Downloaded 18 times
![16
Scripting
• “Palliative care works with me, your [provider], to better manage
your [pain, shortness of breath or other symptom (anxiety,
fatigue, nausea)]. They are experts in looking at this holistically
and make a comprehensive plan for how best to relieve your
[symptom].
• They can answer some of the questions you may have about what
to expect in future as your [disease] worsens.
• They help me formulate a treatment plan that is based on what is
important to you and what is going on with your family.
• There is support staff at the clinic who works with the palliative
care providers to help you and your family cope with these
changes and plan for the future”
How to help other providers refer to palliative care](https://image.slidesharecdn.com/20-220516035404-eea3d88b/85/Primary-and-Specialty-Palliative-Care-pptx-16-320.jpg)
![18
Quality and Quantity
Of the 151 patients who underwent
randomization, 27 died by 12 weeks and 107
(86% of the remaining patients) completed
assessments. Patients assigned to early
palliative care had a better quality of life than
did patients assigned to standard care (mean
score on the FACT-L scale [in which scores range
from 0 to 136, with higher scores indicating
better quality of life], 98.0 vs. 91.5; P=0.03). In
addition, fewer patients in the palliative care
group than in the standard care group had
depressive symptoms (16% vs. 38%, P=0.01).
Despite the fact that fewer patients in the
early palliative care group than in the standard
care group received aggressive end-of-life care
(33% vs. 54%, P=0.05), median survival was
longer among patients receiving early
palliative care (11.6 months vs. 8.9 months,
P=0.02).](https://image.slidesharecdn.com/20-220516035404-eea3d88b/85/Primary-and-Specialty-Palliative-Care-pptx-18-320.jpg)
![42
Unclear Goals = Unplannable Caring
Goals of Care
• “I’m going to beat this [disease]!”
• “My family won’t let me go to a
nursing home.”
• “We’re going to fight this!”
• “I’m going to get my miracle.”
Plan of Care
• These are general, usually not agreed
upon, often unrealistic, and do not
meet a timeline consistent with life
expectancy.
• The plan of care in these case is to
explore:
– “Tell me what this means to you.”
– “Help me understand more about this
by telling me how you feel about…”
And get a family meeting with all the key
partners in the patient’s care both family
and providers.
vitaltalk.org](https://image.slidesharecdn.com/20-220516035404-eea3d88b/85/Primary-and-Specialty-Palliative-Care-pptx-42-320.jpg)
Uploaded byMike Aref
Primary and Specialty Palliative Care.pptx
Palliative care aims to relieve suffering and improve quality of life for patients with serious illnesses and their families. It can be provided alongside curative treatment. The presentation discusses primary palliative care provided in primary care settings and specialty palliative care provided by palliative care specialists. It provides criteria for referring patients to specialty palliative care, such as advanced cancers, organ failures, neurological diseases, and frequent hospitalizations. Early referral to palliative care can improve quality of life and mood and extend survival. While many could benefit from palliative care, there are not enough specialists to meet the need.
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Primary and Specialty Palliative Care.pptx
- 1. 1 Primary and Specialty PalliativeCare Michael Aref, MD, PhD, FACP, FHM, FAAHPM, HMDC Assistant Medical Director of Palliative Medicine
- 2.
- 3. 3 Disclosure of FinancialRelationships and Conflicts of Interest None
- 4.
- 5. 5 Objectives • What ispalliative care? • Basics of primary palliative care. • When to refer for specialty palliative care. • Introducing new options in telepalliative care.
- 6. 6 THE HEALTHCARE WORLDIS FLAT
- 7. 7 Welcome to Healthcaria Bewarethe patient doesn’t fall off! The Healthcare World is Flat Nursing / Social Work / Therapy Primary Care Specialty Care IM FM Peds
- 8. 8 Death is NOTthe enemy We die not because we lose, quit, or fail. We die because that is the natural end of life. The Healthcare World is Flat Nursing / Social Work / Therapy Primary Care Specialty Care IM FM Peds
- 9.
- 10. 10 Questionable Origins “The termpalliative care was coined by Canadian surgeon Balfour Mount in 1975. Palliative care is interdisciplinary care that aims to relieve suffering and improve the quality of life for patients with critical, advanced, or terminal illness, and their families. It is offered simultaneously with all other appropriate medical treatment. No specific therapy is excluded from consideration, including surgical intervention. The indication for palliative care is based on the need to achieve quality-of-life goals, not poor prognosis.”
