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Introduction to Palliative Care

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Webinar presented by VITAS Healthcare on October 13, 2016.
Presented by B. David Blake, MD, DABFM

Published in: Health & Medicine
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Introduction to Palliative Care

  1. 1. Introduction to Palliative Care Developed by: Barry M. Kinzbrunner, MD, FACP Chief Medical Officer VITAS® Healthcare Miami, Florida Presented by: Dr. Bryan Blake
  2. 2. Goal To provide an overview of palliative care services and how they fit into the continuum of care
  3. 3. Objectives At the conclusion of this presentation participants will be able to: • Articulate a rationale for palliative care based on barriers to hospice access • Compare and contrast palliative care and hospice services • Describe the different locations where palliative care may be provided and the indications for palliative care services • Appreciate the role of palliative care as a key element in the continuum of care
  4. 4. Definitions Palliative care • “Palliare,” Latin: to cloak • “Care provided to treat the symptoms of an illness without curing or affecting the underlying illness” • Examples – Insulin “palliates” diabetes – Lasix “palliates” congestive heart failure
  5. 5. Definitions Supportive Care • “Aspects of medical care concerned with the physical, psychosocial and spiritual issues faced by persons with a particular illness (i.e.cancer)” • Includes family and community • Includes palliation of symptoms of the disease and management of untoward effects of treatment
  6. 6. Definitions End-of-Life Care • Care rendered to individuals who are near death or for whom death is expected in a relatively finite period of time • Includes supportive care, palliative care, hospice care • May be provided in virtually any setting where someone may die – ICU – Acute care hospital – LTCF – ALF – Private residence
  7. 7. Definitions Hospice Care • Team-oriented approach to end-of-life care • Expert in medical care, pain and symptom management and emotional and spiritual support • Tailored to the patient’s needs and wishes • Support to loved ones as well • Provided in any setting
  8. 8. The Case for Palliative Care What happens to the approximately 56% of patients who do not die on a hospice program? • Sudden death • Accidental death • Acute illness • Chronic progressive illness not accessing hospice(why do they not receive hospice care?)
  9. 9. Barriers to Hospice Access • Six month prognosis requirement • Communication - Hospice requires Informed Consent - Physicians do not want to tell patients - Patients and families do not want to be told • Lack of inpatient relationships between hospices and hospitals • Hospice reluctance to allow “disease-directed” therapy Wright JB, Kinzbrunner BM: How to assist patients and families in accessing end-of life care. Chapter 2 in Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical Guide. New York: McGraw Hill, 2011, p. 37
  10. 10. Theoretical Trajectories of Dying Lunney, J. R. et al. JAMA 2003;289:2387-2392
  11. 11. Six Month Prognosis Requirement Variable trajectory of death • Sudden death • Terminal illness: cancer – Functional decline several months before death – Relatively steady decline • Progressive organ failure - Waxing and waning course of illness • Frailty - Very poor functional status to start with - Variable decline less perceptible due to poor baseline status
  12. 12. Communication Phase II: Intervention to improve communication • Patient-specific information given to the physician – Probability of six month survival – Risk of patient functional disability • Nurses were trained to facilitate patient/physician communication: – Elicit patient family preferences – Facilitate advance care planning – Improve family understanding of probable outcomes – Improve pain control • Intervention was not successful SUPPORT Principal Investigators: A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). JAMA 274:1591-1598, 1995
  13. 13. Lack of inpatient relationships between hospices and hospitals SUPPORT Study Phase I • “Shortcomings” in hospital care – Physician/patient/family communications – Physician knowledge of patient preferences regarding CPR – Number of days spent in the ICU – Pain control • Majority of deaths occur in hospital – 65% in 1990s – 53% in early 2000s SUPPORT Principal Investigators: A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). JAMA 274:1591-1598, 1995
  14. 14. Hospice reluctance to allow “disease-directed” therapy • Patients often have an unrealistic outlook regarding the potential efficacy of disease directed therapy • Hospice staff is not trained in the proper handling of some of the more complex disease-directed treatments available today • Cost of disease directed therapy and related supportive medications in the face of fixed per diem reimbursement Wright JB, Kinzbrunner BM: How to assist patients and families in accessing end-of life care. Chapter 2 in Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical Guide. New York: McGraw Hill, 2011, p. 37
