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Nathan Goldstein-Palliative care making the case


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  • 1. Palliative Care in Hospitals: Making the Case Nathan Goldstein, MD Associate Professor Hertzberg Palliative Care Institute Brookdale Department of Geriatrics and Palliative Medicine Mount Sinai School of Medicine James J. Peters Veterans Affairs Medical Center Jewish Home Lifecare 11th Annual Palliative Care Conference November 12, 2013
  • 2. What are your objectives? • What do you hope to get out of this session? • Do you have specific questions / topics that you want addressed?
  • 3. Learning Objectives After attending this presentation, the learner will be able to better understand: • The definition of palliative care, and how it differs from the traditional hospice model • Explain four reasons why palliative care is growing as a movement in the United States • Define how palliative care is beneficial for patients, clinicians, and hospitals
  • 4. What is Palliative Care? • Palliative care is specialized medical care for people with serious illnesses whose goal is to improve quality of life for both the patient and the family. • Palliative care is provided by a team of doctors, nurses, and other specialists who work with a patient's other doctors to provide an added layer of support. • Palliative care is appropriate at any age and at any stage in a serious illness, and can be provided together with curative and disease directed treatments
  • 5. Consumer Knowledge of Palliative Care
  • 6. Mount Sinai Palliative Care Service • • Team made up of: • 4 Attending Physicians (pool of ~12) • 4 Nurse Practitioners (pool of 5) • 1 RN (triage nurse) • 3 Social Workers • 7 Fellows • Chaplain • Massage Therapist(s), Yoga Therapist, Art Therapist, Music Therapist • 2-3 Third Year Medical Students • 1-2 Other Rotators 3 Consult services + inpatient unit
  • 7. Palliative Care in Practice • Expert control of pain and symptoms • Uses the crisis of the hospitalization to facilitate communication and decisions about goals of care with patient and family • Coordinates care and transitions across fragmented medical system • Provides practical support for family and other caregivers (+ clinicians)
  • 8. Ms. M • 45 year old woman with metastatic breast cancer • Admitted with worsening neurological symptoms – found to have brain mets • Person calling in pall care consult: • “She knows everything that’s going on we just want to make sure she is comfortable.” • Whoops…
  • 9. The Cure - Care Model: The Old System Life Prolonging Care Palliative/ D E Hospice A T Care H Disease Progression
  • 10. A New Vision of Care Disease Modifying Therapy curative or restorative intent Life Closure Diagnosis Palliative Care Death & Bereavement Hospice
  • 11. Palliative Care
  • 12. Aug 19 2010;363(8):733-42.
  • 13. Palliative Care “Modern Medicine” Hospice
  • 14. Palliative Care Is  Excellent, evidencebased medical treatment  Vigorous care of pain and symptoms throughout illness  Care that patients want at the same time as efforts to cure or prolong life Palliative Care Is NOT Not “giving up” on a patient Not in place of curative or lifeprolonging care Not the same as hospice or end-oflife care
  • 15. Why is hospital palliative care growing so rapidly in the United States?
  • 16. Hospital-based Palliative Care: The 4 Main Arguments 1. 2. 3. 4. Clinical Quality Patient and Family Preferences Demographics Financial
  • 17. Why palliative care? 1. The Clinical Imperative The need for better quality of care for people with serious and complex illnesses.
  • 18. Everybody with serious illness spends at least some time in a hospital... • 98% of Medicare decedents spent at least some time in a hospital in the year before death. • 15-55% of decedents had at least one stay in an ICU in the 6 months before death. Average length of stay in the ICU is 2-11 days. Dartmouth Atlas of Health Care 1999 & 2006
  • 19. Symptom Burden of Patients Hospitalized With Serious Illness at 5 U.S. Academic Medical Centers % of 5176 patients reporting moderate to severe pain between days 8-12 of admission Colon Cancer Liver Failure Lung Cancer COPD CHF 60% 60% 57% 44% 43% Desbiens & Wu. JAGS 2000;48:S183-186.
  • 20. ICU and intervention costs rising prior to death 50% 45% 44.4% 39.8% 39.3% 40% Barnato et al HSR April 2004 Trends in inpatient treatment intensity among Medicare beneficiaries a the end of life 38.0% 35% 1985 1999 30.3% 30% 25% 20% 17.8% 15% 10% Dying in hospital ICU during last admit Intensive proc during last admit
  • 21. But ICU Care Decreases Satisfaction • Bereaved family members (n=778) of patients who died in regions of highest vs. lowest ICU intensity deciles surveyed re quality of eol care. • Highest ICU use areas: Patients more likely to die in an ICU, be transferred in last month, and their families believe that not enough life sustaining treatment was given. • Higher ICU care regions associated with family reports of: • Inadequate emotional support • Inadequate shared decision-making • Inadequate information on what to expect • Lack of respect • Lower overall satisfaction Teno et al. JAGS 2005;53:1905-11.
  • 22. Why palliative care? 2. Concordance with patient and family wishes What is the impact of serious illness on patients’ families? What do persons with serious illness say they want from our healthcare system?
  • 23. What Do Patients with Serious Illness Want? • Pain and symptom control • Avoid inappropriate prolongation of the dying process • Achieve a sense of control • Relieve burdens on family • Strengthen relationships with loved ones Singer et al. JAMA 1999;281(2):163-168.
  • 24. “Difficult” Conversations Improve Outcomes • Multisite, longitudinal study of 332 patient-family dyads • 37% of patients reported having prognosis discussion at baseline • These patients had lower use of aggressive treatments, better quality of life, and longer hospice stays • Family after-death interviews showed better psychological coping for those with conversations as compared to those without Wright et al. JAMA 2008 300(14):1665-1673.