- 11. 11 Definitions • Palliative careis 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. • Palliative care, and the medical sub-specialty of palliative medicine, is specialized medical care for people living with serious illness. It focuses on providing relief from the symptoms and stress of a serious. Illness whatever the diagnosis. The goal is to improve quality of life for both the patient and the family. • Palliative care is the relieving or soothing of symptoms of a disease or disorder while maintaining the highest possible quality of life for patients. WHO • CAPC • AAHPM www.who.int/cancer/palliative/denition/en/ www.capc.org/about/palliative-care/ palliativedoctors.org/palliative/care
- 12. 12 Type Goal InvestigationsTreatments Setting Active 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 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 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 Victoria Classification of Palliative Care J Palliat Care. 1993 Winter;9(4):26-32.
- 13. 13 Sufferology • The areaof medicine that deals with alleviating the physical, mental, spiritual and familial suffering of patients with chronic, progressive illness. • Palliative care is concerned with three things: • the quality of life, • the value of life, and • the meaning of life. More than “there’s nothing left to do” Doyle D, Oxford Textbook of Palliative Medicine, 3 ed.
- 14. 14 DIAGNOSIS $35 With 1Hospitalization $175. With 2 Hospitalizations 500. With 3 Hospitalizations 1100. With 4 Hospitalizations 1300. With Hospice $1500. Mortality Value $175 Hospitalizations cost $200K. each Hospice, $0. plus (or minus) 4 hospitalizations. If a patient owns ALL the Symptoms of any Color Group, the opiates are Doubled on Uncontrolled Symptoms in that group. Mortalopoly and Morbidopoly • Palliative care is a philosophy of care for seriously ill patients, it is – NOT a place – NOT a status – NOT limited by curative intent
- 15. 15 With, For, andTo Never say nothing • Even when we cannot cure their illness or prevent their death, we can always do something: provide the best care possible. #with4not2 • Do as little to the patient as possible. • Do for the patient what they cannot do themselves. • Do as much with the patient as you are able.
- 16. 16 Scripting • “Palliative careworks with me, your [provider], to better manage your [pain, shortness of breath or other symptom (anxiety, fatigue, nausea)]. They are experts in looking at this holistically and make a comprehensive plan for how best to relieve your [symptom]. • They can answer some of the questions you may have about what to expect in future as your [disease] worsens. • They help me formulate a treatment plan that is based on what is important to you and what is going on with your family. • There is support staff at the clinic who works with the palliative care providers to help you and your family cope with these changes and plan for the future” How to help other providers refer to palliative care
- 17. 17 Palliative Care andHospice Clin Geriatr Med 2013; 29:1–29 www.nationalconsensusproject.org www.nia.nih.gov/health/publication/e nd-life-helping-comfort-and- care/providing-comfort-end-life Palliative Care Symptom Management of Life Limiting Illness Curative or Palliative Treatment Disease Management of Life Limiting Illness Symptom burden despite or due to disease modification End of Life or Hospice Care Symptom Management and Comfort Care Untreatable disease No longer desiring treatment Symptom burden increases due to treatable disease burden 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.
- 18. 18 Quality and Quantity Of the 151 patients who underwent randomization, 27 died by 12 weeks and 107 (86% of the remaining patients) completed assessments. Patients assigned to early palliative care had a better quality of life than did patients assigned to standard care (mean score on the FACT-L scale [in which scores range from 0 to 136, with higher scores indicating better quality of life], 98.0 vs. 91.5; P=0.03). In addition, fewer patients in the palliative care group than in the standard care group had depressive symptoms (16% vs. 38%, P=0.01). Despite the fact that fewer patients in the early palliative care group than in the standard care group received aggressive end-of-life care (33% vs. 54%, P=0.05), median survival was longer among patients receiving early palliative care (11.6 months vs. 8.9 months, P=0.02).