  15. 15. Institute of Medicine: 1997 Study on End-of-Life Care • Improve patient education • Improve education of physicians and other health care providers • Relax regulatory barriers that impede proper management of pain and suffering • Create research initiatives • Elevate palliative care to a defined specialty area
  16. 16. Palliative Care Services • Extends principles of hospice care to a broader population • Earlier in disease course than hospice • Comprehensive and specialized • Pain and symptom management, advance care planning, psychosocial and spiritual support, coordination of care • Definition may be able to be expanded to all aspects of medical care
  17. 17. Palliative Care Programs Goals: • Increase patient access to end-of-life care • Reach patients who are not currently being reached by hospice • Overcome barriers to hospice access Wright JB, Kinzbrunner BM: How to assist patients and families in accessing end-of life care. Chapter 2 in Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical Guide. New York: McGraw Hill, 2011, p. 37
  18. 18. Hospice Hospice Palliative Care • Palliative Care can be provided to patients who are not terminally ill or eligible for hospice • Hospice can be considered palliative care for the terminally ill
  19. 19. Comparison of Hospice & Palliative Care Programs Wright JB, Kinzbrunner BM: How to assist patients and families in accessing end-of life care. Chapter 2 in Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical Guide. New York: McGraw Hill, 2011, p. 37 Eligibility Prognosis < 6 months None required Determined by program Other services Professional Services Interdisciplinary team Physician Nurse Social Worker Pastoral counselor Certified nursing assistants Others as need Inter or multidisciplinary team Physician Nurse Social Worker Others as needed Medications DME Bereavement care Others (see Table 1-2) No required services. Determined by program. Characteristic Hospice Palliative Care Location of Services Characteristic Hospice Palliative Care Comprehensive Home care LTCF Inpatient Based on program Some Comprehensive Some inpatient only Some LTCF based
  20. 20. Comparison of Hospice & Palliative Care Programs (Cont.) Wright JB, Kinzbrunner BM: How to assist patients and families in accessing end-of life care. Chapter 2 in Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical Guide. New York: McGraw Hill, 2011, p. 37 Other services Social Worker Pastoral counselor Certified nursing assistants Others as need Social Worker Others as needed Medications DME Bereavement care Others (see Table 1-2) No required services. Determined by program. Location of Services Characteristic Hospice Palliative Care Funding Comprehensive Home care LTCF Inpatient Based on program Some Comprehensive Some inpatient only Some LTCF based Some require networking between hospital and hospice or home based home-health programs Medicare Hospice Benefit State Medicaid programs HMOs and commercial insurers Charity (not for profit hospices) Traditional hospital coverage Traditional home care coverage Support from hospitals and hospice partner organizations Grants Charity
  21. 21. Eligibility • Hospice – Prognosis of < = six months • Palliative care – No specific eligibility requirement – Determined by provider Comparison of Hospice & Palliative Care Programs (Cont.) Wright JB, Kinzbrunner BM: How to assist patients and families in accessing end-of life care. Chapter 2 in Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical Guide. New York: McGraw Hill, 2011, p. 37
  22. 22. Comparison of Hospice & Palliative Care Programs (Cont.) Professional Services • Hospice: defined interdisciplinary team – Physician – Social Worker – Certified Nursing Ass’t – Nurse – Pastoral Counselor – Others Wright JB, Kinzbrunner BM: How to assist patients and families in accessing end-of life care. Chapter 2 in Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical Guide. New York: McGraw Hill, 2011, p. 37
  23. 23. Comparison of Hospice & Palliative Care Programs (Cont.) Professional Services • Palliative Care: inter-or multi-disciplinary team consisting of one or more of the following: – Physician – Nurse Practitioner – Others as needed • May be less of an issue as standards are introduced defining minimum professional requirements for Palliative Care Teams Wright JB, Kinzbrunner BM: How to assist patients and families in accessing end-of life care. Chapter 2 in Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical Guide. New York: McGraw Hill, 2011, p. 37 – Nurse – Social Worker
  24. 24. Other Covered Services • Hospice – Medications – DME – Bereavement Care • Palliative care – No required services – Most non-professional services are provided by existing insurance coverage if available Comparison of Hospice & Palliative Care Programs (Cont.) Wright JB, Kinzbrunner BM: How to assist patients and families in accessing end-of life care. Chapter 2 in Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical Guide. New York: McGraw Hill, 2011, p. 37
