1. WRHA Palliative Care Program November 2012 Lori Embleton, Program Director

2. What Is Palliative Care? Palliative Care is an approach to care which focuses on comfort and quality of life for those affected by life- limiting/life-threatening illness. Its goal is much more than comfort in dying; palliative care is about living, through meticulous attention to control of pain and other symptoms, supporting emotional, spiritual, and cultural needs, and maximizing functional status.

3. What Is Palliative Care? Not defined by: – Body system (compare with dermatology, cardiology) – What is done (compare with anesthesiology, surgery) – Age (compare with pediatrics, geriatrics) – Sex of patient (such as with gynecology) – Location of Care (compare with ER, critical care) Any illness, any age, any location…

4. What Is Palliative Care? The spectrum of investigations and interventions consistent with a palliative approach is guided by goals and expectations of patient and family and by accepted standards of health care, rather than being bound by preconceptions of what is or is not "palliative".

5. Potential Palliative Care Interventions Palliative Emotional Spiritual Psychosocial Support Control of Pain Dyspnea Nausea Vomiting Variable Infections Transfusions Hypercalcemia Dialysis Tube Feeding CPR Ventilation Highly burdensome Interventions Generally Not Palliative

6. No Community Outreach Seven Oaks Hospital HSC Concordia Hospital Victoria Hospital Victoria Hospital Grace Hospital Grace Hospital SBGH 20 beds served SBGH and local area SBGH 20 beds served SBGH and local area 39 PCHs RHC 30 beds patients primarily from HSC & community RHC 30 beds patients primarily from HSC & community Jocelyn House 5 beds Jocelyn House 5 beds Winnipeg Palliative Care Services: Pre-Regionalization Inpatient attending & consulting Home consultative support No formal services

7. C C Seven Oaks Hospital HSC Concordia Hospital Victoria Hospital Victoria Hospital Grace Hospital Grace Hospital SBGH 15 beds SBGH 15 beds 39 PCHs Grace Hospice 12 beds Grace Hospice 12 beds RHC 30 beds RHC 30 beds Jocelyn House 4 beds Jocelyn House 4 beds Winnipeg Palliative Care Services: Post-Regionalization Inpatient attending & consulting Home & facility consultative support Childrens Hospital Childrens Hospital Completely new component

8. Palliative Care Program Two streams of service delivery: 1.Registration on Program 2.Consultative Services

9. REGISTRATION ON PALLIATIVE CARE PROGRAM

10. Registration on Program Patients can be registered on the Palliative Care Program if they meet program criteria: – Prognosis of less than 6 months – No longer receiving aggressive treatment which requires on-going monitoring for and treatment of serious complications – Have chosen a comfort-focused approach including a decision to decline attempted resuscitation

11. Registration on Program Once registered with the program, patients are eligible for: – Case management through Palliative Care Coordinator – Access to Community Palliative Care Nursing 24/7 Palliative Care Nurses have access to Palliative Care Physician – Admission to Palliative Care Units (PCU) and Hospice – if bed available – Enrollment on Provincial Palliative Care Drug Access Program

12. When to Register a Patient on Palliative Care Program Patients are considering going home from acute care – Need to plan for services to be in place Patients being transferred to Long Term Care Setting

13. How to Register a Patient on PC Program Complete the Application for Registration form – 2 page form –completed forms can be processed more quickly Completed forms are reviewed by PC coordinator – Accepts on to Program – Rejects application – all reviewed by Manager, Program Director or Medical Director

14. Acute Palliative Care Units St. Boniface Hospital 15 bed unit Access to tertiary care services Riverview Health Centre 30 bed unit (2 beds currently closed) Long term care facility

15. Acute Palliative Care Units (PCU) Admission to PCU for symptom issues – Physical symptoms – Psycho-social distress – Caregiver distress Admissions managed centrally by PC program staff – Bed management guidelines

16. Acute Palliative Care Units Once symptoms are controlled, actively discharge to appropriate site – Approximately 75% of patients die on PC unit – Approximately 20% of patients are discharged home from Palliative Care Units – Lack of care options if home not possible PCH Chronic Care Hospice

17. Hospice settings in WRHA Grace Hospice 12 beds in stand alone facility near Grace hospital RN staffing 24/7 Limitations in care that can be provided

18. Hospice settings in WRHA Jocelyn House 4 beds in split-level home in St. Vital RN staffing 4 hours a day – 5 days a week HCA provide care 24/7

19. Hospice Hospice is appropriate when: – Symptoms well controlled – Care needs are not complex – Prognosis of 1 – 3 months – Patients cannot or do not wish to be cared for in the community

20. Care in the Community Majority of patients on Palliative Care program are in the community Recently expanded community model of care to incorporate an Inter-professional approach

21. Community Teams: Community Nurses CNS MD Coordinator Psychosocial

22. Inter-professional Community Model Each community team considers patients in their area as their ward – Inclusive of all care settings – home, acute care and long term care – Team meetings to discuss patient care needs especially when transitioning between care settings – Focus on meeting needs in a proactive way – Opportunity to strengthen networks with other care teams to support patients and families including the opportunity to model palliative care

23. Care at Home Palliative patients in community have same service limitations as all Home Care clients – HCA and PSW services provided by Home Care Program Families/caregivers must be very involved in providing care

24. CONSULTATION SERVICES

25. Consultative Services Available to anyone with a life limiting illness in any care setting for symptom management, psycho-social support or assistance with discharge planning Consultation services are provided by inter- professional team members including: – Palliative Care Physician – Palliative Care Clinical Nurse Specialist – Psycho-social Support Specialist

26. When should Palliative Care be consulted? Assistance with symptom issues – Managing Physical symptoms MD to MD consults for advice 24/7 – Psycho-social Assistance with care planning – What might care team expect as patient nears end of life? Will oral route be available? Could symptoms escalate?

27. When should Palliative Care be consulted? Goals of care are not clear – Discrepancy between patient, family and/or members of care team with plan of care Discharge to community or LTC is anticipated – Does patient need to be or are they currentlyregistered on Palliative Care program? – Would it be appropriate for Palliative Care nurse to see the patient in the community?

28. What information is needed on consult? Main reason for consult – What is the main symptom issue? Urgency of consult Is the physician aware of the consult?

29. Diagnosis of Life-Limiting Illness Transitioning to Palliative Palliative Consult Service Community Palliative Nursing Case Coordinator Admission Eligibility Medication Coverage comfort-focusedcomfort-focused prognosis 6 mo. or lessprognosis 6 mo. or less some treatment limitations (DNAR, no TPN, no chemoTx with high adverse effectssome treatment limitations (DNAR, no TPN, no chemoTx with high adverse effects aggressive, often toxic treatment focused on cure or life-prolonging disease modification

30. Palliative Care as a philosophy of care Formal Program Formal Program Increase capacity through education, advocacy, partnerships Resources