2. • Palliative care is a medical specialty backed by an interdisciplinary team
that supports the attending physician’s care of patients with serious
and life-threatening illnesses.
• Palliative care supports the attending physician’s plan of care by making the
patient as comfortable as possible at all stages of illness,
simultaneously with curative care or any other medical treatment.
• Palliative care is evidence-based medical treatment that has been shown to
significantly lower pain and discomfort, improve patient outcomes and
boost patient and family satisfaction, while freeing the attending
physician from time-consuming coordination and support.
• Palliative care may also complement care provided to patients receiving
disease-modifying treatment. This team assists the physician in clarifying
the patient/family’s goals of treatment and designing an individualized
plan of care that addresses the patient’s physical, psycho-social, spiritual
and cultural needs.
What is Palliative Care?What is Palliative Care?
3. • Palliative care is NOT in place of curative care.
• Patients benefit from palliative care before, during and
after beneficial, curative or life-prolonging care.
• Palliative care is NOT the same as hospice. Palliative
care is offered at any stage of any illness, while hospice
care is appropriate for people with terminal illnesses,
at the last stages of life and a prognosis of six
months or less and for whom curative or life-prolonging
therapies are not effective.
What is it not?What is it not?
4. Physician Role in Addressing
Advance Care Planning
• Patient options for treatment
• Chances of survival or prognosis
• Options for pain/other symptoms of disease
• Patient/family’s decision about treatment
• Spiritual needs assessment
How does CHW define
Advance Care Planning?
How does CHW define
Advance Care Planning?
5. Physician Role in Addressing
Advance Care Planning
DISCUSSION & DOCUMENTATION
OF THE FOLLOWING:
• Patient options for treatment
• Chances of survival or prognosis
• Options for pain/other symptoms of disease
• Patient/family’s decision about treatment
Physician Role in
Advance Care Planning
Physician Role in
Advance Care Planning
6. 1/30/2009 6
Advance Care Planning is
ALL about TIME
•TIME intensive patient family centered communication around
goals of care.
•INTEGRATE pain and symptom management with all other
appropriate treatment to achieve the highest quality of patient care.
IMPROVE patient satisfaction with the hospital, overall medical
treatment, physicians and health care team.
•MEET decision making needs of patients ensuring fully informed
consent based on burdens of the treatments and wishes of the
family.
•EASE case management burdens on physicians and support for
the plan of care by helping to coordinate the treating physician’s
orders; including safe and effective discharge planning.
Benefits of Advance Care PlanningBenefits of Advance Care Planning
7. • Traditional Medicine
– Cure illness
• Prolong life
Palliative Care
Improve quality of life
Pain management
Symptom management
Emotional support
Advance Care Planning
Does not exclude
traditional therapy
Medical Therapy ChoicesMedical Therapy Choices
8. • Reduce the suffering and increase the comfort of our
patients through symptom control and restoration of
functional capacity.
• Participate in the CHW palliative care initiative.
• Plan for future medical care in the event a patient is
unable to make their own decisions.
• Remain sensitive to personal, cultural and religious
values and beliefs.
CHMC’s - Palliative Care Service GoalsCHMC’s - Palliative Care Service Goals
9. • Pain Management
• Symptom Management
• Emotional Support
• Advance Care Planning
• Provide assistance with:
– In-hospital support
– Transitions to Home, SNF or Hospice, Home Health
Palliative Care Service
Key Components
Palliative Care Service
Key Components
10. • Cancer
• HIV/AIDS
• ESRD, on dialysis with diabetes
• End stage lung disease/COPD
• Acute or chronic respiratory failure
• Cardiac condition
• CAD with bypass and CHF
• ICB
• Cirrhosis
• Dementia with PEG/NG aspiration
Appropriate Palliative Care
Referral Diagnoses
Appropriate Palliative Care
Referral Diagnoses
12. MD order for actual team intervention
• Comfort Measures (Supportive Care) ***
• End-of-life Care
• Hospice Care End of Life Patients ONLY
• Terminal Care
How is a Palliative Care
Physician Order Written?
How is a Palliative Care
Physician Order Written?
13. • Palliative Care Service helps the patient/family make
choices regarding goals of care and may include disease
modifying treatment as well as comfort measures.
• Hospice Services are for patients that have a life
expectancy of 6 months or less. Hospice focuses on
comfort care at the end of life.
What is the difference between
Palliative Care Services and Hospice?
What is the difference between
Palliative Care Services and Hospice?
14. • Prognosis is poor, less than 6 months
• A referral must first be made to CHMC Palliative
Care Services
• Primary Physician agrees that hospice services are
appropriate and thus orders hospice care
• Patient/family agree to hospice care
• Patient meets admitting criteria.
What is required to make a
Hospice Referral?
What is required to make a
Hospice Referral?
15. • ALS ( Lou Gehrig’s Disease)
• End Stage CA ( i.e. Pancreatic Cancer)
• End Stage Alzheimer’s Disease
• Failure To Thrive
• End Stage Renal Disease
• End Stage Parkinson’s
• End Stage MS
• End Stage PVD
• End Stage CVD/Stroke
• HIV/AIDS
Appropriate Hospice
Referral Diagnoses
Appropriate Hospice
Referral Diagnoses
16. Write an order in the patient’s chart for a
Palliative Care Consult
Central Intake Lisa McCullough 213-742-5560
Call Sheldon Lewin Director, Palliative Care Services,
213-742-5525 or hospital pager 307-2368
Contact Robert Rothbart MD,
Palliative Care Medical Director
Contacting the
CHMC’s Palliative Care Service
Contacting the
CHMC’s Palliative Care Service
17. • Central Intake Lisa McCullough 213-742-5560
• Program Administration Sheldon Lewin 213-742-5525 / 773-968-1960 (cell) / 213-307-2368 (pager)
• Educator/Clinical Specialist JO Medina 213-742-6446
• Unit Directors
• Flo Guerra (Critical Care) 213-742-5624
• Rita Mae Feliciano (DOU) 213-742-5835
• Naty Armstrong (Medical Surgical, TCU, Ortho) 213-742-5423
• Chaplain:
• Brother Louis, Sister Judeen` 213-742-6472
• MSW:
• Herb Moorman (DOU/TCU, Orthopedics) 213-307-2326
• Robert Savedra (Critical Care) 213-307-2259
• Kristen Turski (Medical Surgical) 213-307-2288
• Lisa McCullough 213-307-1807
• RN Case Manager:
• Myrna West x6486
• Alicia Pangilinan x6358
• Joyce Galantai x6484
• Sharon Tool x6347
• Patient Representative:
• Ana Cacao x5858
CHMC Palliative Care Core TeamCHMC Palliative Care Core Team
18. CHMC “COMPASSIONATE CARE” PROGRAM
Palliative Care/Advance Care Planning
CASE FINDING, REFERRAL & CONSULT PROCESS
CASE FINDING
INTAKE SCREEN ONLY (For Internal Use/ Not Part of Medical Record)
PRIMARY/ CHARGE RN ---- OBTAIN MD ORDER
Comfort Measures(Supportive Care)
End of Life Care
Hospice Care
Terminal Care
TRIGGER PC CONSULT VIA AS400 TO SOCIAL SERVICES
“COMPASSIONATE CARE” TEAM INTERVENTION & DOCUMENTATION
CARE PLANNING ROUND(S) (Verbal and written)
CARE PLAN IMPLEMENTATION
Palliative Care Core Team Back –Up Clinical/ Intake
Primary RN
Chaplain: Brother Louis, Sister Judeen` *JO Medina
MSW: Herb Moorman, Robert Savedra, Kristen Turski Lisa McCullough * Lisa McCullough
RN Case Manager: Myrna West, Alicia Pangilinan, Joyce Galantai Sharon Tool
Patient Representative: Ana Cacao
Social
Work
Case Management
RNSpiritual
Care
Ancillary
Employees
As Needed
Rehab, Dietary,
Pharmacy
Patient Representative
CHMC - Palliative Care ProcessCHMC - Palliative Care Process
19. Daily Automated
Palliative Care Screening Report
• California Hospital Medical Ctr
• Advance Care Planning & Palliative Care Screening Report
• QUERY NAME . . . . . HSQSHELADT
• LIBRARY NAME . . . . HS#LIBRCMC
• FILE LIBRARY MEMBER FORMAT
• PHPACCT PH#FILECMC PHPACCT PHPACCTA
• DATE . . . . . . . . 09/06/08
• TIME . . . . . . . . 04:30:06
• Advance Care Planning & Palliative Care Screening
• California Hospital Medical Ctr
• 09/06/08 04:30:06
• MR# Acct# Admit Name Aprox Disch LOS Min Serv Room Bed C/C Dr # Dr Last
Name
• Date Age DOB Pt Code
• Dx
• 6000 12345 20080905 BRO 77 19310928 0 0 I DOU 0936 01 1110 3997 KIRSONIS
• ACUTE COPD
• 13333 145 20080905 HO, 52 19561012 0 0 I ICU 0326 01 2102 7763 ZAHED
• COPD CHF
• 1111 81282525 20080705 THO72 19361210 0 0 I DOU 0950 01 1000 3983 KIM
• SOB/CHFEG
• 1111 16539 20080905 NI, 49 19590603 0 0 I DOU 0930 01 2503 66 AMOOIE
• WEAKNESS R/O CVA
• 22222 12321 20080905 TAYLOR, 54 19540222 SNF 2000 5785 PECKNER
• COPD, STAPH SEPSIS, VRE URINE, DVT RT
• 5678 4567 20080905 CRINER, RITA 54 19540222 SNF 0656 01 2000 5785 PECKNER
• COPD, SEPSIS, VRE URINE, DVT RT THIGH
•
• FINAL TOTALS
• COUNT 6
• * * * E N D O F R E P O R T * * *
Automated Daily PC ReportAutomated Daily PC Report
20. CHMC - Palliative Care Intake ScreenCHMC - Palliative Care Intake Screen
I. General Information MSW/ RN COMPLETE
Date_________________ Time____________________
Medical Record #_______________________________
Patient ID #____________________________________
Admit Date____________________________________
Referral Source________________________________
MD Palliative Care Order Yes No
Advance Directive: Type_______________Yes No
On Chart Yes No
Code Status- Circle all that apply
Do not resuscitate
Do not Hospitalize (SNF, subacute)
Comfort Measures (Supportive Care)
Hospice (Referral)
Full Code
Limited DNR
Admitting Diagnosis______________________________________
Religion/Clergy_________________Race_____________________
Next of Kin
Name______________________ Relationship________________
Phone #________________ Work#____________________
II. *** Are we addressing the 5 components of
Advance Care Planning?
Patient Options for Treatment
Chances of Survival or Prognosis
Options for pain/other symptoms of disease
Patient decision about treatment
Spiritual care assessment
Palliative Care/Advance Care Planning
“COMPASSIONATE CARE TEAM”
INTAKE SCREEN ONLY
(Do Not Place in Medical Record)