  25. 25. Location of services • Hospice: Availability of services required in all locations – Private Residence – Nursing Home – Adult Living – Inpatient Care Comparison of Hospice & Palliative Care Programs (Cont.) Wright JB, Kinzbrunner BM: How to assist patients and families in accessing end-of life care. Chapter 2 in Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical Guide. New York: McGraw Hill, 2011, p. 37
  26. 26. Location of services • Palliative Care: Varies based on program – Home care only – Inpatient only – Nursing home only – Combination – Networking between hospital and hospice or home-based home-health program Comparison of Hospice & Palliative Care Programs (Cont.) Wright JB, Kinzbrunner BM: How to assist patients and families in accessing end-of life care. Chapter 2 in Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical Guide. New York: McGraw Hill, 2011, p. 37
  27. 27. Current funding sources • Hospice – Medicare Hospice Benefit – Most state Medicaid programs – MCOs and commercial carriers – Charitable funding to supplement cost of care can be raised by non-profit hospices • Palliative care – Traditional hospital insurance coverage – Traditional home health care coverage – Support from hospital and hospice partner organizations – Charitable funding Comparison of Hospice & Palliative Care Programs (Cont.) Wright JB, Kinzbrunner BM: How to assist patients and families in accessing end-of life care. Chapter 2 in Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical Guide. New York: McGraw Hill, 2011, p. 37
  28. 28. Palliative Medicine Recognition • Hospice & Palliative Medicine – 2006 - recognized by American Board of Medical Specialties (ABMS) – 2007 - recognized by American Osteopathic Association (AOA) – 2008 - first board exam offered by ABIM, >1400 examinees • Certification also available for: – Nurse Practitioners – Registered Nurses – Licensed Clinical Social Workers
  29. 29. Palliative Care Programs Hospital-based Palliative Care • Interdisciplinary or multi-disciplinary • Typically physician led • Physician consults with supplementation by other disciplines • Some academic centers and hospitals have discreet inpatient units • ICU consults to facilitate end of life decision making • Reduces ICU utilization Wright JB, Kinzbrunner BM: How to assist patients and families in accessing end-of life care. Chapter 2 in Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical Guide. New York: McGraw Hill, 2011, p. 37
  30. 30. Palliative Care Programs (Cont.) Hospital-based Palliative Care • Reimbursement through traditional system – No specific reimbursement stream for “palliative care” – Physician consults – DRGs for hospital care • Savings by reducing ICU and inpatient days • Improved quality of inpatient care • May partner with a hospice to provide more comprehensive services Wright JB, Kinzbrunner BM: How to assist patients and families in accessing end-of life care. Chapter 2 in Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical Guide. New York: McGraw Hill, 2011, p. 37
  31. 31. Palliative Care Programs (Cont.) Long-term care palliative care • Need for palliative care for patients accessing Medicare Part A for nursing home care • Physician consult services • Partnerships with hospices Wright JB, Kinzbrunner BM: How to assist patients and families in accessing end-of life care. Chapter 2 in Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical Guide. New York: McGraw Hill, 2011, p. 37
  32. 32. Palliative Care Programs (Cont.) Home-based palliative care • Home health agency services • May be independent or affiliated with a hospice program • Patients need to be home-care eligible • Pre-hospice “bridge” programs – Affiliated with hospice – Reimbursed as home health agencies – Hospice or hospice trained staff Wright JB, Kinzbrunner BM: How to assist patients and families in accessing end-of life care. Chapter 2 in Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical Guide. New York: McGraw Hill, 2011, p. 37
  33. 33. Home-based palliative care • Pre-hospice “bridge” programs – Affiliated with hospice and reimbursed as HHA – Hospice or hospice trained staff – Longer median survival (52 vs. 20 days) – Supplementary funding for non-covered services – Patients living > six months doubled from 6-13% – Patients were hospice eligible – No data on why patients did not elect hospice – May have desired treatment hospice was unwilling to provide Effectiveness of Palliative Care Casarett D, Abrahm JL: Patients with cancer referred to a hospice versus a bridge program: Patient characteristics, needs for care, and survival. J Clin Oncol 19:2057, 2001.
  34. 34. Disease-based palliative care • Focused on special needs of patients with specific chronic and potentially terminal Illnesses – Cancer – HIV – Pediatrics – Dementia Palliative Care Programs (Cont.) Wright JB, Kinzbrunner BM: How to assist patients and families in accessing end-of life care. Chapter 2 in Kinzbrunner BM, Policzer JS (eds): End-of-Life Care: A Practical Guide. New York: McGraw Hill, 2011, p. 37.
