Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Consolidating, Improving, and Novel Palliative Care: Order Sets

543 views

Published on

A selection of slides, taken from a series of presentations, showing the evolution of consolidating and developing order sets for delivery of primary palliative care in our healthcare system.

Published in: Healthcare
  • Be the first to comment

  • Be the first to like this

Consolidating, Improving, and Novel Palliative Care: Order Sets

  1. 1. COIN-PC: COnsolidating, Improving, and Novel Palliative Care Order Sets
  2. 2. What We’re Doing 1. Improving the quality of palliative care delivered across the system by consolidating current order sets (and perhaps creating new ones) which should: • Increase productivity • Improve care • Decrease cost • Decrease length of stay • Decrease readmissions • Decrease adverse drug reactions and overdoses 2. Overall increase referrals to palliative care
  3. 3. Victoria Classification of Palliative Care 12/9/14 8 Type Goal Investigations Treatments Setting Active (Blue) To improve quality of life with possible prolongation of life by modification of underlying disease(s). Ex: Pt. who has potentially resectable pancreatic carcinoma. May require immediate symptom control or need guidance in setting future goals. Active (eg, biopsy, invasive imaging, screenings) Surgery, chemotherapy, radiation therapy, aggressive antibiotic use, Active treatment of complications (intubation, surgery) In-patient facilities, including critical care units; Active office follow-up Comfort (Green) Symptom relief without modification of disease, usually indicated in terminally ill patients. Ex. Pt. who has unresectable pancreatic carcinoma, no longer a candidate for or no longer desires chemo or radiation therapy. Minimal (eg, chest radiograph to rule out symptomatic effusion, serum calcium level to determine response to bisphosphonate therapy) Opioids, major tranquilizers, anxiolytics, steroids, short- term cognitive and behavioral therapies, spiritual support, grief counseling, noninvasive treatment for complications Home or homelike environment Brief in-patient or respite care admissions for symptom relief and respite for family Urgent (Yellow) Rapid relief of overwhelming symptoms, mandatory if death is imminent. Shortened life may occur, but is not the intention of treatment (this must be clearly understood by patient or proxy). Ex. Patient who has advanced pancreatic carcinoma reporting uncontrolled pain (8 on a scale of 10), despite opioid therapy. Only if absolutely necessary to guide immediate symptom control Pharmacotherapy for pain, delirium, anxiety. Usually given intravenously or subcutaneously and in doses much higher than most physicians are accustomed to using. Deliberate sedation may need to be used and may need to be continued until time of death. In-patient or home with continuous professional support and supervision J Palliat Care. 1993 Winter;9(4):26-32.
  4. 4. • Palliative Care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. • Hospice care is end-of-life care. A team of health care professionals and volunteers provides it. They give medical, psychological, and spiritual support. The goal of the care is to help people who are dying have peace, comfort, and dignity. The caregivers try to control pain and other symptoms so a person can remain as alert and comfortable as possible. Hospice programs also provide services to support a patient's family. Usually, a hospice patient is expected to live 6 months or less. Hospice care can take place - At home - At a hospice center - In a hospital - In a skilled nursing facility • Hospice Respite Care is short-term inpatient care provided to the individual only when necessary to relieve the family members or other persons caring for the individual at home. • Comfort Care is an essential part of medical care at the end of life. It is care that helps or soothes a person who is dying. The goal is to prevent or relieve suffering as much as possible while respecting the dying person’s wishes. Definitions http://www.who.int/cancer/palliative/definition/en/ http://www.nlm.nih.gov/medlineplus/hospicecare.html http://www.nhpco.org/sites/default/files/public/regulatory/Respite_Tip_sheet.pdf http://www.nia.nih.gov/health/publication/end-life-helping-comfort-and-care/providing-comfort-end-life Hospice Comfort Care Palliative Care Hospice Respite Care
  5. 5. Palliative Care PowerPlan and Phase Proposal • Symptom Management Phases: Useful for isolated symptom management at any care classification, input from acute and chronic pain services, psychiatry, others? • Delirium Management Phase: Diagnostic testing and acute management, developed in conjunction with neurology and psychiatry. • Acute In-Patient Palliative Care PowerPlan: Commonly used nursing interventions, diagnostics, symptom management phases. • Palliative Sedation Phase: Palliative sedation orders, developed in conjunction with ethics. • End-of-Life PowerPlan and Terminal Wean Phase: Updating existing end-of-life orders. Medical and Surgical PowerPlans months•years Acute In-Patient Palliative Care PowerPlan days•weeks Palliative Sedation Phase Terminal Wean Phase hours•days / Delirium Management PowerPlan Symptom Management Phase / / Delirium Management and Symptom Management Phases / / End-of-Life PowerPlan / / End-of-Life PowerPlan / • Pain Subdivided by organ system • Dyspnea • Nausea • Diarrhea • Constipation • Anorexia • Depression • Anxiety • Insomnia
