1. Palliative Care Hospice is not enough
Traditional Hospital Care is not enough
Karl Sash, MD
Board Certified: Internal Medicine, Geriatrics, and Hospice and Palliative Medicine
Medical Director, St Mary’s Palliative Care Program
Medical Director, Heart to Heart Hospice Evansville IN
Medical Director, Heart to Heart BRIDGE Palliative Care

2. Choices
Life sustaining
Or…
Comfort
Example: BiPAP

3. Hospice is: A mindset: comfort is more important than duration of life
A benefit that Medicare and other insurances cover - what does this cover?
Medications and everything else related
Day to day care
Bereavement for 13 months
A team consisting of the nurse manager, aide, chaplain, social worker, volunteer, medical director and others

4. Hospice Eligibility Does the person deserve hospice?
Would the person benefit from hospice?
Does the person meet the criteria for hospice?

5. Hospice Eligibility
Symptoms
Functional impairment
Prognosis

6. Hospice Successes
Hospice use among Medicare beneficiaries increased to 42.2 percent in 2009, up from percent in 2000

7. Hospice Failures
More than 28 percent of these dying individuals received hospice care for three days or less

8. Hospice Failures
The % of people who had a stay in an Intensive Care Unit in the last month of life increased to % in 2009 from 24.3 % in 2000

9. Hospice Failures
35.7 percent of hospice patients died or were discharged within seven days of admission
Whereas, only 11.4 percent of patients were under care for longer than 180 days

10. Hospice Failures
The average rate of health care transitions in the last 90 days of life increased from 2.1 per decedent in 2000 to 3.1 per decedent in 2009, including multiple hospitalizations

11. Hospice Failures
Transitions in the last 3 days of life increased from 10.3 percent to 14.2 percent in 2009.

12. Joan M. Teno, M.D., M.S., of the Warren Alpert Medical School of Brown University, Providence, R.I
“Our findings of an increase in the number of short hospice stays following a hospitalization, often involving an ICU stay, suggest that increasing hospice use may not lead to a reduction in resource utilization. Short hospice lengths of stay raise concerns that hospice is an ‘add-on’ to a growing pattern of more utilization of intensive services at the end of life”

13. Palliative Care Across all stages of treatment Addresses Pain
Suffering
Quality of life
Across all stages of treatment
It does not exclude life-prolonging treatment and rehabilitation

14. Current Care Model Symptom control and Palliative Care
“Curative” or “Life-Prolonging” Treatment

15. Doing Everything
Dichotomy between “doing everything” versus providing comfort care—a dichotomy that often fails to focus on relieving suffering and improving quality of care

16. Proposed Care Model “Curative” or “Life-Prolonging” Treatment
Symptom control and Palliative Care

17. Palliative Care vs Hospice
Nonhospice palliative care may be offered along with curative or life-prolonging therapies for patients with complex, life-threatening disorders
Hospice palliative care is offered when patients reach their final weeks or months of life, when the likely harm of life-prolonging or curative therapies exceeds benefit, and these therapies are discontinued

18. Courses of Illness: Cancer

19. Courses of Illness: Heart and Lung

20. Courses of Illness: Frailty and Dementia

21. Real World Experience

22. Multifaceted approach
Clarifying goals of treatment
Communication: listening and asking
Advanced Care Planning
Advanced Directives
POST

23. Multifaceted approach
Managing symptoms
Pain
Constipation
Fatigue
Dyspnea
Nausea
Anorexia and Nutrition
Depression
Delirium

24. Multifaceted approach
Mobilizing resources to optimize care and social support

25. Multifaceted approach
Integrating care across settings
Physician Office Hospital
Nursing Facilities Home

26. Bereavement and Grief
Approximately 15% of bereaved survivors experience complicated grief, defined as grief persisting over 6 months

27. Palliative Care and Quality of Life
Emerging data , concurrent palliative care intervention in the treatment of cancer suggest that patients using palliative care services have higher scores for quality of life and mood than those undergoing cancer treatment alone
2011:
63% “very likely to consider palliative care”
29% ‘somewhat likely…”

28. Palliative Care and Life Expectancy
Patients with newly diagnosed metastatic non–small cell lung cancer randomly assigned to standard oncologic therapy alone versus early palliative care with standard oncologic therapy, patients in the palliative care group had a mean survival of months as compared with 8.9 months in the group not provided early palliative care.
The intervention group also experienced less depression and better quality of life

29. Palliative Care and Costs
Palliative care consultation programs are also associated with significant hospital cost savings, with an adjusted net savings of:
$1696 in direct costs for patients discharged alive from the hospital, and
$4908 net savings for patients dying in the hospital as compared with patients who receive usual care

30. Location of Palliative Care
Hospitals
Nursing Homes
Home based
Medical offices

31. Location of Palliative Care: Hospitals
Comfort Care
Setting limits on Aggressive Care
Example: Hemodialysis
General Inpatient Hospice Care
Vague guidelines
Length of stay and mortality data
More support and more layers

32. Providers of Palliative Care
Nurses
Nurse Practioners
Physician Champions
Social workers
Chaplains

33. Payers for Palliative Care
Hospices
Accountable Care Organizations – Managed Care/At Risk Contracts
Payers:
Aetna: Compassionate Care Program
Excellus BCBS: CompassionNet
Highmark: Advanced Illness Services Program

34. Key Point 1
Palliative care addresses pain, suffering, and quality of life across all stages of treatment and does not exclude life-prolonging treatment and rehabilitation

35. Key Point 2
More aggressive care at the end of life FREQUENTLY does not improve either quality or duration of life

36. Key Points 3: End of Life Guilt: Provider and Family
Respiratory depression as a side effect of morphine occurs rarely in patients who are actively in pain
IV Fluids and Enteral Hydration increase pain and distress

37. Key Point 4
The first step in communication with patients, families, and caregivers regarding palliative care is to establish goals of care in a patient-centered, open-ended format
Physicians must be willing to have discussions with their patients regarding goals of care and the meaningful risks and benefits of treatment options
Physicians must reassure their patients that they support them and their choices regardless of how aggressive or non-aggressive they may be

38. Key Point 5
When a person is diagnosed with a chronic and/or potentially terminal diagnosis and during the course of that illness he or she should expect
An explanation of the natural course of the illness
A discussion regarding the likelihood of benefit and harm from testing and or treatment
Support for palliative care on the part of the primary provider or specialist or a referral

39. Going forward: Inpatient St Vincent Palliative Care Outpatient
Office based palliative care
In the primary care and specialist’s office
Palliative care referral
Community based Palliative care
Heart to Heart Palliative Care Bridge Program - communication driven supportive care

40. Go home and spend time with your family: