Palliative Care and the Future of Family Medicine Phil Rodgers, MD Director, Palliative Care Program Assistant Professor, Department of Family Medicine University of Michigan STFM Annual Conference Baltimore, MD May 2, 2008

Conclusions Family Medicine and Palliative Care share core values, and imperatives Family physicians are uniquely suited to provide, teach and lead Palliative Care in the ‘Advanced Medical Home’ Opportunities exist today for you to engage patients, learners and institutions to improve care for patients and families living with advanced illness

What is Palliative Care? WHO Definition Palliative care is an approach that improves the quality of life of patients and their families facing the problems 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. http://www.who.int/cancer/palliative/definition/en/

What is Palliative Care? WHO Definition Palliative care is an approach that improves the quality of life of patients and their families facing the problems 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. http://www.who.int/cancer/palliative/definition/en/

What is Palliative Care? WHO Definition Palliative care is an approach that improves the quality of life of patients and their families facing the problems 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. http://www.who.int/cancer/palliative/definition/en/

The Nature of Suffering and the Goals of Medicine The relief of suffering and the cure of disease must be seen as twin obligations of a medical profession that is truly dedicated to the care of the sick. Physicians’ failure to understand the nature of suffering can result in medical intervention that (though technically adequate) not only fails to relieve suffering but becomes a source of suffering itself. Cassell, E. NEJM 1982;306:639-45.

Dame Cicely Saunders: ‘Total Suffering’ Physical Psychological and emotional Social Spiritual Modern interdisciplinary hospice and palliative care is committed to the relief of Total Suffering

Patients with Serious Illness Today Older and more complexly ill More functionally impaired Frequently hospitalized Incur most health care costs in last year of life Often need surrogates or proxies More likely to live alone, and away from family More likely to die in an institution (hospital or ECF) CAPC, 2004

Demographic Imperative The number of people over age 85 will double to 10 million by the year 2030. The 23% of Medicare patients with >4 chronic conditions account for 68% of all Medicare spending. US Census Bureau, CDC, 2003 Anderson GF. NEJM 2005;353:305 CBO High Cost Medicare Beneficiaries May 2005

Tenuous ‘balance’ of care Less time to spend with patients and families Less consensus among providers about appropriate interventions Less ‘intact’ extended families and communities Less homogeneity in cultural beliefs about health care Less certainty about reimbursement and financial support for care More complexly ill patients More available interventions & much higher expectations More well-informed (and less satisfied?) patients and families More ‘efficiency’ pressures and resource demands More regulatory oversight More racial and SE disparities

What does Palliative Care do? Provides meticulous pain and symptom control Helps explore values, establish goals of care Promotes advance care planning Helps with communication challenges Eases transitions to appropriate sites of care Coordinates complex care systems Organizes health care resources Affirms the whole person and family Regards dying and death as normal processes

PALLIATIVE CARE “Modern Medicine” Hospice

How does Palliative Care get done? Primary Palliative Care Provided by primary care physicians Home, extended care facility (ECF), hospitals Secondary Palliative Care Provided by hospice interdisciplinary teams Home hospice Residential (dedicated hospice, or hospice care in ECF) Tertiary Palliative Care Provided by dedicated palliative care teams Often hospital-based, including consultation services and units

Traditional Model of Care for Serious Illness Curative Care Hospice Death Diagnosis of Serious Illness

Model for Integrating Palliative Care Curative Care: optimizes disease-specific treatments Hospice Palliative Care: maximizes comfort and quality of life Bereavement Care Death Diagnosis of Serious Illness

IOM: 21st Century Health Care Continuous healing relationships Care customized to patient needs and values Shared knowledge, information Safety is a priority Transparency is necessary Needs are anticipated Waste is continuously decreased Cooperation among clinicians is a priority IOM/Nat Acad Press 2001, Crossing the Quality Chasm

Palliative care is growing up 1998: US Palliative Medicine fellowships start 2007: ABMS and ACGME Recognition 1987: AAHPM is founded 1994: Project on Death in America (PDIA) opens, scholars funded 2004: National Consensus Project (NCP) clinical guidelines, adopted by NQF 1973: First US hospice opens 1988: First US hospital-based, academic palliative care programs organize 1999: Center to Advance Palliative Care (CAPC) funded 2008: ACP EB Guidelines for Palliative Care Published 2006: Largest R01 awarded for multi-site study of Palliative Care Programs 1996: American Board of Hospice and Palliative Medicine (ABPHM) begins certification

Palliative Care today PC programs in ~35% of US hospitals Curricular presence in medical schools and residencies in some specialties Palliative Medicine now recognized as an ABMS Subspecialty (first exam in 10/08) Palliative Medicine Fellowship Training now eligible for ACGME accreditation (first application 6/08) JCAHO to offer PC certificate in 2009

Family Physicians and Palliative Medicine 25-30% of ABHPM-certified physicians are family-medicine trained Most staff hospices, usually part-time Staff some number of hospital-based and academic Palliative Care programs ‘Stealth’ leadership at many levels

Future of Family Medicine: Key Attributes of a Family Physician A deep understanding of the dynamics of the whole person A generative impact on patients’ lives A talent for humanizing the health care experience A natural command of complexity A commitment to multidimensional accessibility Ann Fam Med 2004; 2(suppl 1): S12

Why do family physicians succeed in Palliative Care? Shared values and philosophy Broad knowledge base Tolerance of uncertainty and complexity Strong communication skills Commitment to family care Recognition of interdisciplinary team Used to being ‘redheaded stepchild’

Why aren’t family physicians more visible in Palliative Care? ‘Them’ reasons Local institutional opportunity (politics) Financial constraints Palliative Medicine subspecialty bias ‘Us’ reasons Reluctance to ‘carve out’ palliative care Lack of clear comfort with ‘expert’ role Concern for Identity Creep

Opportunities. . . Primary Palliative Care Curriculum development Meaningful to patients, families, and you Powerful role-modeling Curriculum development Residency: win-win-win (faculty-resident-ACGME) Undergraduate: often plays to our strengths Growing set of teaching resources

. . .Opportunities Hospice medical director Palliative Care Physician Natural fit, may require some knowledge and skill development Creates educational opportunities Palliative Care Physician More commitment, but very doable Resources available to help grow into role Opens clinical, educational and scholarly doors

. . .Opportunities Palliative Medicine clinician-educator Not possible everywhere, but rewards can be high May require program development effort, significant time and career investment Palliative Medicine research Nascent, but growing Very collaborative Methods potentially a good fit to our strengths

Curative Care Traditional Model of Care Hospice Death Diagnosis of Serious Illness Hospice Curative Care Curative Care: optimizes disease-specific treatments Palliative Care: maximizes comfort and quality of life Bereavement Care Traditional Model of Care Integrated Model of Care

Comprehensive, Life-long Model of Care Diagnosis Death HEALTH ILLNESS DEATH Curative & Life Prolonging Care Palliative Care Symptom Management Life Closure EOL/ Dying Bereavement Prevention CURATIVE CARE HOSPICE CARE

Palliative Care Resources Organization and professional development: www.aahpm.org Program development: www.capc.org Practice guidelines: www.nationalconsensusproject.org Education: www.eperc.mcw.edu Research: www.npcrc.org

“Although the world is full of suffering, it is also full of the overcoming of it.” -Helen Keller, Optimism (1903)