PALLIATIVE CARE AT STANFORD James Hallenbeck, MD Medical Director, Stanford Hospice, VA Hospice Care Center

Definitions Palliative Care Palliative Medicine Hospice Supportive Care

The Need SUPPORT Study Studies on Communication Stanford Study

SUPPORT STUDY 1995 46% of DNR orders written with 2 days of death 40% of patients/surrogates had discussed CPR with physician Of 60% who had not done so, 41% wanted to ~ 50% wanted a DNR status, but did have it 50% of patients reported as being in 7/10 or greater pain in last three days of life SUPPORT JAMA 1995; 274:1591-1598.

Tulsky Study on Advance Directive Discussions Conversations averaged 5.6 minutes Physicians spoke 66% of the time Used vague language Patients values rarely explored Tulsky JA et. al. Opening the black box: how do physicians communicate about advance directives? Ann Intern Med 1998 Sep 15;129(6):441-9.

Stanford Survey 1998 617 Stanford Clinicians, 35 families Staff and families identified communication as the area most needing improvement 35% of staff felt inexperienced communicating with dying patients and families (residents 64%) Broad support for a consultation team 61% of physicians surveyed felt that a consultation team would be moderately or extremely helpful 47% of attendings, 64% of residents stated that they would often or always use a consultation team in care of dying pts

Stanford- What We Do Not Know... Site-specific data Annual # of hospital deaths by age, insurance status COD and LOS by DRG, Location of death In most hospitals LOS for patients who die in hospital 2-3 X for those discharged alive Cost per case by DRG for deceased vs. alive Audits of quality of symptom relief, documentation of patient preferences

The Context JCAHO ABIM AAMC ACGME New Policy and Regulatory Mandates... JCAHO ABIM AAMC ACGME

Palliative Medicine Evolving as a Medical Subspecialty American Board of Hospice and Palliative Medicine- > 600 physicians boarded since 1996 A Push for ACGME Accreditation Currently approximately 16 fellowships nationwide VA Palo Alto HCS has 2 one-year fellows

Palliative Care Services being Integrated into Healthcare Systems Consultation teams and/or dedicated beds more common ~ 50% of California hospitals surveyed have or are planning dedicated services VA Palo Alto HCS: 30 dedicated beds, consult team UCSF: Comfort Care Suites, consult team Santa Clara Valley Med: 2 dedicated beds, evolving consult team

Growing Public Demand for Expert Palliative Care Bill Moyer’s September Public Television Special on Death and Dying in America Sept. 10-13 Numerous associated events: KQED f/u special on associated issues in the Bay Area Community Action Groups Community meeting at VA Palo Alto HCS on September 27, sponsored by community hospices

Models for Success McGill University- Consult Service Demonstrated average length of stay halved for terminally Northwestern Memorial Hospital Consult and inptatient service since 1994 Average 55 consults a month Followed for an average of 2 days (range 2-10) Revenue 1.5 million in 1996, excluding donations exceeded direct costs of ~ 1 million

Models for Success Oregon Health Sciences University Consult Service (of 67 serial consults) 66% Cancer, 34% Non-cancer 59% receiving life-prolonging treatment 41% hospice/palliative care only 20% died during hospitalization Symptoms addressed: pain, nausea, constipation, delirium… 65% received assistance in EOL care decision making Bascom PB. A hospital-based comfort care team: consultation for seriously ill and dying patients. Am J Hosp and Palliat Care. 1997

Models for Success Philadelphia VA: Consult team for Cancer Patients (of 75 patients studied) 164 medical problems identified 31 patients inadequate pain relief Other problems: skin care, oral care, nutrition nausea, constipation mental status 15 patients referred for hospice- no documentation of wishes regarding resuscitation 36 patients required psychosocial counseling

Philadephia VA Study Of 22 patients followed in Medical Oncology Clinics: 21 had one or more problems identified by consult team Principally financial, social or spritual 11 patients reported inadequate pain relief Abrahm JL et al. The impact of a hospice consultation team on the care of veterans with advanced cancer. J. Pain Symptom Manage. 1996; 12:23-31.

What are Our Choices? Status Quo Palliative Care geared to meet JCAHO minimum standards- a process of ‘quality improvement’ A minimalist Palliative Care service A comprehensive interdisciplinary palliative care consult team A comprehensive Palliative Care service, bridging venues of care

From Consult Team to Palliative Care Service Establish an interdisciplinary consult team Attendings, fellow, elective resident/students, nurse, social worker, chaplain Coordinate with others working in related areas Stanford Hospice, Pain Service, Pediatrics, Ethics Center, VA Hospice Care Center Consider identifying dedicated beds, outpatient clinic in later years