Transitioning to Palliative Care: Starting the Conversation Dr. José Pereira Head Division of Palliative Care, University of Ottawa Medical Chief, Palliative Care Service, Bruyère Continuing Care & The Ottawa Hospital Provincial Medical Lead for Palliative Care, Cancer Care Ontario

Faculty/Presenter Disclosure  Faculty: Dr. José Pereira  Program: 51 st Annual Scientific Assembly  Relationship with commercial interests: –Grants/Research Support: Takeda (past) Education grant to conduct review of breakthrough pain –Speakers Bureau/honoraria: Nil to report –Consulting Fees: Nil to report –Other: Nil to report

Disclosure of Commercial Support  This program has NOT received financial support  This program has NOT received in-kind support (except for myself and my organization who have allowed me to be here to present on their time)  No potential for conflict(s) of interest to declare

Mitigating potential bias  Jose Pereira –Nil to declare

QUESTIONS What is the annual mortality rate of patients with NYHA Class II? What is annual mortality rate of patients with NYHA Class IV? CHF Mortality 5

QUESTIONS What is the annual mortality rate of patients with NYHA Class II? What is annual mortality rate of patients with NYHA Class IV? CHF Mortality NYHA Class II - Annual mortality rate 5-15% % die suddenly NYHA Class IV - Annual mortality rate 30-70% % die suddenly 6

7 Heyland DK et al. Discussing prognosis with patients and their families near the end of life: impact on satisfaction with end-of-life care. Open Medicine 2009;3(2): QUESTION In a study of 440 patients with end-stage disease, the % of patients who recalled prognosis discussions with their families : 1.Cancer patients? 2.CHF patients? 3.COPD patients? Participants who recalled prognosis discussions

Patients (n=440) :18% Family members (n=160): 30% 8 Patients Had discussion % Did not have discussion % Cancer patients (n=151)27%73% CHF (n=99)14%86% COPD (n=115)9%91% Cirrhosis (n=47)21%79% Heyland DK et al. Discussing prognosis with patients and their families near the end of life: impact on satisfaction with end-of-life care. Open Medicine 2009;3(2): Participants who recalled prognosis discussions

Old model of Palliative Care

Palliative Care: Earlier in illness, not only at end-of-life

RCT of patients with newly diagnosed metastatic lung cancer Early palliative care consultation versus standard of later referral for end of life care Compared to late referred patients, patients with early palliative care consultation had: –Less depression & anxiety –Better quality of life –Lived longer (3 months) Temel J, et al. Early Palliative Care for Patients with Metastatic Non–Small-Cell Lung Cancer. NEJM 2010; 363: Activating palliative care does not shorten life

Palliative and End of Life Trajectories 12   

Palliative Alerts 13 For some patients the decline may be more gradual while for others it may be more precipitous Death Explore pt’s understanding of illness, discuss prognosis & goals of care. Encourage patient to see family physician regularly or find one. Advance care planning. Discuss code status Review treatment plan Advance care planning. Discuss code status Review treatment plan Ensure ESAS & PPS/ECOG done at each visit. Initiate home care Establish plans to deal with emergencies (e.g. pain crisis) DNR & Advanced directives Discuss preferred versus optimal place of death based on needs & circumstances ILLNESS TRAJECTORY IN PROGRESSIVE CANCER Consult Palliative Care Team as needed %

Palliative and End of Life Trajectories 14   

Palliative and End of Life Trajectories 15   

“Will I be surprised if this patient died in the next 6 to 12 months?” 16 Ask the question

Gold Standards Framework: General and Disease-specific indicators

19 How did you feel while viewing the video? What was done well? What can be done better? What are some useful phrases? Goals of care 1

20 How did you feel while viewing the video? What was done well? What can be done better? What are some useful phrases? “How long do I have to live?”

“I wish things were different” Quill T. Ann Int med 2001

23 QUESTION What prevents us from having end-of-life discussions?

QUESTIONS??