In early 2012 members of the Palliative Outreach Consult Team (POCT) collaborated to create a teaching tool to help clinicians identify patients living with chronic illness who are within the last year of life and likely to benefit from palliative care. concerns of POCT that most patients with a life-limiting diagnosis were referred quite late if at all, in their illness trajectory and sometimes only when imminent death approached. This illustrates that the philosophy of palliative care is not well developed across disciplines and units, reaffirming a detrimental lack of palliative care awareness across professional groups (Bruera, 2004).
BC MOHS: The Palliative Approach to care: WHO definition: Palliative Care: P rovides relief from pain and other distressing symptoms; affirms life and regards dying as a normal process; integrates the psychological and spiritual aspects of patient care; offers a support system to help patients live as actively as possible until death; offers a support system to help the family cope during the patients illness and in their own bereavement; uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated; will enhance quality of life, and may also positively influence the course of illness; is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications. It aims to improve quality of life in all life-limiting illness , not just cancer. Is an approach delivered by health care providers and can be deployed by any member of the health care team with appropriate support from hospice/palliative care specialists as required. Facilitates early identification of patients/families wishes/choices about care throughout a period of declining health, and especially during end-of-life care.
Started with Heart Failure group (iPALL) RN sitting in with this team noting the gaps Anecdotal evidence from allied team and nursing members about distress of lack of palliative approach despite consult team still getting consults late if at all (see previous) Literature will have more Interestingly the MD wanted this for MDs specifically and residents to learn from whereas RNs wanted everyone to see
Estimated that by 2020 40% more deaths annually than in 2003 approximately 90% of Canadians will eventually die as a result of a prolonged illness.
2007- Health Care Use at the End of Life in Western Canada (on-line document) B.C. conducted an analysis of service utilization, using techniques to measure intensity of service use in the last two years of life. Here, health service use peaked in the last three to six months of life, the traditional period of focus for end-of-life palliative care. However, the B.C. findings illustrate that with an older population, where chronic illness and comorbid conditions are common, end-of-life care is needed well before the last three to six months.
Given this situation we were unhappy and prompted to action moving to background in 2011 the Parliamentary Committee on Palliative and Compassionate Care created the document entitled “Not to be Forgotten: Care of Vulnerable Canadians”. While progress has been made, Canada still falls far short of quality end-of-life care for all, with only 16-30% of those who need it receiving palliative care. “failing grade in any ordinary exam” http://pcpcc-cpspsc.com/wp-content/uploads/2011/11/ReportEN.pdf In early 2012 members of the Palliative Outreach Consult Team (POCT) collaborated to create a teaching tool to help clinicians identify patients living with chronic illness who are within the last year of life and likely to benefit from palliative care. Literature supports that those patients and families who accept a palliative approach earlier in the illness trajectory are more satisfied with their care. The evidence is fits with concerns of POCT that most patients with a life-limiting diagnosis were referred quite late if at all, in their illness trajectory and sometimes only when imminent death approached. This illustrates that the philosophy of palliative care is not well developed across disciplines and units, reaffirming a detrimental lack of palliative care awareness across professional groups (Bruera, 2004).
Literature supports that those patients and families who accept a palliative approach earlier in the illness trajectory are more satisfied with their care
A3 Romayne Gallagher - Identifying Patients who may benefit from Palliative Care: Introducing iPall
Identifying patients who may benefit from palliative care: Introducing iPall Romayne Gallagher MD, CCFP, FCFPKate McNamee-Clark RN, MSN (candidate), CHPCN (c) Providence Health Care
Objectives• Define palliative care• Provide background to iPALL• Identify those who might benefit from palliative care• Show evidence on benefits of earlier palliative care involvement• Highlight harm associated with late referral• Show how iPALL can be used to improve care• Present next steps
WHO definition 2005Palliative care is an approach that improves thequality of life of patients & their families facing theproblem associated with life-threatening illness,through the prevention and relief of suffering bymeans of early identification, impeccableassessment & treatment of pain and otherproblems, physical, psychosocial and spiritualhttp://www.who.int/cancer/palliative/definition/en/ 3
Palliative Care Palliative Care vs End-of-Life Care vs Terminal Care Palliative Care Introduction to palliative care Symptom Ongoing medical treatments as management Weeks to appropriate months to live End-of-Life Terminal CareMaximizing Symptom Controlquality of life Care Psychosocial support of patient/family Hospice Days to hours of life Maximizing Care community supports Living with a life-limiting illness – any prognosis
Background to iPALL• Heart Failure clinic team• Interdisciplinary moral distress• MSJ EOL council• PHC consult team experience• Literature Reviews & Statistics
Background to iPALLBy 2020, there will be 40% more deaths annually than in 2003 (Stats Canada)• ~ 90% of Canadians die of prolonged illnessCanadian Strategy on Palliative and End-of-Life Care: Final Report, 2007. Retrieved from http://www.hc-sc.gc.ca/hcs-sss/pubs/palliat/2007-soin_fin-end_life/index-e
Background to iPALL Health Care Use at the End of Life in Western CanadaB.C.• Health service use peaked in the last three to six months of lifeOlder population• Chronic illness and co-morbid conditions are common• End-of-Life care is needed well before the last three to six months.• Leading causes of death in western Canada are circulatory & respiratory diseases; cancerCanadian Institute for Health Information (2007) Retrieved from https://secure.cihi.ca/free_products/end_of_life_report_aug07_e.pdf
Background to iPALLOnly 16-30% of those in need receiving palliative carehttp://pcpcc-cpspsc.com/wp-content/uploads/2011/11/ReportEN.pdfCarstairs (2010) report: Palliative care for patients late if at all even with available palliative care specialistPan Canadian study - SUPPORT: Heyland,et al, (2004) about increase aggressive interventions prior to death
Does palliative care improve outcomes in hospital? Results of systematic reviewsCompared to conventional care, palliative care teams were associated with significant improvements in: – Pain – Non-pain symptoms – Patient/family satisfaction – Hospital length of stay – Reduces in-hospital deaths * Jordhay et al Lancet 2000*Higginson et al, JPSM, 2003; †Finlay et al, Ann Oncol 2002; Higginson et al, JPSM 2002.
Incorporating palliative care into oncology -• 1409 patients with lung cancer – 1095 on pathway that incorporates early goals of care discussion into the pathway• Costs 35% less over 12 months• No difference in survival Neubauer et al. (2010) J Clinical Oncology
NEJM 2010• 151 patients newly diagnosed with metastatic lung cancer, randomized to early palliative care v.s. usual care• Outcomes: length of life, quality of life, mood• The two groups had the same amount of chemotherapy• Early palliative care group: – Quality of life better p=0.03 – Fewer depressive symptoms p=0.01 • Temel et al NEJM 2010
Improved survival Length of life was 2.7 months longer Average 2.7 months p=0.02 13
Late referral decreases quality• 237 bereaved family members of hospice patients asked about timing of the referral• 13.7% reported referral “too late”• Compared to family members referred early or at the right time, these respondents reported Lower satisfaction More unmet needs Lower confidence More concerns about coordination Schockett, Teno, Miller, Stuart. (2005) JPSM
Incorporating palliative care into oncology -• 1409 patients with lung cancer – 1095 on pathway that incorporates early goals of care discussion into the pathway• Costs 35% less over 12 months• No difference in survival • Neubauer et al. J Clinical Oncology 2010
Next Steps• Quantitative study to measure utility of iPALL with GPs in Interior Health• Roll out use of iPALL throughout PHC acute and residential care sites• Ongoing: sharing iPALL with colleagues at every health authority in BC and Yukon
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