1. Palliative Care Consultation Elizabeth Whiteman, MD James Davis MD

2. Goals and Objectives Provide effective consultation Improve Communication skills with primary team Be able to assess patient palliative symptoms Write a concise exam and recommendations Follow up and provide support to patient and family as well as assist primary team in patient care

3. How does the role of a consultant differ from that of a treating physician? Consultant The consultant is asked to answer specific questions relating to an area of expertise. The consultant provides advice and recommendations to another physician or colleague. Treating Physician The treating physician chooses whether or not to carry out recommendations

4. Who is your client 1. The requesting physician/ team 2. The Patient 3.The patients family ▫All of the above, but the requesting physician is the one who has the question and requested the consult ▫Often may be in a difficult situation, work together with team to address teams questions AND patient goals

5. Key Components to effective consultation Initial Contact Patient Assessment Written Note Follow-Up

6. Initial Contact, You Should... Identify the consulting physician – resident, attending Establish the reason for the consultation and the urgency Discuss/negotiate with the resident – in person or by phone Additional suggestions

7. Reasons for Inpatient Palliative Care Consultation Pain management Other symptom management End of Life Care Goals of Care discussion Family Support/ Physician Support Hospice referral/ Discharge planning

8. Palliative Medicine The active” total care” of patients ▫With chronic disease ▫With reversible /curable disease ▫With palliative treatment plan ▫With disease not responsive to treatment ▫With ongoing symptoms ▫Near end of life

9. Objectives for a Palliative Care physician Control of physical and psychological symptoms Competency in bioethical principles Understanding options for care in end of life patients; home care, hospice, nursing home Communication skills

10. Patient Assessment Assess for any acute symptoms that need urgent management. Review other palliative symptoms that may need treatment or intervention. Contact family members, nurses report and address teams questions. Facilitate discussion or family meeting, other interdisciplinary needs (eg: chaplain, social worker)

11. Patient Assessment - cont’d. Perform pertinent exam Look for common secondary issues: malnutrition, weakness, anorexia, delirium, spiritual suffering

12. The Palliative Examination – Symptoms ▫Pain ▫Shortness of Breath ▫Nausea, Vomiting ▫Dry mouth, secretions ▫Constipation, diarrhea ▫Anorexia ▫Fatigue ▫Depression/Anxiety

13. Rate Pain 0-10 ▫Factors that improve or make worse Dyspnea ▫Rest, ambulation Mental status: depression, Assess for delirium if appropriate

14. Additional problems may need further assistance Spiritual Social Ethical Discharge plan Facilitate communication Resources Goals of care Prognosis Legal : advance directives/POLST, wills

15. The Written Note Consulting Physician Reason for consultation Problem List Recommendations Discussion

16. Consulting Physician Write the name of the physician who called and name the Attending Physician I need advice could you help? Sure I need advice could you help? SURE

17. Reason for consultation A concise phrase or sentence giving the reason or reasons you are seeing the patient. This should be agreed upon and understood by the treating physician.

18. History/ Current Problems List problems that relate to the reason for consultation first. Summary syndromes related to diagnosis or symptoms.

19. Past Medical history List pertinent current diagnosis Recent interventions, treatments Coexisting medical conditions Any surgical history especially related to disease

20. Medications List all current medications Note any past medications on hold

21. Allergies True allergies Side effects from medications ▫Eg: nausea from certain medicine ▫Eg: lethargy or insomnia

22. Social history Pertinent social history including: ▫Recent functional status prior to hospital AND current functional status (ADL and IADL) ▫Social support: caregivers, family ▫Living situation ▫Smoking, ETOH, drugs ▫Advance directive or primary contact in event of emergency

23. Review of Symptoms- Palliative focus Pertinent 14 point review of systems Palliative care assessment ▫Anxious/nervous ▫Sad/Depressed ▫Dyspnea ▫N/V ▫Fatigue ▫Consciousness ▫Stool Pattern ▫Spiritual/Emotional Distress ▫Other ▫Functional Status ECOG

24. Physical exam Vitals General HEENT: oral exam, NG tubes Lungs CV, vascular Abdomen Extremities Skin-decubitus ulcers, skin rashes, discoloration Muscle tone, motor function, contractures Psych: depression, anxiety, delirium

25. Labs, tests Pertinent labs Radiologic studies ▫X-rays ▫CT/ MRI/ PET Other: swallow studies, EMGs etc.

26. Assessment and plan Short summary -1 LINE List active symptoms ▫Make sure to address teams question List other palliative care symptoms active AND those potential symptoms future Code Status Goals of care, include patient’s primary contact in event of emergency Social-caregivers, family support Plan for follow up

27. Recommendations List these in a column and number them. They should look like orders that could be transcribed on to the order sheet. Make specific recommendations and limit the number FOCUS on Palliative recommendations Carry out any recommendations you can with the agreement of the treating physician.

28. Example: 68 year old male with metastatic colon cancer, new pain and nausea Pain ▫Morphine sulfate 30 mg PO q 12 hour ▫Morphine sulfate 10mg q4 hr PRN Nausea ▫Start prochlorperazine 10mg q6hr prn Social- pt request info on hospice care, order hospice consult

29. Follow-Up Be flexible – be prepared to alter recommendations as events unfold. Add recommendations as new problems arise. Maintain verbal communication – directly contact the consulting physician with any important new recommendations. Get feedback on prior recommendations. Anticipate – every patient needs a discharge plan, advanced directives

30. References Weissman, D, Consultation in Palliative Medicine, Arch Internal med, Vol 157, Apr 14, 1997.