V. Check current and or recommended services
Social Services MSW COMPLETE
Emotional Support
Advance Care Planning
Advance Directive Information & Education
Family conference
Case Management
Hospice Facility ___________________________
***Home Care Hospice–Palliative Care Services
Name ______________Contact_____________________
Insurance______________Tele #____________________
Nursing Home SNF with Hospice Services
Residential Housing with Hospice Services
Long-Term Care Facilities
Durable Medical Equipment
Patient & Family Education
Family Conference
Chaplain Services
Spiritual Needs Assessment & Support
Grief & Bereavement
Family Conference
VI. Summary: (Comments) MD approved/declined PC Consult
MSW/ RN COMPLETE
IV. Check current and or recommended services
RN COMPLETE
***Pain Management Pain Rating________
Symptom Management – Circle all that apply
Respiratory
Dyspnea Cough
GI
Anorexia Constipation
Diarrhea Nausea / Vomiting
Terminal Dehydration
Neuro/Psych
Fatigue Depression/Anxiety
Delirium/Agitation/Confusion
Patient & Family Education
Family Conference
III. Does the patient meet the following criteria?
Diagnostic Criteria RN COMPLETE
Patients with cancer
Patients with AIDS
Patients over 50 years with ESRD, on dialysis with diabetes
Patients over 50 years with end stage lung disease/COPD
Patients with acute or chronic respiratory failure
Patients with cardiac condition
Patients over 65 with CAD with bypass and CHF
Patients over 65 with ICB
Patients over 65 with cirrhosis
Patients over 65 with dementia with PEG/NG aspiration PNA
ADDRESSOGRAPH
21. 1/30/2009 21
CHMC- FY09 PC Metrics
Metric FY09
Target
FY 09
Performance
Advance Care Planning >70% 53.76%
Number of PC Consults (YTD) 128
Palliative Care Outcome Goals
Must achieve target in 2 measures
% Patients discharged to Hospice (YTD) .60% 2.67%
% End-of-life patients discharged to Hospice at Home
(YTD)
2.20% 1.48%
Avatar Improvement in Pain Management (YTD) 88.5% 86.21%
CHMC – FY09 PC/ACP MetricsCHMC – FY09 PC/ACP Metrics
22. 1/30/2009 22
AB 3000 was signed into law by the Governor on
August 4. This new law ensures that when a patient
has a completed Physician Orders for Life-Sustaining
Treatment (POLST) form, the form must be honored
by all health care providers.
(POLST) is like a prescription and gives direction in
very quick, concise language about the procedures
medical personnel should and should not perform.
The POLST form is completed by the attending
physician after discussion with patient/family or
surrogate decision-maker regarding patient
preferences including :
patient options for treatment, chances of survival or
prognosis, options for pain or other symptom
management and most importantly the patients
decision about treatment.
POLST-Physician Orders
Life Sustaining Treatment
• The POLST represents a very specific way of
summarizing wishes of an individual regarding life-
sustaining treatment.
The form accomplishes two major purposes:
• It is portable from one care setting to another
• It translates wishes of an individual into actual
physician orders.
If you have any questions about POLST or AB 3000,
please contact:
Judy Citko , Coalition for Compassionate Care
at (916) 552-7573 or jcitko@finalchoices.org
Jamie Terrence, CHMC Risk Management
(213)742-5882
Sheldon Lewin, CHMC Social Services &
Education at (213) 742-5525
23. 1/30/2009 23
What Advantage does a POLST form
offer vs. an Advance Directive?
An advance directive is recommended for ALL adults. POLST is
recommended for people who are terminally ill.
POLST translates the person’s broader/more general wishes (as reflected
on the advance directive) and operationalizes those wishes given the
person’s actual medical condition.
Advance directives come in too many shapes and sizes to be useful to
emergency responders. Emergency responders need to make a decision
in split second whether to start life support & don’t have time to read
through a multi-page document.
POLST is standardized and uses clear, consistent language.
24. 1/30/2009 24
What is a POLST Form?
The POLST form is a bright pink medical order form signed by a
California State Licensed physician that indicates why types of life-
sustaining treatment the patient does or does not want if they
become seriously ill.
Additionally, a health care professional must sign this form in order
for it to be followed by other health care professionals.
The form includes medical orders and patient preferences regarding;
•CPR (cardiopulmonary resuscitation)
•Intubation and mechanical ventilation
•Artificial hydration and nutrition
•Future hospitalization and transfer
•Antibiotics
