medical treatment experience

What about Pain Management? Pain is the single most common reason individuals seek medical care Pain Management can be part of Palliative Care However, not every patient receiving pain management services is identified as a palliative care patient Consider the goals of your patient’s care (cure vs. care) Consider the cause of the pain (ex. cancer, physical injury, etc.) How far advanced is the patient’s disease process? What is patient’s quality of life? Does my patient need both pain management and palliative care? Goal: control pain well enough to enhance quality of life

And Comfort Care? Comfort care is an essential part of medical care at the end of life Goal: prevent or relieve suffering as much as possible while providing for a “good” death It sounds like palliative care, but it is different Palliative Care may be provided at any time along with curative or life-prolonging treatment. While Comfort Care is reserved for end of life (or dying) care.

It’s confusing because quite often these different services are provided by the same team of practitioners. Remember! It’s never too early to initiate the conversation regarding patient wishes regarding care

Conceptual Shift of Care Goals Curative Care Model Integrative Model of Care

Categories of illness appropriate for Palliative Care Services These are examples, not an all-inclusive list Pancreatic, Esophageal or Stomach Cancer Brain Cancer Lung Cancer Peritoneal Cancer Secondary Malignant Neoplasms Cystic Fibrosis and ventilator support or oxygen dependence COPD and ventilator support or Oxygen Dependence Heart Failure ESRD Dementia Stroke Parkinson’s ALS Any end-stage disease

Triggers for Patient Referrals Patient with advanced long term condition or new diagnosis of a serious illness or both? Would you be surprised if this patient died within the next year? Does the patient: Have decreased function Live in a nursing home Progressive weight loss Assisted living ≥ 2 unplanned admits in past 12 months Need more personal care at home Similar to EPIC Does this patient have advanced cancer or heart, lung, kidney, liver or cognitive failure?

Provider Expectations Document care appropriately What are the goals for your patient? How far along is the disease process? Pain management, palliative care or both? The patient may require multiple types of care or services. Palliative Care is appropriate at any stage of illness. Hospice is targeted to end of life (≤ 6 months). Patient typically goes home with Hospice care or is transferred to Inpatient Hospice Comfort Care is part of the medical care provided at end of life. The patient may or may not be transitioned to Hospice. Often seen in the hospital.

Case Study #1 60 year old male with stage 4 non-small cell carcinoma [adenocarcinoma] of possible pancreaticobiliary origin with progressive pulmonary metastatic disease who is hospitalized with progressive respiratory distress leading to intubation and mechanical ventilation. He has chronic and poorly controlled pain and anxiety.

Case Study #1 Is he appropriate for hospice? Would he benefit from a Palliative Care Referral? Answer: His survival is likely to be less than 6 months making him eligible for hospice services. He has uncontrolled symptoms and no clear goals of care that are realistic and appropriate to his situation making him an appropriate palliative care referral.

Case Study #2 77 year old male with advanced combined Heart Failure with Atrial Fibrillation, ischemic cardiomyopathy and severe Mitral Regurgitation. Ejection Fraction 25%. His goal is to try short term rehabilitation and return home. He would want to return to the hospital for any acute symptoms.

Case Study #2 Is he appropriate for hospice? Is he appropriate for palliative care? Answer: He does have an advanced medical condition that is likely approaching end stage, however, he wishes to pursue active treatment including hospitalization and predicting a 6 month prognosis is difficult. He is not appropriate for hospice. He does have an advanced medical condition that is life limiting and will likely cause him to be symptomatic and he would be appropriate for palliative care referral.

Case Study #3 98 year old female hospitalized with moderate dementia, moderate COPD, hypertension, CKD III, UTI and mild confusion. She lives independently in a Continuous Care Community in her own apartment and is capable of managing her own ADL’s. She has an advance directive and a POLST. After 2 days of antibiotic therapy she is less confused, ambulating with assist of 1 and feeding herself.

Case Study #3 Is She appropriate for hospice? Is She appropriate for palliative care? Answer: She does not have an end stage medical condition and does not have a prognosis of 6 months or less. She is not eligible for hospice. She has no uncontrolled symptoms, she has documented advance directives with clear wishes and goals of care. She is not appropriate for a palliative care consult.