WakeMed Palliative Care QI Projects Alisha Benner, MD

WakeMed quality improvement pilots Improving identification of CHF patients who would benefit from palliative care consultation Decreasing placement of feeding tubes in patients with advanced dementia

Death from CHF NYHA III-IV mortality at 1 year is 52% Hospitalization only improves symptoms in 35-40% (Ward, 2002) DNR orders 5% of CHF patients 47% of cancer patients

End-of-life care in CHF In the last 6 months of life High symptom burden 80% of patients are hospitalized Average days in hospital: 20 Average days in ICU:4.6 Costs rising Readmissions common Unroe et al. Arch Int Med 2011;171:196-203 Curtis et al. Arch Int Med 2008;168:2481-88

Benefits of palliative care Better communication among the patient, caregivers and the treatment team Better understanding of what effects the disease has on the patient (family, physician) Better symptom control Better understanding of disease prognosis

Patient perception 2008 DCRI study (Duke) To determine personal predictions of life expectancy 122 patients with NYHA III or IV Average age 62, 47% African American Median overestimation was 40% longer

Physician perception of prognosis We are unable to predict timing of exacerbations or sudden cardiac death (up to 50% of patients) In general, clinicians tend to overestimate life expectancy (by a factor of 5.3) Increased duration of patient-physician relationship results in less accurate prognostication

6A Pilot preparation prior to launch April 2015 Education of all unit staff on all shifts - live or YouTube RN SW Chaplaincy Educational sessions with cardiologists and APP’s Study design Initially focused CHF patients seen followed by the CHF team Eventually included all patients admitted to 6A

Palliative Care Consult Triggers – 6A Pilot 2+ admissions to the hospital for the same diagnosis within 3 months (CHF) Prolonged length of stay without evidence of progress Consideration of artificial nutrition/PEG tube for patient with short anticipated survival or for dementia More than one ICU admission during same hospitalization Patient and family in disagreement over advance directive Critically ill patient with no advance directive or goals of care established Patient with life threatening illness and patient and/or family with unrealistic goals of care or expectations of recovery

Protocol Bedside RN supplied with copy of paper Trigger Tool which was completed daily During CHF rounds the charge RN would inquire about the Trigger Tool If a patient met 1+ triggers the RN would alert the attending MD/APP and request PC consultation Data collection – by CHF RN All patients meeting trigger If PC consult ordered and completed during that hospital stay Readmission and disposition

Obstacles Completion of Trigger Tool took months to become part of the nursing “daily routine” Paper Trigger Tool after EPIC launch More difficult to incorporate in daily routine Patient/family refused consults Early in pilot cardiologists were often refusing to place the PC consults “They are not ready for that yet”

What is in a name? 2009 survey of 140 medical oncologists and midlevel providers Supportive Care Palliative Care Service name preference 57% 19% Advanced cancer patients 89% 69% Non-cancer primary disease 79% 45% Service name perceived as barrier to referral 6% 23% Service name perceived cause of decreasing hope 11% 44% Service name perceived as causing distress 3% 33% Cancer 2009 May 1;115(9):2013-21

The new model of palliative care

CHF pilot results Decreased overall readmissions Patients receiving PC consults discharged to SNF had higher readmission rates Consult notes discuss lack of family readiness to accept palliative care Likely attributable to lack of hospice services provided at SNF 6A nurses have become champions of palliative care Advocate for consults Pilot is expanding to more units

Feeding tubes in advanced dementia Dementia is a terminal illness, the 6th leading cause of death in the US (Sept 2015) Difficulty eating is common and expected in end-stage dementia It is a marker for the terminal stage of dementia Finucane TE, et al. JAMA 1999

Family and physician goals for PEG tubes Prevent aspiration Healing pressure ulcers Improve functional status/survival Provide comfort Shega et al. J Palliat Med 2003; 6(6):885-893

Aspiration pneumonia and feeding tubes Numerous case-control studies identified TF as an independent risk factor for aspiration and demonstrated high rates of aspiration PNA and death in TF patients Nonrandomized prospective study, orally fed patients with oropharyngeal dysphagia had significantly fewer aspiration events than TF patients No published studies suggesting that TF can reduce the risk of aspiration PNA Finucane TE, et al. JAMA 1999

Pressure ulcers and tube feeding Two retrospective studies of 800 patients during follow-up after PEG placement TF not associated with healing of preexisting pressure ulcers Did not afford protection from new pressure sores Bedbound and incontinent TF patients are will make more urine and stool PEG tube placement often leads to patients being physically restrained

Functional status/survival and tube feeding MEDLINE review of literature 1966-1999 No studies demonstrating nutritional intervention facilitating recovery of function or slow its decline Retrospective review found no SNF patients with improved functional status during 18 months after PEG placement Study of 1386 patients with severe cognitive impairment, no improved survival between patients with and without TF

Patient comfort and tube feedings When TF are used as a permanent alternative to oral intake, they are deprived of the enjoyment derived from eating Ability to taste food Socialization from mealtimes Human touch from careful hand-feeding 1993 prospective study of terminally ill patients with anorexia due to cancer or CVA (no cognitive impairment) Few experienced hunger or thirst Relieved with small amounts of food, fluid, ice chips and lip lubrication

AMERICAN GERIATRICS SOCIETY Feeding Tubes in Advanced Dementia Position Statement May 2013 Percutaneous feeding tubes are not recommended for older adults with advanced dementia. Careful hand‐feeding should be offered; for persons with advanced dementia, hand feeding is at least as good as tube‐feeding for the outcomes of death, aspiration pneumonia, functional status and patient comfort. Tube feeding is associated with agitation, increased use of physical and chemical restraints, and worsening pressure ulcers.

Feeding tube pilot Goal: To decrease feeding tube placement in patients with advanced dementia Focused only on hospitalized patients with advanced dementia Alzheimer's Multi-infarct Other causes (Frontal lobe, HIV) In collaboration with WakeMed GI department MD APP

Feeding tube pilot – study design Study population All hospitalized patients with advanced dementia with GI consult placed for PEG tube placement in 2015 Hospital-wide Intervention begun June 2015 Protocol Patients had completed consult by GI APP/MD Caregivers were informed of WakeMed hospital policy requiring palliative care consultation prior to PEG tube placement Palliative care consult placed by GI APP/MD

Feeding tube pilot - Results Compared feeding tube placement pre- and post- intervention Still awaiting data collection and analysis Increased provider understanding (upstream effect) Anecdotal evidence of decrease in GI consults for PEG placement for patients with advanced dementia

Lessons learned Find good people to collaborate with Ask your data people about study design Let them guide you on what data to collect Check in with them early Quality improvement projects are a learning process but bring great benefit to patients and families Improved job satisfaction

Questions?