1. Supportive & Palliative Care Service: Professional Practice Conference Caroline Olney, RN MSN NP October 21, 2010 San Francisco General Hospital

2. What we hope you will learn: Identify the relationship between palliative care and hospice care Become familiar with new palliative care resources for pts/families/staff at SFGH Recognize where and how to document a patient’s wishes Identify other resources in the Bay Area

4. What is Palliative Care? “Palliative care is the medical subspecialty focused on preventing, treating and relieving the pain and other debilitating effects of serious and chronic illness.” “Palliative care is not dependent on prognosis and can be delivered at the same time as curative treatment. The ultimate goal: to improve quality of life for patients and families facing serious illness.” Center to Advance Palliative Care, 2009

5. Palliative Care Patient and family as unit of care Attention to physical, psychological, social and spiritual needs Interdisciplinary team approach Education and support of patient and family Extends across illnesses and settings Bereavement support http://www.nhpco.org

6. Traditional Approach to End-of-Life Care Curative care % Focus Time DeathTerminal phase 100 Palliative or Hospice Care 0 “Nothing more we can do” Adapted from S Pantilat, PCLC 2005

7. Integrated Model for End-of-Life Care Curative care % Focus 0 100 Time DeathTerminal phase “Best care possible” Bereavement Adapted from S Pantilat, PCLC 2005 Hospice Care Palliative Care

8. The Palliative Care Spectrum Hospice Pain Management Life-Prolonging Therapy

9. Palliative Care vs. Hospice Care Palliative Care Eligibility does not depend on prognosis Can be given at the same time as life-prolonging interventions Provided in hospital, SNFs, outpatient clinics, or home Hospice Care Usually only accessible for pts with very limited prognosis (<6 months) Best for patients who choose to forego life- prolonging treatments Can be provided at inpatient hospice, in SNF/RCFE, or home Both involve comprehensive management of physical, psychosocial, emotional, spiritual components of care, to enhance quality of life for patients and families

10. Early Palliative Care for Patients with Metastatic Non-Small-Cell Lung Cancer “Among patients with metastatic non small-cell lung cancer, early palliative care led to significant improvements in both quality of life and mood. As compared with patients receiving standard care, patients receiving early palliative care had less aggressive care at the end of life but longer survival” N Engl J Med 2010; 363:733-742 New York Times Aug 19, 2010

11. Supportive & Palliative Care Service Inpatient Consult Service, launched December 2009 An interdisciplinary team including: –Physicians: Anne Kinderman, MD, Medical Director Heather Harris, MD, Associate Medical Director –Nurse: Caroline Olney, RN MSN NP –Social Worker: Regina Epperhart, MSW –Chaplains: Eric Nefstead, MDiv and Elizabeth Welch, MDiv

12. Supportive & Palliative Care Service Expertise in: –Communicating with patients and families (explaining diagnoses or prognoses, establishing goals of care, and facilitating family meetings) –Treating refractory or complex symptoms –Addressing psychosocial or spiritual concerns –Coordination of care across health care settings –Facilitating transitions from life-prolonging care to comfort care or hospice care

13. SPCS: 443-5063 Available to all patients in the hospital Monday-Friday 8am-5pm (except holidays) Consult requests must come directly from the inpatient primary physician –All providers (nurses, social workers, nutritionists, etc.) are encouraged to recommend consults to the primary team

14. How do you request a consult? The best way to ensure that your patient gets a palliative care consult is to include this in your note in LCR. Also, contact the admitting team directly to ensure your request for a consult was received.

15. Which patients might benefit from a SPCS consult? Patients with ANY advanced or life-limiting illness and: –Unclear goals of care –Frequent ED visits or hospitalizations –Uncontrolled pain or other symptoms –Psychosocial/spiritual distress (pt/family member) –Difficult decision-making with pt/family or difficult communication with pt/family Patients who are transitioning to comfort-oriented care or who may die in the hospital

16. SPCS: Resources for Patients and Families Comfort Care Suites –2 double rooms converted into single room suites located on 5A (9 & 12) –Suites redecorated with the help of grant support from the SFGH Foundation and Healing Environments (new flooring, furniture and art) –Occupancy triaged by 5A charge nurse and SPCS. Patients who are imminently dying are prioritized over med/surg patients. –More room for visitors to stay with the patient; visiting hours 24/7 –5A nurses have additional training, experience with end-of-life care Social Work –Provide information on community resources (hospice, funeral arrangements, bereavement support, etc.) Chaplaincy –Sojourn chaplaincy: 206-8500 –Catholic priest: 206-8119

19. SPCS: Resources for Staff Provide education and training –Physicians & Nurses –Rehab specialists, social workers, interpreters, etc. Support/debrief difficult patient or family interactions, particularly regarding end-of-life issues Provide information on community resources (hospice, funeral arrangements, bereavement support, etc.)

20. Communication Toolbox 3 questions: –What do you know? –What do you want to know? –Who do you want with you? 3 techniques: –Clarify ambiguity –Talking / listening / silence –Affect vs. cognition

21. Communication Toolbox Helpful open-ended questions: –What led to your diagnosis? –What do you know about your diagnosis? –What does that mean to you? –What is life like for you now? –What concerns you the most? –What are you hoping for? –What gives you strength?

22. Communication Toolbox Other helpful questions: –Are you comfortable? –Do you feel that your treatments are causing you more harm than good? –Do you feel like you have a good quality of life right now? –If we could do one thing other than cure your illness, what would it be? Helpful phrases: –Your diagnosis is beyond our control but we can still control your symptoms –While we are hoping for a miracle, we are preparing for the worst For more information: www.caringinfo.org

23. Communication Toolbox Sit down Active listening Silence Avoid medical jargon Be respectful Be honest Do not be afraid to use the words death/dying

24. Ira Byock: The 4 Things That Matter Most Please forgive me I forgive you Thank you I love you (Goodbye) (Byock, 2004)

25. Communicating Goals of Care: Advanced Directive & POLST Advanced directive note in LCR Advanced directive in LCR: can be completed by ANY health care provider POLST in LCR: can be printed and filled out by any physician or nurse practitioner California Advance Directive: available in Spanish and Chinese

26. Advanced Directive: CPR/Medical Interventions tab

27. Advanced Directive: Agents/Health Advocate tab

28. Advanced Directive: Organ Donation tab

29. Advanced Directive: Document Location tab

30. Advanced Directive: Confirmation panel

31. Partial view of Advance Directive in LCR

32. Medical alert bracelet May indicate advanced directive and code status Can be linked to the medical record

33. Local Resources In-home support: –Health at home –Sutter VNA AIM Program Hospice –Hospice By The Bay –Pathways Hospice Inpatient Hospices: –Gift of Love Home –Laguna Honda Hospice –Maitri: HIV/AIDS patients –SFVA –Coming Home Hospice –Zen Hospice (Guest House)

34. Questions?

35. Thank You Thank you for joining us today. We appreciate your participation and helping us to develop our palliative care team. Thank you for all that you do.