  35. 35. Common Reasons for Palliative Care Consults • Goals of care identification/advance care planning • Coordination of care across settings • Complex pain and symptom management • Counseling and emotional support • Spiritual support • Physician support w/complex decision making – (e.g. tube feeding, withdrawal of dialysis)
  36. 36. Effectiveness of Palliative Care Hospital-based palliative care consultation Results of retrospective analysis at two VA centers: • Total inpatient direct costs – PC: $ 1000 • Ancillary costs – PC: $ 123 • PC patients were 42% less likely to use ICU • No difference in inpatient pharmacy costs – Non-PC: $ 1239 Diff: $ 239 – Non-PC: $ 221 Diff: $ 98 Penrod JD, et al. Cost and utilization outcomes of patients receiving hospital-based palliative care consultation. J Pall Med 9(4):855-860, 2006.
  37. 37. Effectiveness of Palliative Care (Cont.) Inpatient palliative care team: RCT • Multi-center randomized trial • Inpatient palliative care service (IPCS) vs. usual care (UC) Results • Hospice utilization: median LOS – IPCS: 24 days – UC: 12 days (p = 0.04) • Advance directives at hospital discharge – IPCS: 91.1% – UC: 77.8% (p = 0.001) – No difference in % of patients with ADs prior to study • Mean satisfaction with hospital care and providers – Place: IPCS: 6.8 – UC: 6.4 (p = < 0.001) – Providers: IPCS: 8.3 – UC: 7.2 (p = < 0.001) • No differences in survival or symptom control Gade G, et al. Impact of an inpatient palliative care team: A randomized control trial. J Pall Med 11(2):180-190, 2008.
  38. 38. Effectiveness of Palliative Care (Cont.) Results Total healthcare expenditures for six months following index hospitalization: • Total mean costs – IPCS: $14,486 – UC: $21,252 Diff: $6,766 (p = 0.001) • Net savings after subtracting consult staff costs – Net savings: $4,855 – Staffing cost: $1,911 • Number of hospital readmissions was not different between the two groups during the six months following index hospitalization • Cost of hospital readmission during the six months – IPCS: $6,241 – UC: $13,275 (p = 0.009) • Number of ICU stays on readmission – IPCS: 12 – UC: 21 (p = 0.04) Gade G, et al. Impact of an inpatient palliative care team: A randomized control trial. J Pall Med 11(2):180-190, 2008.
  39. 39. Effectiveness of Palliative Care (Cont.) Zhang B, et al. Health care costs in the last week of life. Associations with end of life conversations. Arch Int Med 169(5):480-488, 2009 Health care costs and EOL conversations • 603 patients with advanced cancer • Interviewed at baseline and followed to death • All costs in the last week of life—ICU, hospital, hospice and life-sustaining procedures including resuscitation and ventilation—were aggregated Results • 188 (31.2%) reported EOL discussion at baseline • Costs of care in last week – w/EOL: $1876 – wo/EOL: $2917 Diff: $1041 (p = 0.002) • Patients with higher costs had worse quality of death in their final week (p = 0.006)
  40. 40. Early Palliative Care in Cancer Patients • Significant improvement of quality of life of life at 12 weeks as measured by three validated instruments • Significantly lower percentage of patients with depression and anxiety • Significant improvement in patient survival up to two years following diagnosis Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 363:733-742, 2010
  41. 41. Survival of patients with metastatic non-small cell lung cancer patients receiving early palliative care interventions alongside chemotherapy Early Palliative Care in Cancer Patients (Cont.) Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 363:733-742, 2010
  42. 42. Hospice/Palliative Care Interface Traditional Model of Health Care Emanuel, von Gunten, Ferris. Plenary 3: EPEC series and reproduced in Kinzbrunner. Palliative Care Perspectives, Chapter 1 in Kuebler, Davis,Moore Palliative Practices, An Interdisciplinary Approach, 2005, p. 21
  43. 43. Hospice/Palliative Care Interface (Cont.) Integrated Palliative Care Model Modified From Emanuel, von Gunten, Ferris. Plenary 3:EPEC series and reproduced in Kinzbrunner. Palliative Care Perspectives, Chapter 1 inKuebler, Davis, Moore Palliative Practices, An Interdisciplinary Approach, 2005, p. 22.
  44. 44. For those eligible to obtain CE credit: 1. Enter the following website information in your web browser: www.VIT.CmeCertificateOnline.com 2. Click on the link: Introduction to Palliative Care– 10.13.16 3. You will be asked to complete a brief questionnaire, and your certificate will be available to print immediately afterward. A copy of the certificate will also be sent to you via email. Questions? Email Certificate@AmedcoEmail.com

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