  6. 6. Terminal Ventilator Wean • Palliative care is involved in < 100% of terminal ventilator weans. • Medical and surgical critical care is involved in 100% of terminal ventilator weans. FF #33-35
  7. 7. Patients, Providers, and Places months•years days•weeks hours•days Patients Providers Places Intern Experienced Palliative Care Specialist No or nascent palliative care service Mature, fully staffed, palliative care service
  8. 8. Current Situation months•years days•weeks hours•days Patients Providers Places Intern Experienced Palliative Care Specialist No or nascent palliative care service Mature, fully staffed, palliative care service
  9. 9. Consolidation and Standardization months•years days•weeks hours•days Patients Providers Places Intern Experienced Palliative Care Specialist No or nascent palliative care service Mature, fully staffed, palliative care service e
  10. 10. Hierarchy Goals-of-Care Symptom Management
  11. 11. Separate Palliative Care PowerPlans Proposal Advantages • Provider can search for exactly what patient needs. • Modular Phase design can be integrated easily into other PowerPlans. Disadvantages • Increased confusion due to seemingly more choices. • Increased risk of less appropriate order selection. • Risk of multiple orders for the same medication due to using different phases. • Symptom Management Phases • Delirium Management Phase Medical and Surgical PowerPlans months•years • Goal-of-Care PowerPlan days•weeks • End-of-Life PowerPlan FF #3, 106, 107
  12. 12. Single Palliative Care PowerPlan Proposal Advantages • All-inclusive, everything contained in one place. • Stratifying medication orders by classification might increase safety. Disadvantages • Necessitates large size may complicate usability. • Separating orders by classification may complicate management when orders needed are in different part of the PowerPlan. • Dose Limited Symptom Management Phases • Delirium Management Phase months•years • Goal-of-Care Phase • Dose Liberalized Symptom Management Phases days•weeks • End-of-Life Phase • Continuous Infusion Symptom Management Phases • Palliative Sedation Phase • Terminal Wean Phase hours•days FF #3, 106, 107
  13. 13. Wheel of Consolidation Consolidation • Institutional Goal • Existing PowerPlans • Different Points-of-view • Internal data • Literature • https://www.capc.org/fast-facts/overview/ • Repetition, e.g. “Favorites” • Education • Software Limits • IUH Policy • Site Differences • Beginning a process, not racing for a goal • Primum non nocere AMIA Annu Symp Proc. 2007 Oct 11:568-72.
  14. 14. Query #1 • If we don’t admit patients, why do we have admission order sets? • Primary services admitting for “palliative care” or end-of-life care. • Would an adjunctive palliative care or end-of-life care orders used in conjunction with a generic admission order set be more universally usable?
  15. 15. Query #2 • In general as a consulting service, are we recommending orders or placing them? • Using our own PowerPlans should be easy • Recommending from our own power plans is more challenging • Pre-generated phrases that reference palliative care Phases and PowerPlans
  16. 16. Query #3 • Can pain management be better organized? • By type? • Nociceptive • Neuropathic • Psychogenic • By location? • Headache • Gastrointestinal • Genitourinary • Boney Metastasis
  17. 17. Physical Cause? Assoc. Sx Debility and Fatigue Social Role Relationship Occupation Financial Cost Spiritual Existential coping Religious beliefs Meaning of life/illness Personal value Psychological Emotional Response Comorbid mood disorder ± anxiety Adjustment to new baseline Symptom Chaplaincy Art & Music Therapy Social Work Financial Navigator Occupational Therapy Social Work Psychology Psychiatry Acute Pain Service Chronic Pain Service Palliative Care Other Specialities Physical Therapy Total Symptoms
  18. 18. Symptom Management Diagnosis? Desired and Feasible? Yes No No Yes Disease Modifiable? No Yes Desired and Feasible? Work-up Beyond Scope of Palliative Care Order Sets No Yes Treatment Resolves/Improves Sx? Yes No Palliative Care Symptom Management Orders Palliative Care Symptom Management Orders Palliative Care Symptom Management Orders Palliative Care Symptom Management Orders Discharge
  19. 19. Model Intern Experienced Palliative Care Specialist End-of-Life Pain Management Dyspnea Management End-of-Life Pain Management Dyspnea Management Palliative Sedation Pain Management Dyspnea Management Primary Palliative Care Tools (Phases) and Toolboxes (PowerPlans) Specialist Palliative Care Tools (Phases) and Toolboxes (PowerPlans) People deliver high- quality palliative care. Orders that compose Phases that make-up PowerPlans are the tools and organization of those tools to effectively deliver that care.
