Quality of life medical decisions Manouchka Joseph MD Palliative Care Medical Director Banner Desert Medical Center Clinical assistant professor University of Arizona Email: Manouchka.Joseph@bannerhealth.com

Objectives Review Vision for Palliative Care Review the conceptual model for Palliative Care. How to navigate medical decisions in Cancer care Review the importance of matching treatment plan to quality of life goals

Palliative Care Specialized medical care for people with serious illness Provides relief from symptoms E.g. pain/nausea/delirium/constipation Improves quality of life Provided by an interdisciplinary team that works with the primary medical team to provide an extra layer of support e.g. Doctors/nurses/social work/PharmD and other specialists Appropriate at any age and at any stage in serious illness Provided along with curative treatment

Hospice, palliative care aim to ease suffering Hospice, palliative care aim to ease suffering. Palliative care is designed to help patients understand options. “Americans often confuse hospice care, which precludes aggressive medical treatment and usually requires a prognosis of six months or less, and palliative care.” “The nub of the difference is that a palliative care team can be providing pain relief, psychological and spiritual support — even as another medical specialist is aggressively trying to cure or treat disease” Cited From Kaiser Family Health 02/26/2010

Palliative Care vs Hospice Hospice Care Treatment Palliative Care Death Presentation 6m Bereavement Care Pain and Symptom Management

Common Myths Myth: Palliative care will “take over” the role of the primary team Reality; we will work with you to help problem solve and achieve the optimal care outcomes Myth: Palliative care is stopping all life saving treatments Reality: Palliative care seeks to use life sustaining treatments when they match patient-defined goals of care and the benefit > burden

National Palliative Care Report Card 2015 The Growth of Palliative Care in U.S. Hospitals: A Status Report Dumanovsky T1, Augustin R1, Rogers M1, Lettang K1, Meier DE1,2, Morrison RS J Palliat Med. 2016 Jan;19(1):8-15. doi: 10.1089/jpm.2015.0351. Epub 2015 Sep 29

National Palliative Care Report Card 2015 The Growth of Palliative Care in U.S. Hospitals: A Status Report Dumanovsky T1, Augustin R1, Rogers M1, Lettang K1, Meier DE1,2, Morrison RS J Palliat Med. 2016 Jan;19(1):8-15. doi: 10.1089/jpm.2015.0351. Epub 2015 Sep 29

Palliative Care Extends Life, Study Finds “palliative care” 16,200,000 (accessed 8/12/2010) Palliative care can help cancer patients live longer USA Today (8/18/10) Palliative Care Extends Life, Study Finds The New York Times (8/18/10) Study shows value of quality-of-life cancer care8/10) Advanced Cancer Patients Receiving Early Palliative Care Lived Longer The Wall Street Journal (8/18/10) 9 9 9

How to get to quality of life medical decisions?

When you see your doctor? Look up his specialty and compare to your diagnosis Ask pertinent questions See how he makes you feel Does he/she listen to me or does he/she hear me? Bedside manners matter Do I feel informed and ready for treatment? Most common side effects?

Where am I? What is the stage of my disease? What is the data about treatment options? How will the treatment affect my life and those I love? What are my values and beliefs? How is my support system?

Shared medical decisions? Shared decision making (SDM) is a collaborative process that allows patients and their providers to make health care decisions together. It takes into account the best clinical evidence available, as well as the patient’s values and preferences.

Quality of life? World health organization defines Quality of Life as an individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns.  Affected by their physical health, psychological state, personal beliefs, social relationships and their relationship to salient features of their environment. http://www.clipartkid.com/rodin-the-thinker-cliparts/

Quality of life considerations… Quality of life as a property of the individual.  Quality of life as a goal of care. Quality of life as a social situation. Quality of life as the moral worth of a life.

Advance Care Planning A Process Not an Event

What is Advance Care Planning? Process of planning for future medical care Values and goals are explored, documented Determine proxy decision maker

What is Advance Care Planning? Trust building Uncertainty reduced Helps to avoid confusion and conflict Permits peace of mind

6 Steps: Successful Advance Care Planning 1. Introduce the topic 2. Engage in structured discussions 3. Document patient preferences 4. Review, update 5. Apply directives when need arises 6. Revisit

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Thank you!

Some Great Resources Department of Palliative Medicine 602-839-5843 Office of the Arizona Attorney General www.azag.gov Five Wishes www.agingwithdignity.org Area Agency on Aging-Phoenix www.aaaphx.org