  • 25. What Do Family Caregivers Want? Study of 475 family members 1-2 years after bereavement • • • • • • • • • • Loved one’s wishes honored Inclusion in decision processes Support/assistance at home Practical help (transportation, medicines, equipment) Personal care needs (bathing, feeding, toileting) Honest information 24/7 access To be listened to Privacy To be remembered and contacted after the death Tolle et al. Oregon report card.1999
  • 26. Family Perspectives on Quality of Hospice as the Last Place of Care As compared to hospital, nursing home, and home care, hospice care at home superior for • • • • • • • Pain Emotional support Contact with MD Respect Family support Knowing what to expect Overall quality Hospice rated excellent by 71% vs. <50% at all other sites Teno et al. JAMA 2004;291:88-93.
  • 27. Families Want to Talk About Prognosis • Qualitative interviews with 179 surrogate decision makers of ICU patients • 93% of surrogates felt that avoiding discussions about prognosis is an unacceptable way to maintain hope • Information is essential to allow family members to prepare emotionally and logistically for the possibility of a patient's death. • Other themes: • moral aversion to the idea of false hope • physicians have an obligation to discuss prognosis • surrogates look to physicians primarily for truth and seek hope elsewhere Apatira et al. Ann Intern Med. 2008;149(12):861-8
  • 28. Why palliative care? 3. The demographic imperative Hospitals need palliative care to effectively treat the growing number of persons with serious, advanced and complex illnesses.
  • 29. Chronically Ill, Aging Population Is Growing • The number of people over age 85 will double to 10 million by the year 2030. • The 23% of Medicare patients with >4 chronic conditions account for 68% of all Medicare spending. • Hospice most comprehensive insurance program to care for these older adults with chronic disease -- Not without its limitations US Census Bureau, CDC, 2003. Anderson GF. NEJM 2005;353:305 CBO High Cost Medicare Beneficiaries May 2005.
  • 30. Medicare Hospice Benefit • Prognosis of 6 months or less if disease follows its usual course • Willingness to forego regular Medicare services focused on life-prolongation or cure for primary illness • Does NOT mean patient has to die in 6 months or else you give up your license
  • 31. Are we getting the message out to patients and families about the benefits of hospice? NHPCO Facts and Figures, 2010 (using data from 2009)
  • 32. The Reality of the Last Years of Life: Death Is Not Predictable Cancer 100 End-Stage Organ Failure 80 Function 90 Dementia (years) 70 60 50 40 30 20 10 0 Time (slide adapted from Joanne Lynn, MD, Rand Health/CMS)
  • 33. Why palliative care? 4. The fiscal imperative Hospital and insurers of the future will have to efficiently and effectively treat serious and complex illness in order to survive.
  • 34. Healthcare Spending and Quality U.S. leads the world in per capita spending 27th in life expectancy 37th in overall quality of healthcare system (WHO)
  • 35. How Palliative Care Reduces Length of Stay and Cost Palliative care: • Clarifies goals of care with patients and families • Helps families to select medical treatments and care settings that meet their goals • Assists with decisions to leave the hospital, or to withhold or withdraw treatments that don’t help to meet their goals
  • 36. Costs and Outcomes Associated with Hospital Palliative Care Consultation 8-hospital study Live Discharges Costs Total Per Day Usual Care Palliative Care Hospital Deaths P Usual Care Palliative Care P $1,450 $1,171 <.001 $2,468 $1,918 <.001 Directs Per Admission $11,1240 $9,445 .004 $22,674 $17,765 .003 Laboratory $1,227 $803 <.001 $2,765 $1,838 <.001 ICU $7,096 $1,917 <.001 $15,542 $7,929 <.001 Pharmacy $2,190 $2,001 .12 $5,625 $4,081 .04 Imaging $890 $949 .52 $1,673 $1,540 .21 Died in ICU X X X 18% 4% <.001 Adjusted results, n>20,000 patients Morrison et al. Arch Internal Med. 2008. 168 (16).
  • 37. 8 Hospital Study: Costs/day for patients who died with palliative care vs. matched usual care patients Usual care PC consult day 8-9 PC consult day 4-5 PC consult day 10-11 PC consult day 6-7 PC consult day 12-13 2000 Direct Cost ($) 1750 1500 1250 1000 750 500 250 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Day of Admission
  • 38. Cost Savings – Medicaid in NY State Cost savings/Day for Live Discharges Morrison et al. Health Affairs 2011 30:454-63
  • 39. What Does All this Mean from the Patient Perspective? For patients, palliative care is a key to: • • • • • relieve symptom distress navigate a complex medical system understand the plan of care help coordinate and control care options allow simultaneous palliation of suffering along with continued disease treatments (no requirement to give up life prolonging care) • provide practical and emotional support for exhausted family caregivers
  • 40. What Does All this Mean from the Clinician Perspective? For clinicians, palliative care is a key tool to: • Save time help to handle repeated, intensive patient-family communications, coordination of care across settings, comprehensive discharge planning • Provide Symptom Control assists with controlling pain and distress for highly symptomatic and complex patients, 24/7 -thus supporting clinician’s treatment plan • Promote Satisfaction increases patients’ and families’ satisfaction with the quality of care provided by the clinician
  • 41. What Does All this Mean from the Hospital Perspective? For hospitals, palliative care is a key tool to: • effectively treat the growing number of people with complex advanced illness • provide excellent patient-centered care • increase patient and family satisfaction • improve staff satisfaction and retention • meet accreditation and quality standards • rationalize the use of scarce hospital resources • increase bed/ICU capacity, reduce costs
  • 42. Summary • Palliative care improves quality of care for our sickest and most vulnerable patients and families. • Serious illness is a universal human experience and palliation is a universal health professional obligation.