2. Perspectives on Palliative Care Timothy G. Ihrig, MD, MA Medical Director, Palliative Medicine Trinity Regional Health System ihrigtg@ihs.org

3. Objectives Define the scope and role of palliative care as specialized medical care for people with serious illnesses Coordinate palliative care between professionals and across institutional settings

4. Definition Palliative care is specialized medical care for people with serious illnesses. It is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness—whatever the diagnosis. The goal is to improve quality of life for both the patient and the family.

5. Palliative Care: Defined Palliative care is provided by a team of doctors, nurses, and other specialists who work together with a patient's other doctors to provide an extra layer of support. It is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment.

6. Palliative Care: Defined - Cancer -Cardiac disease (Congestive Heart Failure) -Chronic Obstructive Pulmonary Disease -Kidney failure -Dementia - HIV/AIDS -Amyotrophic Lateral Sclerosis (ALS)

7. Palliative Care: Defined What is it? 1.Pain & Symptom Management 2.Communication/Counseling 3.Care Planning

8. Pain & Symptom Management – Sx’s: Nausea, Anorexia, Anxiety, Delirium, Diarrhea, Dyspnea – Education: O2 and the Management of Dyspnea – Systems: Advocacy for opioid availability, including proper dosing forms Palliative Care: Pain & Symptoms

9. Communication – Determining the Decision Maker or Process – Facilitating decision making – Determining Goals of Care – Preferred Intensity of Care – Delivering Bad News – Prognostication: Average MD overestimates by average of 5 fold Counseling – Grief Counseling – Anticipatory Guidance – Parenting – Depression – Spirituality Palliative Care: Communication

10. Goals Cure Restore Function Maintain Function Live Longer Be at Home Avoid Bankruptcy See the birth of a grandchild Treatments Mechanical Vent CPR Electrical Cardioversion Artificial Nutrition Rehospitalization Communication: Goals First!

11. Personalized Care: 1.Recommend treatment plans to match goals – Don’t recommend treatments that won’t accomplish stated goals. 2.Facilitate Continuity of Care Plan Across Settings – Discharge Planning / Case Management – Clear documentation – Rational DNR/LLST Orders – POLST (Physician Orders for Life Sustaining Treatment) Palliative Care: Care planning

12. Harvard Oncology Group Study N Engl J Med 2010;363:733-42. Patients who received Palliative Care:  Less Depression  Less Chemotherapy  Less Hospitalization  More Likely to Die at Home on Hospice  More likely to be DNR  Higher Quality of Life  *Life Expectancy : 2.7 months longer!!! Palliative Care: Myth of “giving up”

13. Physician: Board Certified Specialty (same as Cardiology, etc) Nurse: HPNA, Hospice & PC Certification. ELNEC Training Chaplain: Clinical Pastoral Education, Board Certification Social work: Palliative Care Certification Administrator: Certification (NHPCO) Palliative Care: Expertise

14. Interdisciplinary Team Unique model in health care: One Care Plan organized by patient issue. Shared accountability for all issues. Flat MD, RN, LVN, NP, LCSW, Chaplain, Admin., Volunteer, Pharmacist Multidisciplinary Group Parallel Play Individual care plans organized by specialty Hierarchical, with a physician “In charge”. Minimal shared accountability amongst group members for individual patient outcomes Palliative care: The Team

15. Palliative Care: Defined Medicare Hospice Benefit Life Prolonging Care Old Palliative Care Bereavement Hospice Care Life Prolonging Care New DxDeath

16. Objective Two Coordinate palliative care between professionals and across institutional settings

17. 22 5 Physical Therapists 37 Nurses A Year in the Life of a Patient 6 Social Workers 19 Clinic Visits 2 Home Care Agencies 6 Community Referrals 5 Months of Home Care 4 Occupational Therapists 13 Meds 2 Nursing Homes 16 Physicians 6 Weeks SNF Care 5 Hospital Admissions Source Johns Hopkins, RWJ 2010 (G Anderson)

18. Coordinate Why: Transitions in Care Concerns “Coordinating Care – A Perilous Journey through the Health Care System” (T. Bodenheimer, MD NEJM 358 March 2008) – 1/3 of patients with chronic illness and hospitalization had no post discharge follow-up arrangements – Less than ½ of PCPs were provided discharge information / medications – 3% of PCPs are involved in discussions with hospitalists regarding patients’ discharge plans – PCPs are infrequently notified that patient discharged

19. Why: Readmissions - 1 in 5 Medicare patients re-hospitalized within 30 days of discharge - Half of these occurred before seeing outpt MD - Estimated cost 17.4 billion Jencks, Williams, and Coleman NEJM 2009, Vol 360, 1418-1428

20. Inpatient Care Palliative Care Patients

21. Services / Design Options for Palliative Care

22. Coordinate: Difficulties Generalist Palliative Care: all clinicians – “Routine” communication/symptom control *** Specialty Pall Care *** – Family meetings—esp. “difficult cases” – Complex symptom management – Time management – Support for difficult decisions

23. Coordinate: Opportunities What would the ideal look like? - Efforts to broaden the spread of palliative care principles through 1. early patient identification (triggers) 2. systems change to guide right care at right time - routine family meetings 3. emphasis on more generalist palliative care 4. specialists for truly complex problems 5. quality improvement-data driven change

24. Coordinate: Opportunities What would this look like to a patient? - I am screened on admission for unmet pall care needs; if present … 1. My primary providers have policy-defined roles in the assessment of my pall care needs 2. My providers have the training to complete routine, “generalist level” pall care interventions 3. My family is informed and engaged in the process of care 4. Specialist Pall Care services are involved by hospital standards, based on my condition/problems