The Case for Palliative Care

The Eperc Project How Americans died in the past Early 1900s average life expectancy 50 years childhood mortality high adults lived into their 60s Prior to antibiotics, people died quickly infectious disease accidents Medicine focused on caring, comfort Sick cared for at home with cultural variations

Medicine’s Shift in Focus Marked shift in values, focus of North American society “death denying” value productivity, youth, independence devalue age, family, interdependent caring Death “the enemy” organizational promises sense of failure if patient not saved

Medicine’s Shift in Focus Science, technology, communication Potential of medical therapies fight aggressively against illness, death prolong life at all cost Improved sanitation, public health, antibiotics, other new therapies increasing life expectancy 2010 avg 78.7 years

We Hope to Die in my sleep Die suddenly

The Reality 90% of us will die after a progressive decline from chronic illness.

Results More than 70% of Americans say they would prefer to die at home 25% of deaths occur at home (Robert Wood Johnson Foundation)

From This

The number of people over age 85 will double to 10 million by the year 2030 People living longer with chronic disease. The 23% of Medicare patients with > 4 chronic conditions account for 68% of all Medicare spending Aggressive treatment at end of life often leads to a decrease in quality of life for patients and their families Significant association between increased cost and lower quality of death in the final week of life The Demographic Imperative Chronically Ill, Aging Population is growing

9000 Patients with life-threatening illness, 50% died within 6 months Half of patients had moderate-severe pain, >50% in the last 3 days of life. 38% of those who died spent >10 days in ICU, in a coma or on a ventilator

Why Difficult to discuss “I’ll die in my sleep” Magical thinking “If I talk negatively, it will happen” Seen as “giving up” Family doesn’t want to discuss Some would argue that in general we have lost faith in transcendent life Advance care planning consists mostly of funeral arrangement

Most people say they want to discuss their values and wishes about end of life care with their physician—and they expect the physician to bring up the topic Physicians feel patients will have difficulty discussing these sensitive issues Most people are never asked about their wishes Only 10-15% of Americans have Advance Directives

Intro to Palliative Care "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." The Nature of Suffering and the Goals of Medicine- Eric Cassell

Intro to Palliative Care Medical code of ethics and clinical guidelines explicitly indicate the importance of respecting patients’ rights, goals and values, as well as good communication, advance care planning, and recognizing when continuing treatment is more harmful than beneficial.

Patient and family centered care Optimizes quality of life by anticipating, preventing and treating suffering Throughout the course of illness A holistic approach that includes physical, intellectual, emotional, social and spiritual needs Facilitates patient autonomy, provides information and choice

Traditional Care Model Curative Care Hospice Care < Disease Process – 

Conceptual shift for Palliative Care – ever increasing presence of Palliative Care throughout the disease process.

Pain and symptom control Avoid inappropriate prolongation of the dying process Achieve a sense of control Relieve burdens on family Strengthen relationships with loved ones Closure – I love you and goodbye

 Loved one’s wishes honored  Inclusion in decision process  Support/assistance at home  Honest information  Personal care needs met (bathing, etc.)  To be listened to  Privacy  To be remembered after the death What do Patients and Families Want

Palliative Care Services Provides: Compassionate care Management of distressing symptoms Clarification of treatment options Improves communication between patients and caregivers Assists with establishing advance directives Help patients to develop their goals of care Time to listen

Goals of Care Family discussions to determine patient’s wishes – What is important to the patient and their family Determine setting for care Provide information re: Hospice as appropriate Evaluate support systems Evaluate spiritual needs Provide information regarding treatment options Talk about what happens at the end of life Assist patients and families with Advance Directives

Symptom Management Pain Nausea Constipation Anxiety Shortness of Breath Agitation Depression

Palliative Care Assists With I hope treatments will be explained and I will be included in treatment decisions I hope my life has meaning I hope I can still meet some of the goals that are important to me I hope I can get help with the practical things I need to do before I die Redefining Hope

Palliative Care Assists With Healing fractured relationships Completing unfinished business Taking a trip The Bucket List Maintain Dignity Redefining Healing

Relief of distressing symptoms Help navigating a complex medical system Understanding the plan of care Coordination and control of care options Allowing simultaneous palliation of suffering along with continued treatment Practical and emotional support for patients and exhausted family caregivers

Hope for the best, But make arrangements just in case.

Hippocratic Ethos To cure occasionally To relieve often To comfort always

Please join us: -harrison-medical-center/ & Quality of Life Forum Harrison Silverdale May 21 st at 5:30 PM or