1. Palliative Care with Older Adults Section 1: Approaches to Care of Advanced Illness in Elders, Palliative and Hospice Care Grace Christ, MSW, PhD Susan Blacker, MSW,RSW Resource Review for Teaching Resource Review for Teaching

2. Synopsis “Palliative care is the interdisciplinary specialty that focuses on improving quality of life for patients with advanced illness and for their families through pain and symptom management, communication and support for medical decisions around goals of care, and assurance of safe transitions between care settings.” Morrison, Maroney-Galin, Kralovec & Meier, 2008, p. 1784

3. Social Workers provide the majority of mental health, psychosocial, and bereavement services in hospice and in hospital-based palliative care. As the older population increases and requires more palliative services it is essential for social workers to develop expertise in this area. Connor, 2007-2008 Synopsis

4. Palliative care is also a care coordination intervention model that aims to organize patient care for patients with advanced illnesses to be more effective in meeting patients’ needs. Social Work needs to take leadership in evaluating, modifying, and improving hospice and palliative care models using the Social Work knowledge, skill, and value base. Synopsis

5. Hospice and Palliative Care: Two Different Approaches to Advanced Illness Hospice is most often provided in the home or in a long-term care facility. The patient must be off curative treatment, with a 6-month life expectancy, and have a care partner in order to receive reimbursement for Hospice in home Palliative care is most often provided in the hospital or in an outpatient facility without the requirement of a specific prognosis. It can be delivered in combination with curative treatment; however, home care is not adequately provided under this reimbursement structure and therefore palliative care patients are often referred to Hospice when they are in the home and no longer receiving curative treatments.

6. Palliative Philosophy The palliative care philosophy developed within Hospice to improve quality of life of patients and their families facing the problems of life threatening illness. This is accomplished by early identification and careful assessment of pain as well as other physical, psychosocial, and spiritual problems.

7. Hospice Care Hospice initiated the palliative care approach. However, in the U.S. treatment reimbursement restrictions prevent many patients from receiving this care.  Two physicians must state life expectancy is less than 6 months. Newer options make such a determination more difficult.  Patients must agree to forgo curative treatments. These, however may aid in reducing pain and other serious symptoms. Palliative care was initiated to broaden the access to these services, specifically in hospitals to be able to provide both supportive and curative care throughout the period of advanced illness.

8. Palliative Care Model Components Palliative Care: 1.Provides relief from pain and distressing symptoms. 2. Affirms life and regard dying as a normal process. 3. Intends to neither hasten nor postpone death. 4. Integrates psychological/spiritual care. 5. Offers a support system to help patients live as actively as possible until death.

9. Palliative Care Components 6. Offers a support system to help families cope during the patients illness and their own bereavement. 7. Uses a team approach to address needs of patients including bereavement counseling when indicated. 8. Enhances the quality of life for the patient and possibly influence the course of illness. 9. Is applicable early in the course of illness, in conjunction with other therapies intended to prolong life, and includes investigation needed to better understand and manage distressing complications.

10. Traditional Model of Care

11. Combined Model of Care

12. Integrated Model of Care A Model to Guide Hospice Palliative Care: Based on National Principles and Norms of Practice. Ferris FD, Balfour HM, Bowen K, Farley J, Hardwick M, Lamontagne C, Lundy M, Syme A, West P. A Model to Guide Hospice Palliative Care. Ottawa, ON: Canadian Hospice Palliative Care Association, 2002.

13. Demographic Context of Illness: A Century of Change CDC. (2007). Centers for Disease Control and Prevention and the Merck Company Foundation: The State of Aging and Health in America 2007 (Publication. Retrieved 1/15/2008: www.cdc.gov/aging and www.merck.com/cr)

14. Social Context of Illness Six social realities shape the discussion of advanced and terminal illness in the U.S.: 1. The aging of the Baby Boom generation. 2. High profile media debates: e.g., assisted suicide. 3. Increased mass violence, human caused and natural disasters. 4. Caregiver burden. Family and community caregivers shouldering increasing burden of longer trajectory of advanced illness. 5. Access problems at all levels: Uninsured, underinsured, reduced coverage of insurance in long-term severe disorders such as mental illness. 6. Quality of care problem: Emerging criticism of our current system.

15. Changing Epidemiology of Disease As populations age, the pattern of diseases that people suffer and die from also changes. Increasingly more people die as a result of serious chronic illnesses such as heart disease, cerebrovascular disease (including stroke), respiratory disease, and cancer (Murray & Lopez, 1997). Older people often suffer from multiple chronic conditions that might contribute to death, making it difficult to establish the main cause of death.

16. Major Challenges of Advanced Illness in Older Adults Greater medical complexity in older adults. Changing course of advanced chronic and terminal diseases. 1.Cancer: Rates increase in older populations 75% of deaths from cancer occur age 65+. 2.Heart failure: Incidence of 10% age 70+; 5-year mortality (80%) is greater than for cancer. 3.Dementia: Affects 6% to 10% of aged 65 or older. Affects 30% of aged 85 or older. Median survival after diagnosis is 8 years.

17. Movement Toward Integration Hospices, traditionally located in the community, now frequently provide service in long-term care facilities, hospitals, and other health care programs. Palliative care has emerged as a sub-specialty within medicine and a program within hospitals to provide cost savings and high quality alternatives to intensive care units for advanced illness. Advocates of both approaches are working to develop a model of a seamless continuum of services for advanced illness that address patients’ varied needs and preferences over the long course of their illnesses.

18. Social Work Role Differences in Hospice and Palliative Care in US Hospice makes extensive use of home-based services in which the social worker has autonomy with patient and family, and also unique responsibility. In hospital, the palliative care social worker collaborates extensively with multiple professionals and teams. Patients electing palliative care that permits curative treatment are more ambivalent about confronting the terminal nature of their illness too directly. This requires more flexible use of directness in interventions.

19. Conclusions During the past decade there has been a strong national movement to extend the holistic palliative philosophy throughout the course of treatment rather than only when death is imminent. Since 2000 Palliative Care Programs have increased from 632 to over 1300. These programs have been accepted within hospitals as an alternative to intensive care of terminally ill patients. These programs were developed to address the vast unmet needs among aging and dying patients, but also to address concerns about the cost of care for a growing aging populations.