1. Integrated regional Palliative Care Services – supporting end of life care Options Dr Robin Fainsinger Professor & Director Division of Palliative Care Medicine University of Alberta Edmonton, Alberta Canada

2. Objectives Describe integrated palliative care service options Discuss results demonstrating end of life care outside of hospitals

3. 65 year man with Ca Lung Admitted to hospital with confusion Given IM morphine for pain Found to have Brain mets Transferred for radiotherapy Given IV morphine & IV hydration Family want to take him home Discharged without any discussion of home care plan or end of life care options

4. Integrated PC Services Exist across Canada

5. 65 year man with Ca Lung Admitted to hospital with confusion Assessed by Palliative Care team & started on Sc morphine & hypodermoclysis for hydration Found to have Brain mets Transferred for radiotherapy Assessed by PC team, Sc morphine & hypodermoclysis continued

6. Family want to take him home PC team contacts family physician & Palliative home care Ongoing maintenance of Sc opioids & hydration by hypodermoclysis on return home 3 weeks later admitted to Hospice PCU Sc opioids & hypodermoclysis continued Same clinical & psychosocial assessments at all points of care Goals of care communicated across points of care

7. Bruera et al Edmonton RPCP impact on patterns of terminal cancer care. CMAJ 1999;161:290 Retrospective study comparing the patterns of care and sites of death before the RPCP (1992/1993) and 2nd year of operation (1996/1997) Cancer related deaths in acute care facilities decreased from 86% in 1992/1993 to 49% in 1996/1997 Inpatient days in acute care hospitals decreased from 24,566 to 6,960 over the same period

8. Palliative Care Programs in Alberta Calgary (October 1996) Edmonton (July 1995) Interdisciplinary Coordinated Comprehensive Integrated

9. Utilization & costs of the introduction of system-wide palliative care in Alberta, 1993- 2000 Fassbender K, Fainsinger RL, Brenneis et al Palliative Medicine 2005;19:513-520

10. Figure 4: Probability of Referral to Palliative Care by Type of Service at Any Time in Last Year of Life, 1993/94 to 1999/00, n= 16,282. Referral to any palliative care service

11. Location for the last 365 days before death (1999/00) n = 2549

12. Fainsinger R, Brenneis C, Fassbender K Edmonton, Canada: A Regional Model of Palliative Care Development JPSM 2007;33:634 27.8% of cancer patients die at home Location of death 3.4% die in nursing homes 28.9% of patients die in hospice 40.0% die in acute care 8.4% in the tertiary palliative care unit

13. Patients spend 87.1% of their time at home in the last year of life - Location of Care 3.5% of time is spent in nursing homes, 2.4% of time is spent in hospice PCU 8.1% is spent in acute care Includes 0.6% in the tertiary palliative care unit

14. P & EOL Care Achievements Access & availability increased Continuity of care/family physician involvement Cost Neutral Decreased hospital care days