1. PALLIATIVE CARE AT STANFORD
James Hallenbeck, MD
Medical Director, Stanford Hospice,
VA Hospice Care Center

2. Definitions Palliative Care Palliative Medicine Hospice
Supportive Care

3. The Need
SUPPORT Study
Studies on Communication
Stanford Study

4. SUPPORT STUDY 1995 46% of DNR orders written with 2 days of death
40% of patients/surrogates had discussed CPR with physician
Of 60% who had not done so, 41% wanted to
~ 50% wanted a DNR status, but did have it
50% of patients reported as being in 7/10 or greater pain in last three days of life
SUPPORT JAMA 1995; 274:

5. Tulsky Study on Advance Directive Discussions
Conversations averaged 5.6 minutes
Physicians spoke 66% of the time
Used vague language
Patients values rarely explored
Tulsky JA et. al. Opening the black box: how do physicians communicate about advance directives? Ann Intern Med 1998 Sep 15;129(6):441-9.

6. Stanford Survey 1998
617 Stanford Clinicians, 35 families
Staff and families identified communication as the area most needing improvement
35% of staff felt inexperienced communicating with dying patients and families (residents 64%)
Broad support for a consultation team
61% of physicians surveyed felt that a consultation team would be moderately or extremely helpful
47% of attendings, 64% of residents stated that they would often or always use a consultation team in care of dying pts

7. Stanford- What We Do Not Know...
Site-specific data
Annual # of hospital deaths by age, insurance status
COD and LOS by DRG, Location of death
In most hospitals LOS for patients who die in hospital 2-3 X for those discharged alive
Cost per case by DRG for deceased vs. alive
Audits of quality of symptom relief, documentation of patient preferences

8. The Context JCAHO ABIM AAMC ACGME
New Policy and Regulatory Mandates...
JCAHO
ABIM
AAMC
ACGME

9. Palliative Medicine Evolving as a Medical Subspecialty
American Board of Hospice and Palliative Medicine- > 600 physicians boarded since 1996
A Push for ACGME Accreditation
Currently approximately 16 fellowships nationwide
VA Palo Alto HCS has 2 one-year fellows

10. Palliative Care Services being Integrated into Healthcare Systems
Consultation teams and/or dedicated beds more common
~ 50% of California hospitals surveyed have or are planning dedicated services
VA Palo Alto HCS: 30 dedicated beds, consult team
UCSF: Comfort Care Suites, consult team
Santa Clara Valley Med: 2 dedicated beds, evolving consult team

11. Growing Public Demand for Expert Palliative Care
Bill Moyer’s September Public Television Special on Death and Dying in America Sept
Numerous associated events:
KQED f/u special on associated issues in the Bay Area
Community Action Groups
Community meeting at VA Palo Alto HCS on September 27, sponsored by community hospices

12. Models for Success McGill University- Consult Service
Demonstrated average length of stay halved for terminally
Northwestern Memorial Hospital
Consult and inptatient service since 1994
Average 55 consults a month
Followed for an average of 2 days (range 2-10)
Revenue 1.5 million in 1996, excluding donations exceeded direct costs of ~ 1 million

13. Models for Success
Oregon Health Sciences University Consult Service (of 67 serial consults)
66% Cancer, 34% Non-cancer
59% receiving life-prolonging treatment
41% hospice/palliative care only
20% died during hospitalization
Symptoms addressed: pain, nausea, constipation, delirium…
65% received assistance in EOL care decision making
Bascom PB. A hospital-based comfort care team: consultation for seriously ill and
dying patients. Am J Hosp and Palliat Care. 1997

14. Models for Success
Philadelphia VA: Consult team for Cancer Patients (of 75 patients studied)
164 medical problems identified
31 patients inadequate pain relief
Other problems: skin care, oral care, nutrition nausea, constipation mental status
15 patients referred for hospice- no documentation of wishes regarding resuscitation
36 patients required psychosocial counseling

15. Philadephia VA Study
Of 22 patients followed in Medical Oncology Clinics:
21 had one or more problems identified by consult team
Principally financial, social or spritual
11 patients reported inadequate pain relief
Abrahm JL et al. The impact of a hospice consultation team on the care of veterans with advanced cancer. J. Pain Symptom Manage. 1996; 12:23-31.

16. What are Our Choices? Status Quo
Palliative Care geared to meet JCAHO minimum standards- a process of ‘quality improvement’
A minimalist Palliative Care service
A comprehensive interdisciplinary palliative care consult team
A comprehensive Palliative Care service, bridging venues of care

17. From Consult Team to Palliative Care Service
Establish an interdisciplinary consult team
Attendings, fellow, elective resident/students, nurse, social worker, chaplain
Coordinate with others working in related areas
Stanford Hospice, Pain Service, Pediatrics, Ethics Center, VA Hospice Care Center
Consider identifying dedicated beds, outpatient clinic in later years