Palliative Care: Emergency Room Interaction Pippa Hawley, UBC and BCCA, Vancouver July 2016

Objectives Discuss words used when talking about palliative care Present a visual model to help you describe it’s various aspects to patients, families, colleagues and the public Give you confidence in knowing what to say when your patient is seriously ill

Historical Understanding of Palliative Care ACTIVE (“CURATIVE”) TREATMENT

CHPCA Model ~yr 2000 Focus of Therapy to modify disease care Hospice Palliative Care Bereavement This is still referred to as the ”new” model in many references

What Patients See (Google Images search )

“This is Not For Me” Too little palliative care too late No time for advance care planning Low expectations for symptom management Expectation of suffering Caregiver burden High cost (taxpayers and families)

WHO Definition Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.

WHO Definition Continued… ………early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications.

Integration of Palliative Care with Disease Management There is now clear evidence that Specialist Palliative Care Consultation…. Improves quality of life of patients Improves quality of life of care-givers Reduced dysfunctional grief Increases the chance of death occurring in the chosen location (home or hospice vs hospital)

Integration of Palliative Care with Disease Management Reduces risk of inappropriate interventions, e.g.. ICU admissions where no advance care planning has been done chemotherapy within last days/weeks of life Reduces costs to health care system ER admissions Acute bed stays Doctor visits

Mass. General Study Increased survival; Temel et al 20102 RCT of mandatory US Cancer centre-based PSMPC clinic referral at diagnosis of metastatic lung cancer vs discretionary referral by oncologist Median Survival 11.6 vs. 8.9 months p<0.02 2. NEJM 2010;363:733-742

Integration of Palliative Care with Disease Management PC is most valuable when integrated early in the course of illness, particularly in care for chronic illness where a palliative approach to care is most appropriate PC is shifting from focus on cancer to focus on all diseases with differing illness trajectories and care needs Prognostication is getting harder with new disease-modifying medical advances There is no longer a “right time” for palliative care referral

A New Model of Integrated Palliative Care Disease Management

A New Model of Integrated Palliative Care Chemotherapy Radiotherapy Transfusions Palliative Care Disease Management Hormone therapy Anti-nausea drugs Antibiotics Targeted therapy Surgery

A New Model of Integrated Palliative Care Survivorship Cure Rehabilitation Palliative Care Disease Management Symptom Management Advance Care Planning Palliative Care Unit Control Hospice Bereavement End of Life Care

Goals for Bowtie Model Accurately describe the current WHO definition of palliative care, for our patients, their families and our colleagues Emphasize that a definite and inevitably fatal course is not a prerequisite for eligibility “If you get over this we will all be thrilled” “If you don’t, you will have had access to the best possible care, all the way along”

Specialist Palliative Care Specialist Palliative Care is provided by a specially-trained team of doctors, nurses, social workers and other specialists who work together with a patient’s primary care team to provide an extra layer of support for people with serious illness. It focuses on providing relief from the symptoms and improving quality of life for both the patient and the family. It is appropriate at any age and at any stage of a life-threatening illness and can be provided along with curative-intent treatment.

Specialist Palliative Care Services Unable to take care of all of clinical needs Often rationed arbitrarily according to prognosis We are not very good at prognostication Barriers to access including DNR status: this should be a goal, not a requirement Mis-use of the word “palliative” as a euphemism for many concepts, e.g “dying”, “incurable”, “close to death”, “suffering greatly” etc. No wonder patients don’t want it!

Hospice Care that focuses on relieving symptoms and supporting patients with incurable illness that have a life expectancy of weeks to months. In most cases hospice care is provided to a patient in his or her own home. It also can be provided in freestanding hospices, hospitals, nursing homes and other long-term care facilities.

Palliative Medicine The medical specialty focusing on the knowledge and skills which make up the physician’s role in providing specialist palliative care, including teaching and research.