Hospital Based Palliative and Supportive Care and the “Conversation” Jeremy Grosser, MD Medical Director NHMC Palliative and Supportive Care Program, Medical Director NHMC Transitional Care Program

Agenda Why I chose Palliative Care / background Hospice vs. Palliative Care Disease Trajectory / Disease Specific issues The Supportive Care Consult / The “Conversation” Specific questions for consult and suggestions Prognosis Special Issues

Disease Trajectory Key question supporting a palliative care consult: “Would you be surprised if these patients died in the next 6-12 months?”

Disease Specific Issues / When is a Palliative Care Consult appropriate? Dementia/ Neurodegenerative disorders/ CVA Renal Failure/ Hemodialysis Congestive Heart Failure Chronic Respiratory Failure/COPD Liver Cirrhosis Cancer

Supportive Care Consult “The Conversation” Setting the stage Review of current clinical condition with patient/ family, symptom management questions Describe the previous 6-12 months of patients life, i.e., hospitalizations, functional status, weight loss, living arrangements, family dynamics * Advanced Directive / Code Status – how does current illness play into disease trajectory, Have you/ your loved one completed an Advanced Directive Patients wishes and realistic expectations for the future** Follow up meeting / phone call, contact information

Sample questions / comments Functional status questions / prehospital condition: (tailor if asking patient or family or both) Tell me about the last 6-12 months of their life How many hospitalizations have they had in the last year? What was their functional status and how much help did they need prior to this hospitalization? Have you noticed decline in your loved ones overall health in the last 6-12 months?

Sample questions cont. Patient wishes / expectations What do you hope for in the future given the nature of your illness? What are your worries/fears for the future? Where do you want (your loved one) to live? Are you spiritual or religious and what role does it play in your illness? “I am worried about you/ your loved one because….”

Supportive Care Consult Do not tell patients or family their loved one is dying, rather describe why you feel they are declining from their illness Empathy / Compassion / Honesty / Patience/ Listening are important skill sets; Listen to their story “Know your audience”, Who are the decision makers? What are patient / family expectations? Setting realistic expectations from hospital stay and on going care - what does a “good” and “bad” outcome look like for the patients future

Supportive Care Consult Cont. Meetings take 30-60 minutes For many patients, multiple meetings are required The first meeting is to establish a relationship and set the tone for the follow up meeting Don’t rush the meetings, set up follow up meetings as needed, don’t push patients and families to achieve an outcome (patience….it’s a process) Communication skills – need to develop these skills over time and comes with experience

Prognosis Not much analytical data to drive discussions Difficult for physicians to discuss prognosis for fear of being “wrong” Patients and families will ask “how long” We are notoriously wrong when predicting prognosis

Prognosis (continued) “What would you recommend if this were your loved one?” – be able to respond to this question This conversation does not require knowing the patients prognosis, rather using disease trajectory to answer the question: “Would you be surprised if the patient died in the next 6-12 months?”

Special issues ICU care SNF/Nursing Homes/ Subacute Facilities Ethics consult/ futile care Gastrostomy tube placement / Tracheostomy placement – need for “the conversation” Hospice care/ end of life care Referrals to Palliative Care and clinicians willing to have the “Conversation”

Thank You! If you have suggestions or comments for this lecture, please email me -Jeremy.grosser@dignityhealth.org