  20. 20. Tiered Symptom Management Symptom #1 Management Symptom #2 Management … SubphasesPowerPlans BySymptomByUserExpertise Currently Symptom #1 Basic Management Advanced Management Symptom #2 Basic Management Advanced Management … Basic Management Symptom #1 Symptom #2 Advanced Management Symptom #1 Symptom #2 … Symptom #1 Basic Management Advanced Management Symptom #2 Basic Management Advanced Management Basic Management Symptom #1 Symptom #2 … Advanced Management Symptom #1 Symptom #2 … ** * * Example: Palliative Care Primary and Speciality Symptom Management ** Example: Palliative Care Admission / Hospice Admission & Palliative Care Specialty SUBPHASE
  21. 21. Modular Concept Medical & Surgical Admission Orders Palliative Care Primary and Specialty Symptom Management PowerPlan Terminal Wean Subphase Palliative Sedation Subphase or and/or +/- +/- +/- Complication or decline leading to comfort goal-of-care +/- Comfort Care Measures End-Of-Life / Comfort Care / Hospice Respite Admission Orders Bowel Elimination- Constipation Nursing Protocol and/or Palliative Care Symptom Management Subphases Nausea and Vomiting Pain Management Bowel Management
  22. 22. Patient With Suffering Patient With Suffering Home Meds Admitted Palliative Care Primary and Specialty Symptom Management PowerPlan + Medical & Surgical Admission Orders PC Consult
  23. 23. Comfort Care Admissions Patient Dying Within Hours to Days End-Of-Life / Comfort Care / Hospice Respite Admission Orders Admitted Palliative Sedation Subphase+/- Comfort Care Measures Palliative Care Primary and Specialty Symptom Management PowerPlan +/- PC Consult
  24. 24. Oh Yeah!?! What About? Patient Presents with Complaint Home Meds Admitted Medical & Surgical Admission Orders During Hospitalization Patient Decompensates, Transferred to ICU Patient Dying
  25. 25. Oh Yeah!?! What About? Patient Dying Goals-of-Care Shifted to Comfort Measures End-Of-Life / Comfort Care / Hospice Respite Admission Orders +/- Comfort Care Measures Terminal Wean Subphase Patient Remains Alive 24 Hours After Terminal Wean Patient Dying PC Consult
  26. 26. PC Consult Oh Yeah!?! What About? Patient Dying End-Of-Life / Comfort Care / Hospice Respite Admission Orders Palliative Sedation Subphase+/- Comfort Care Measures Palliative Care Primary and Specialty Symptom Management PowerPlan +/-Discharged and Readmitted to In-Patient Hospice
  27. 27. Palliative Care and Hospice • We are not hospice. But, we see a lot of patients who need hospice. • Hospice uses palliative care order sets to admit patients.
  28. 28. Hospice Admissions Home Hospice Patient Needing Respite Home Hospice Patient Needing Acute Symptom Management End-Of-Life / Comfort Care / Hospice Respite Admission Orders Home Meds Admitted End-Of-Life / Comfort Care / Hospice Respite Admission Orders Palliative Care Primary and Specialty Symptom Management PowerPlan Admitted Palliative Sedation Subphase+/- Comfort Care Measures +/- Palliative Care Primary and Specialty Symptom Management PowerPlan +/-
  29. 29. Streamlined Modular Concept Medical & Surgical Admission Orders or +/- +/- Bowel Elimination- Constipation Nursing Protocol and Hospital Admit / To The Floor Orders End-Of-Life / Comfort Care Order Set and/or 2) Non-pharmacological and pharmacological options for the non- specialist for symptom management regardless of goals-of-care 3) Non-pharmacological and pharmacological orders to promote dignity, comfort, and ease suffering at the end-of-life Palliative Care Symptom Management Terminal Wean Order Set 1) Orders for getting any patient, regardless of goals-of-care, admitted to the hospital
  30. 30. Medical & Surgical Admission Orders or +/- +/- Bowel Elimination- Constipation Nursing Protocol and Hospital Admit / To The Floor Orders and/or 2) Non-pharmacological and pharmacological options for the non- specialist for symptom management regardless of goals-of-care Palliative Care Symptom Management Terminal Wean Order Set1) Orders for getting any patient, regardless of goals-of-care, admitted to the hospital Palliative Care Symptom Management End-Of-Life / Comfort Care Order Set Hospice Admission Order Set Hospice Status All Other Statuses - Curative Goal Comfort Goal 3) Non-pharmacological and pharmacological orders to promote dignity, comfort, and ease suffering at the end-of-life 4) Orders for getting any patient admitted to in- patient hospice after hospice consultation and discharge from previous hospital stay Palliative Care, Hospice, End-of-Life, Comfort Care, and Terminal Wean Modular Design
  31. 31. Synonyms Palliative Care Symptom Management Hospice Admission Order Set Palliative Care Symptom Management End-Of-Life / Comfort Care Order Set “Palliative Care” “Symptom” “End-of-Life” “Comfort Care” “Hospice” “Admission” + Palliative Care Symptom Management Hospice Admission Order Set End-Of-Life / Comfort Care Order Set “Comfort Care” “Palliative Care” +
  32. 32. Help, my patient is suffering! Is goal-of-care natural death with dignity and comfort? Yes No Has hospice been consulted and the patient been discharged with intent to readmit on in-patient hospice? Yes No Is the patient on mechanical ventilation? Yes No Palliative Care Symptom Management Terminal Wean Order Set Hospice Team Admission Order Set End-Of-Life / Comfort Care Order Set

×