Palliative Care: A Case Example MJ was an 85 year old women with multiple medical problems including dementia, coronary disease, renal insufficiency, and peripheral vascular disease who was admitted to Mount Sinai with urosepsis. Her hospital course was complicated by gangrene of her left foot, sepsis, pressure ulcers, and repeat infections. She underwent 5 debridements under general anesthesia. When asked by the primary doctor, her family consistently said that they wanted “everything done”. On day 63 of her hospitalization, a palliative care consult was initiated to help clarify the goals of care and to treat the patients’ evident pain and discomfort. She was persistently moaning in pain and resisting all efforts to reposition or transfer her or to change her dressings. The palliative care team met with her son (her health care proxy) and her two grandchildren. During a 90 minute discussion, the team explored with the family what they hoped to accomplish for the patient. The team reviewed the hospital course and clarified any confusion about her diagnosis and prognosis. Possible sources of discomfort and pain were identified. A treatment plan was initiated which included morphine to treat pain, discontinuing antibiotics, acetaminophen for fever, and transfer to the palliative care unit. The patient was discharged 2 days later when a bed in her nursing home, this time with a hospice contract, became available. The family expressed satisfaction with the resolution of her hospitalization and continued to visit her daily in the nursing home where she was reported to be interactive and comfortable until her death 2 months later.

What Does All this Mean from the Patient Perspective? For patients, palliative care is a key to: relieve symptom distress navigate a complex and confusing medical system understand the plan of care help coordinate and control care options allow simultaneous palliation of suffering along with continued disease modifying treatments (no requirement to give up curative care) provide practical and emotional support for exhausted family caregivers

The Clinician Perspective For clinicians, palliative care is a key tool to: Save time by helping to handle repeated, intensive patient-family communications, coordination of care across settings, comprehensive discharge planning Bedside management of pain and distress of highly symptomatic and complex cases, 24/7, thus supporting the treatment plan of the primary physician Promote patient and family satisfaction with the clinician’s quality of care

The Hospital Perspective For hospitals, palliative care is a key tool to: Effectively treat the growing number of people with complex advanced illness Provide service excellence, patient-centered care Increase patient and family satisfaction Improve staff satisfaction and retention Meet JCAHO quality standards Rationalize the use of hospital resources, avoid costs Increase bed/ICU capacity, reduce costs Invest in a Health Care Advisory Board best practice with Grade A rating Improve USNWR hospital ranking

Dr. M, an 89 year old practicing psychoanalyst Admitted to the hospital for scleroderma and new onset kidney failure. Declined hemodialysis. Palliative care consult called to assess patient’s capacity to refuse dialysis and to assure that she was not suicidal. Discharged home with hospice on day 5 of hospital stay. Did well at home for 4 months, remained in active clinical practice. Said good bye to her patients, her son, and her friends, then died quietly at home 3 days later.

Dr. M- How does palliative care deliver quality? She received good hospital palliative care- goals of care assessment and development of a care plan that met her goals, symptom management. Transitioned effectively to, and received good care from, hospice at home- Meticulous symptom management, psychosocial support from hospice RN, SW, MD + primary doc to patient and her distressed family and friends. Assured a peaceful dignified death at home. Demonstrates how the palliative care quality continuum works well from the perspective of the patient and family, the providers, and the payers.

Dr. M’s Care- the Result of Hospice and Palliative Care Partnership As a result of an effective partnership between a hospital palliative care program and a community hospice provider, Dr. M. received care that was: Patient centered- goals were defined and met Beneficial- symptoms managed, family supported Safe- no complications, injuries, errors Timely- palliative care from time of diagnosis of end stage renal disease til death and bereavement Efficient- avoided unwanted dialysis, hospitalizations, surgical procedures, imaging, transport and $$$cost.

# of Hospital Based Palliative Care Programs in the United States, (Source: AHA Annual Survey)

U.S. Hospital Based Palliative Care Programs (AHA Survey 2004)

“No institution is doing everything right. But we found 10 that are using innovation, hard work and imagination to improve care, reduce errors and save money.” “But determined people... are transforming the way U.S. hospitals care for the most seriously ill patients. The engine of change is palliative medicine. “The field is growing because it pays attention to the details,’ says Dr. Philip Santa-Emma … ‘It acknowledges that even if we can’t fix the disease, we can still take wonderful care of patients and their families.” Newsweek Fixing America’s Hospital Crisis October 16, 2006