1. WakeMed Palliative Care QI Projects Alisha Benner, MD

2. WakeMed quality improvement pilots
Improving identification of CHF patients who would benefit from palliative care consultation
Decreasing placement of feeding tubes in patients with advanced dementia

3. Death from CHF
NYHA III-IV mortality at 1 year is 52%
Hospitalization only improves symptoms in 35-40% (Ward, 2002)
DNR orders
5% of CHF patients
47% of cancer patients

4. End-of-life care in CHF
In the last 6 months of life
High symptom burden
80% of patients are hospitalized
Average days in hospital: 20
Average days in ICU:4.6
Costs rising
Readmissions common
Unroe et al. Arch Int Med 2011;171:
Curtis et al. Arch Int Med 2008;168:

5. Benefits of palliative care
Better communication among the patient, caregivers and the treatment team
Better understanding of what effects the disease has on the patient (family, physician)
Better symptom control
Better understanding of disease prognosis

6. Patient perception 2008 DCRI study (Duke)
To determine personal predictions of life expectancy
122 patients with NYHA III or IV
Average age 62, 47% African American
Median overestimation was 40% longer

7. Physician perception of prognosis
We are unable to predict timing of exacerbations or sudden cardiac death (up to 50% of patients)
In general, clinicians tend to overestimate life expectancy (by a factor of 5.3)
Increased duration of patient-physician relationship results in less accurate prognostication

8. 6A Pilot preparation prior to launch April 2015
Education of all unit staff on all shifts - live or YouTube RN SW
Chaplaincy
Educational sessions with cardiologists and APP’s
Study design
Initially focused CHF patients seen followed by the CHF team
Eventually included all patients admitted to 6A

9. Palliative Care Consult Triggers – 6A Pilot
2+ admissions to the hospital for the same diagnosis within 3 months (CHF)
Prolonged length of stay without evidence of progress
Consideration of artificial nutrition/PEG tube for patient with short anticipated survival or for dementia
More than one ICU admission during same hospitalization
Patient and family in disagreement over advance directive
Critically ill patient with no advance directive or goals of care established
Patient with life threatening illness and patient and/or family with unrealistic goals of care or expectations of recovery

10. Protocol
Bedside RN supplied with copy of paper Trigger Tool which was completed daily
During CHF rounds the charge RN would inquire about the Trigger Tool
If a patient met 1+ triggers the RN would alert the attending MD/APP and request PC consultation
Data collection – by CHF RN
All patients meeting trigger
If PC consult ordered and completed during that hospital stay
Readmission and disposition

11. Obstacles
Completion of Trigger Tool took months to become part of the nursing “daily routine”
Paper Trigger Tool after EPIC launch
More difficult to incorporate in daily routine
Patient/family refused consults
Early in pilot cardiologists were often refusing to place the PC consults
“They are not ready for that yet”

12. What is in a name? 2009 survey of 140 medical oncologists and midlevel providers
Supportive Care
Palliative Care
Service name preference
57%
19%
Advanced cancer patients
89%
69%
Non-cancer primary disease
79%
45%
Service name perceived as barrier to referral 6%
23%
Service name perceived cause of decreasing hope
11%
44%
Service name perceived as causing distress 3%
33%
Cancer 2009 May 1;115(9):

13. The new model of palliative care

18. CHF pilot results Decreased overall readmissions
Patients receiving PC consults discharged to SNF had higher readmission rates
Consult notes discuss lack of family readiness to accept palliative care
Likely attributable to lack of hospice services provided at SNF
6A nurses have become champions of palliative care
Advocate for consults
Pilot is expanding to more units

19. Feeding tubes in advanced dementia
Dementia is a terminal illness, the 6th leading cause of death in the US (Sept 2015)
Difficulty eating is common and expected in end-stage dementia
It is a marker for the terminal stage of dementia
Finucane TE, et al. JAMA 1999

20. Family and physician goals for PEG tubes
Prevent aspiration
Healing pressure ulcers
Improve functional status/survival
Provide comfort
Shega et al. J Palliat Med 2003; 6(6):

21. Aspiration pneumonia and feeding tubes
Numerous case-control studies identified TF as an independent risk factor for aspiration and demonstrated high rates of aspiration PNA and death in TF patients
Nonrandomized prospective study, orally fed patients with oropharyngeal dysphagia had significantly fewer aspiration events than TF patients
No published studies suggesting that TF can reduce the risk of aspiration PNA
Finucane TE, et al. JAMA 1999

22. Pressure ulcers and tube feeding
Two retrospective studies of 800 patients during follow-up after PEG placement
TF not associated with healing of preexisting pressure ulcers
Did not afford protection from new pressure sores
Bedbound and incontinent TF patients are will make more urine and stool
PEG tube placement often leads to patients being physically restrained

23. Functional status/survival and tube feeding
MEDLINE review of literature
No studies demonstrating nutritional intervention facilitating recovery of function or slow its decline
Retrospective review found no SNF patients with improved functional status during 18 months after PEG placement
Study of 1386 patients with severe cognitive impairment, no improved survival between patients with and without TF

24. Patient comfort and tube feedings
When TF are used as a permanent alternative to oral intake, they are deprived of the enjoyment derived from eating
Ability to taste food
Socialization from mealtimes
Human touch from careful hand-feeding
1993 prospective study of terminally ill patients with anorexia due to cancer or CVA (no cognitive impairment)
Few experienced hunger or thirst
Relieved with small amounts of food, fluid, ice chips and lip lubrication

25. AMERICAN GERIATRICS SOCIETY
Feeding Tubes in Advanced Dementia Position Statement May 2013 Percutaneous feeding tubes are not recommended for older adults with advanced dementia. Careful hand‐feeding should be offered; for persons with advanced dementia, hand feeding is at least as good as tube‐feeding for the outcomes of death, aspiration pneumonia, functional status and patient comfort. Tube feeding is associated with agitation, increased use of physical and chemical restraints, and worsening pressure ulcers.

26. Feeding tube pilot
Goal: To decrease feeding tube placement in patients with advanced dementia
Focused only on hospitalized patients with advanced dementia
Alzheimer's
Multi-infarct
Other causes (Frontal lobe, HIV)
In collaboration with WakeMed GI department MD
APP

27. Feeding tube pilot – study design
Study population
All hospitalized patients with advanced dementia with GI consult placed for PEG tube placement in 2015
Hospital-wide
Intervention begun June 2015
Protocol
Patients had completed consult by GI APP/MD
Caregivers were informed of WakeMed hospital policy requiring palliative care consultation prior to PEG tube placement
Palliative care consult placed by GI APP/MD

28. Feeding tube pilot - Results
Compared feeding tube placement pre- and post- intervention
Still awaiting data collection and analysis
Increased provider understanding (upstream effect)
Anecdotal evidence of decrease in GI consults for PEG placement for patients with advanced dementia

29. Lessons learned Find good people to collaborate with
Ask your data people about study design
Let them guide you on what data to collect
Check in with them early
Quality improvement projects are a learning process but bring great benefit to patients and families
Improved job satisfaction

31. Questions?