1. PALLIATIVE CARE Sheri Kittelson, MD

2. Palliative Care Learning Objectives: Meet the team Define Palliative Care and Hospice Review of Key Research Advance Directives

3. Palliare… …to cloak PALLIARE... Interdisciplinary care that aims to relieve suffering and improve the quality of life, optimize function, and assist with decision- making for patients with advanced illness and their families.

4. Since 2007, Ranking includes Palliative Care Marker of High Quality

5. Interdisciplinary Team: Department of Medicine  Director: Dr. Kittelson & Hospitalists  Pediatric: Dr. Lagmay  Nurse Practitioners: Debra & Paula  Social Worker: Cathy  Chaplain  Psychology  Ethics  Hospice  Outpt Team: Integrative Medicine/Therapy/Nutrition

6. New Model for the Best CarPe Possible Old Model New Model Adapted from: Lynn, J. (2005). Living long in fragile health: The new demographics shape end of life care. Hastings Center Report, Spec No: S14-18.

7. Spectrum of Palliative Care Services: 7 Inpatient Palliative Consults Outpatient Palliative Consults Home Based Palliative Consults Hospice Patient Inpatient UnitBereavement

8. Palliative Care Consult Service: Holistic Approach. Aggressive pain and symptom management to improve Quality of Life. Lead difficult discussions including Goals of Care (prognosis, code status, completion of advance directives). Prolongation=Function=Comfort

9. Patient Team Goals  Introduction and referral to Hospice when appropriate.  Spiritual Support/Psychological Support  CAM: Arts/Animals/Integrative Medicine  Communication/Family Support/Bereavement Plan

12. Hospice Myths:

13. PalliativeHospice 13  Chronic illness  Can seek life-prolonging, curative treatment  No eligibility criteria  Medicare – part B  Same Co-pay as other MD visits  Terminal illness  Not seeking curative treatment  Expected prognosis of six months or less if the illness runs its normal course  Medicare – part A

14. Key Research in Outcomes, Quality and Cost Metrics CAPC Hospice  Survival for hospice (+29 days) vs. non-hospice decedents.  Lung, pancreatic, colon, breast, prostate, and CHF  Improved sx control, enhanced pt/family satisfaction, improved caregiver outcome, reduced cost  Program (Home, Nursing Home, Care Center)

15. Case Example: 86 year old male presents to the Emergency Department – Fever, shortness of breath, hypotensive – Lung Cancer with Metastases – Family members present: Wife and 2 daughters – “Please do everything” http://www.hscj.ufl.edu/emergency- medicine/RiversideProject.aspx#prettyPhoto/3 5/

16. Next steps? What do we usually do? What do you want to do? What’s “the right thing”?

18. Palliative Care JAMA 2000: Factors Considered Important at the End of Life by Patients, Family, Physicians, and Other Care Providers – >90%: pain and sx management, prognosis: preparation for death, achieving sense of completion, decisions about trx preferences, being trx’d as whole person – 64% NOT being connected to machines

19. Palliative Care New England Journal of Medicine 2010, Early Palliative Care for Patients with Lung Cancer – Patients Lived 3 months Longer – Better Quality of Life and Mood – Less aggressive care JAMA 2014: Surgical Palliative Care Consultations – (Elective) Pre surgical consults in Frail patients – Significant Decreased Mortality

22. Quality of Life Potential Benefits Risks Shared Decision Making

23. Summary Palliative Care – Primary Benefit Patients: Symptoms (13 studies) improved,↑ QOL, live longer despite less aggressive care – “Do everything” Shared/Informed decision making – Secondary Family & Medical Team: Improved care giver satisfaction, communication – Tertiary System: Quality, Education, Integration, Cost (Health Care Resource: Choose Wisely)

24. Generalist Plus Specialist Palliative Care (N Engl J Med 2013;368:1173-75) Primary Palliative Care:  Basic management of: ◦ Pain and symptoms ◦ Depression and anxiety  Basic discussions about ◦ Prognosis ◦ Goals of treatment ◦ Suffering ◦ Code status 24

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26. Generalist Plus Specialist Palliative Care (N Engl J Med 2013;368:1173-75) Specialist Palliative Care:  Management of refractory pain or other symptoms  Management of more complex depression, anxiety, grief, and existential distress  Assistance with conflict resolution regarding goals or methods of treatment ◦ Within families ◦ Between staff and families ◦ Among treatment teams  Assistance in addressing cases of near futility 26

28. Advance Directives

29. La Cross WI

31. Advance Directive Form The UF Health Advance Directive has three sections:  Designation of a Health Care Surrogate  Living Will Declaration  Anatomical Donation Form

32. Florida Yellow DNR Form DF Form 1896 - must be printed on yellow legal paper to be valid If accurately completed, this form will be honored in the emergency department For incapacitated patients, two physicians, one of whom must be the attending must document in Epic

33. DNR Quick Reference Guide