BEST PRACTICES IN CARE OF THE DYING James Hallenbeck, MD Hospice Medical Director VA Palo Alto HCS In Search of

Overview Best Practices Various groups working on guidelines –AMA –ABIM –National Cancer Care Network Position papers/policies –Last Acts: Precepts of Palliative Care –VA policy on Pain as the Fifth Vital Sign A conceptual framework Among others

Domains of EOL Care Pain Management Non-pain Symptom Management Communication Ethics Psychosocial, Spiritual Care System issues

Pain Management Standards of Care Patient Centered Standardized assessment tools –Pain as the Fifth Vital Sign Monitoring is incorporated into quality management Specific prescribing guidelines –Ex. For chronic pain, rely on long-acting oral opioids with short-acting breakthrough doses

Pain Management Controversies Generalist vs. specialist Palliative Care specialist vs. Pain Management specialist In Geriatrics- traditional vs. palliative approach: –Polypharmacy vs. mult-modality therapy –Emphasis on functional status vs. relief of suffering

Non-pain Symptom Management Constipation Dyspnea Nausea and vomiting Dry mouth Plus approximately 50 more... What symptoms are we talking about?

Non-pain Symptom Management Standards of Care Overall- emphasis on tailoring drug therapy to specific cause(s) of symptoms Constipation –start treatment when starting opioids –more patient/nurse autonomy in treatment Dyspnea –central role of opioids, benzodiazepines Nausea and vomiting –dopamine antagonists for opioid related nausea

Non-pain Symptom Management Controversies Role of antibiotics in certain infections Role of artificial hydration/nutrition Use of newer, often more expensive palliative medicines –Ex. 5HT 3 antagonists for nausea Overlap/differences between traditional and palliative care for certain symptoms

Communication Standards of Care Active Listening Assessment of patient preferences –Current as well as advance directives Sharing of bad news How to “pronounce” a patient Patient/family education –Prognosis, care options, goals of therapy, normal changes of dying

Communication Controversies Who should communicate what? Time and money involved in good communication Cultural factors Attending physician role in modeling/teaching communication skills –Much EOL communication part of resident sub-culture

Ethics Controversies Physician Assisted Suicide (PAS) Voluntary Euthanasia (VE) Terminal Sedation (TS) Voluntary Self-discontinuation of Eating and Drinking (VSED) Futility Who pays for what? (Issues of justice) Cultural factors

Ethics Standards of Care Discussion and documentation of current and advance directives Non-abandonment Respect for patient, family, healthcare worker values Importance of cultural competency Availability of ethics consultation

Psychosocial, Spiritual Care Standards of Care Recognition/treatment of depression Recognition of the family as the unit of care Appreciation for economics of EOL care Importance of addressing patient/family spiritual needs Bereavement support

Psychosocial, Spiritual Care Controversies Treatment of terminal delirium Role of the physician in this area, esp. addressing spiritual suffering Are we at risk of forcing our notion of a “good death” onto others? Reimbursement for this care In Geriatrics- Independence vs. Interdependence

System Issues Standards of Care Universal access to appropriate EOL care Coordination of care across venues Treatment of patients in the venue of care desired to the extent possible Interdisciplinary approach to care Incorporation of monitors into quality management structure and accreditation

System Issues Controversies ? Right to EOL care Hospice vs. Palliative care Role of managed care Proper reimbursement structure (taking into account): –different dying trajectories (problems with prognosis) –different patient/family preferences for care –differences in case-mix

Summary Standards of care are beginning to evolve Large gaps between “best practices” and current level of practice Major controversies exist as to what constitute best practices