1. What is Palliative Care?
J. Keith Mansel, M.D.

2. What is Palliative Care?
J. Keith Mansel, M.D.

3. Relevant Financial Relationships
None

4. Objectives Describe Palliative Care and how if differs from hospice
Identify goals of care and how they can help with shared decision making
Define some communication techniques to help with goals of care discussions and breaking bad news

5. UMMC Palliative and Supportive Care
“We are a specialized team that is patient centered and relationship based who care for persons with advanced, serious illness. Our goals are to help them make wise choices, focus on what is most important to them, and provide relief from suffering.”
UMMC Care and Communication Team
Patient Centered and Relationship Based

7. “Where is the knowledge we have lost in the information, And, where is the wisdom we have lost in the knowledge?” T. S. Eliot

8. Case One
You are asked to see a 64 y/o man with recently diagnosed small cell carcinoma of the lung. He is experiencing pain and dyspnea and will begin radiation therapy followed by chemotherapy in the next few days. He has limited disease and his oncologist is optimistic about a positive response.
You begin opioids for symptom management and schedule another visit in one month.

9. Pain is inevitable……Suffering is optional Anonymous

10. Palliative Care Palliare- “to cloak, deceive, or cover”
Palliate- “to lessen or mitigate without curing”
Palliative Care- term first coined in 1974 by Dr. Balfour Mount

11. Palliative Care Provides relief from pain and other symptoms
Affirms life and regards dying as a normal process
Intends neither to hasten death nor postpone death
Integrates the psychological and spiritual aspects of patient care

12. Palliative Care
Offers a support system to families, including bereavement
Uses a team approach
Enhances quality of life and at times may positively influence the course of a disease
Is applicable early in the course of an illness and in conjunction with other life prolonging therapies
Hospice is one facet of palliative care

13. Integrating Palliative Care into Chronic Life-Limiting Disease Management
“best care possible”
Bereavement
Death
Terminal phase
Time %
clinical
efforts
100

14. Palliative Care & Hospice
Comfort

15. Hospice
Support and care for patients and families in the last phase of an incurable illness
Attempt for patients to live as fully and comfortably as possibly
Focus on quality of life and symptom management
Continue to care for the patient, with a shift in focus

16. Hospice Medicare benefit, enacted 1983 Hospice is paid a per diem
Pays for nursing care, meds, DME
No routine office visits

17. Hospice Interdisciplinary approach-nurse driven 24 hour on call RN
Supplies, equipment, most medications are paid for
Hospice takes over medical care
Respite care
Do not have to be DNR

18. Hospice Most care provided in home
May be provided in NH or residential hospice
Two physicians must certify that survival is anticipated if the disease trajectory continues it’s expected course
Patients may stay in hospice more than six months

19. Hospice GIP
Care in an inpatient setting for pain or other symptom management
Cannot be managed in other settings
Intended to be a short term intervention
Hospice makes determination of eligibility
It is not an “automatic” level of care for imminently dying patients
Examples are pain crisis on IV meds and delirium with behavioral issue
Cap on these for each hospice

20. Early Integration of Palliative Care is Indicated for Patients with Cancer
Palliative Care is not just for patients at the end of life
The goal of palliative care is to improve quality of life throughout the trajectory of a serious illness
Focus is on symptom management, advance care planning, psychosocial support, and relief of suffering

21. Early Integration of Palliative Care….
A recent study in patients with advanced lung cancer and early palliative care revealed improvement in quality of life and survival
Palliative Care can be provided with concurrent target-directed therapy
American Society of Clinical Oncology recommends palliative care be integrated early in cancer patients

22. Early Integration of Palliative Care
Generally focus on symptom management initially
Patients want to have relief of symptoms and know you care- this helps build trust
Advance Care Planning (ACP) can come later
ACP is a conversation about the right medical treatment for your patient

23. Early Integration of Palliative Care….ACP
Improves patient compliance
Reduces hospitalizations at the end of life
Leads to greater patient satisfaction
Is longitudinal, iterative, incremental, and almost always changes over time
Slow is sometimes best-patients can only assimilate so much information

24. Take Home Message
Palliative Care is appropriate for patients with serious illness at any stage of their disease process

25. Case Two
An 88 y/o female is admitted to the CCU with a non-STEMI. Her chest pain has resolved and her ejection fraction is preserved. Cardiac catheterization reveals 3 vessel disease. She has Type II diabetes and CKD with a creatinine of 2.1.You are asked to see her for goals of care.

26. Goals of Care A common reason for Palliative Care consultation
Often elderly patients with multiple medical problems and large symptom burden
Not just at end of life

27. Goals of Care…..
Complex interaction requiring an intricate knowledge of the clinical realities as well as prognosis
Necessitates understanding your patient’s values, preferences, and priorities
Skill at responding to emotion, breaking bad news, and using a shared decision making model

28. Goals of Care-How to Conduct the Discussion
Through compassionate listening, establish a bond by making a non-medical connection
Have your patient share their narrative-this can be both diagnostic and healing
Understand their perception of their medical condition (Ask-Tell-Ask)
Ask about the “Big Picture”
Give small pieces of information and check in

29. Goals of Care Guide
If your health worsens, what are your most important goals?
What are your biggest fears and worries about the future of your health?
What abilities are so critical to your life that you can’t imagine living without them?
If you become more ill, how much are you willing to go through for the possibility of gaining more time?

30. “Between the emotion and the response, Falls the shadow” T. S. Eliot

31. Relationships- PEARLS
Partnership- “We are going to work on this together”, “I will be here for you”
Empathy- “You appear sad”, “I wish things were different”, “I imagine this is very hard”, “Tell me more”
….silence….head nodding….emotive vs.
cognitive….never respond to an
emotion with a fact…..state the
obvious…..

32. Communication…PEARLS
Acknowledge/Apologize- “You have done a wonderful job caring for your mother”, “ I am sorry I am running late and made you wait”
Respect- “We may disagree, but I respect what you are telling me”, “I can’t tell you how great it is to see you doing some exercise, that’s really important”

33. Communication PEARLS…
Legitimize- “Anyone in your situation would be tearful”, “It is normal to have the frustrations you are experiencing now”
Support- “ I am going to call your doctor so she knows we are all working together on this”, “Here is my contact information. I am here to work with you.”

34. Communication…Helpful Phrases
“Before we talk about your medical issues, tell me a little about yourself”
“How do you understand the big picture of your health right now?”
“What are your expectations of the time we have together today?”
“What else?”
“Is there anything we haven’t talked about that I should know to help care for you?”

35. Communication….Helpful Phrases
“I think I am beginning to understand what is bothering you”
“Go on”
“Uh huh” with head nodding
“So what I heard is…”
“Let me be sure I got this right”
“I share your sorrow. I consider your father a good friend.”
“Just so we are on the same page…”

36. Case continued…
88 y/o with MI
What did I do?

37. Take Home Message
Goals of Care conversation requires knowing your patient, listening to their story, and understanding their values and preferences
Showing empathy and responding to emotion are essential features of communication
Using a shared decision making model, making a recommendation when appropriate is beneficial

38. Objectives Describe Palliative Care and how it differs from hospice
Identify goals of care and how they can help with shared decision making
Define some communication techniques to help with goals of care and breaking bad news