1. Defining a Palliative Care Consult: Core Elements Cheryl Phillips, M.D. SH Palliative Care Committee April 30, 2007

2. Background Need to move to some definitional standards for measurement, reporting and delivery Variation anticipated with the local teams and facility resources Despite team variation, there should be some common elements that occur in order to “counted” as a Palliative Care consult within the Sutter system. This is critical for the physicians to understand and utilize palliative care programs and is critical for patients and their families to have consistency of service and care across our system

3. In-Patient Hospital Palliative Care Consult: Key Elements for Documentation Evaluation and discussion of patient’s goals of care – may refer to existing documentation if already done Determination of decision-maker (patient or assigned surrogate). If none, then such should be noted in record Review of current treatment plan Review of advance directives and discussion with patient/surrogate as needed. May also refer to existing documentation that may be present in the medical record Assessment of pain and non-pain symptoms Recommendations for interventions to address symptom management Referral, as needed to spiritual support and social services Documentation of above in the medical record to be used by the health care team

4. Example Case Documentation Pt. is a 66 yr old with advanced COPD. She is her own decision-maker, but her husband is very involved in care. She has made clear expressions of her wish to not be intubated or have CPR and this is recorded in her record. PC consult was requested to address patient’s anxiety and SOB and also to provide support to her husband.

5. Case continued: Assessment On assessment she is clearly anxious and breathing rapidly. She denies pain but complains of feeling “claustrophobic and panicy” Lengthy discussion was had about her and her husband’s understanding of her disease and what her goals are. In the past she had believe “this would get better” but now understands that she is end-stage (per her pulmonologist). She has been intubated twice in past. Her goals are now Comfort Care. She wants to go home, she wants to be comfortable and she does not wish any further intubation

6. Case Continued: Plan The following recommendations were made to improving her SOB and anxiety: (listed) Hospice was discussed and offered. Patient agrees and wishes to be DC’d home with hospice. I have discussed this with her attending physician who is in agreement and wishes for a formal Hospice referral.