- 19. 19 Carle Palliative MedicineCriteria General Referral Criteria1 Presence of a serious illness and one or more of the following: • New diagnosis of life-limiting illness for symptom control, patient/family support • Declining ability to complete activities of daily living • Weight loss • Progressive metastatic cancer • Admission from long-term care facility (nursing home or assisted living) • Two or more hospitalizations for illness within three months • Difficult-to-control physical or emotional symptoms • Patient, family or physician uncertainty regarding prognosis • Patient, family or physician uncertainty regarding appropriateness of treatment options • Patient or family requests for futile care • DNR order conflicts • Conflicts or uncertainty regarding the use of non-oral feeding/hydration in cognitively impaired, seriously ill, or dying patients • Limited social support in setting of a serious illness (e.g., homeless, no family or friends, chronic mental illness, overwhelmed family caregivers) • Patient, family or physician request for information regarding hospice appropriateness • Patient or family psychological or spiritual/existential distress Cancer2 • Stage IV disease • Stage III lung or pancreatic cancer • Stage II non-small cell lung cancer3 • Prior hospitalization within 30-days, excluding routine chemotherapy • Hospitalization lasting longer than 7 days. • Uncontrolled symptoms including pain, nausea/vomiting, dyspnea, delirium, and psychological distress. 1 www.capc.org 2 www.oncologypractice.com/single-view/five-criteria-doubled- palliative-care-cut-hospital- readmissions/f37951d2a4828930104a3fa9b91eb013.html 3 N Engl J Med 2010; 363:733-742
- 20. 20 Carle Palliative MedicineCriteria Heart Failure1 • Symptoms • NYHA class III/IV symptoms • Frequent heart failure readmissions • Recurrent ICD shocks • Refractory angina • Anxiety or depression adversely affecting patient's quality of life or ability to best manage illness • Milestones • Referral • VAD • Transplant • TAVR • Home inotropic therapy • Caregiver distress Kidney Disease2 • CKD Stage IIIb, IV, or V with fatigue, muscle cramps, anorexia, nausea, insomnia, neuropathy, gout, itch, headache, or cognitive impairment • ESRD on dialysis with any stage V symptom as well as abdominal pain from peritoneal dialysis or fistula problems from hemodialysis • Calciphylaxis • Symptoms due to comorbid diabetes, cardiovascular disease, or cancer Liver Disease3 • Ascites despite maximum diuretics • Spontaneous peritonitis • Hepatorenal syndrome • INR > 1.2 without anticoagulation • Encephalopathy • Recurrent variceal bleeding if further intervention inappropriate 1 www.acc.org/latest-in-cardiology/articles/2016/02/11/08/02/palliative-care-for-patients-with-heart-failure#sthash.ddHLsX9W.dpuf 2 Adapted from: www.nhslanarkshire.org.uk/Services/PalliativeCare/Documents/NHS%20Lanarkshire%20Palliative%20Care%20Guidelines.pdf 3 www.palliativedrugs.com/download/SpecialistPalliativeCareReferralforPatients.pdf
- 21. 21 Carle Palliative MedicineCriteria Lung Disease Chronic Obstructive Pulmonary Disease1 • Age ≥ 75 • Diabetes, cardiovascular disease, or end-stage renal disease • Change in 6 minute walk by 50 m • Functional dependence and patient reported minimal physical activity • Poor healthcare quality-of-life • FEV1 < 30% • BMI < 20% • ≥ 1 hospitalization within last year Restrictive Lung Disease2 • TLC or FVC < 50% Neurological Disease3 Presence of any of the General Referral Criteria above, and/or: • Folstein Mini Mental score < 20 • Feeding tube is being considered for any neurological condition • Status Epilepticus > 24 hrs • ALS or other neuromuscular disease considering invasive or non-invasive mechanical ventilation • Any recurrent brain neoplasm • Parkinson’s disease with poor functional status or dementia • Advanced dementia with dependence in all activities of daily living 1 Int J Chron Obstruc Pulmon Dis. 2015; 10:1543-51 2 Based on severity obtained from review of courses.washington.edu/med610/pft/pft_primer.html#algor 3 www.capc.org
- 22. 22 Carle Palliative MedicineCriteria • If you want to do everything for your patient and they have a diagnosis which says or means failure, they would likely benefit from a palliative care referral. – Symptomatic heart, lung, kidney, or liver failure. – Cancer is cellular failure. – Stroke, dementia, and neurological degenerative diseases (ALS) are neurological failure. General Referral Criteria
- 23. 23 Choosing Wisely Don’t delaypalliative care for a patient with serious illness who has physical, psychological, social or spiritual distress because they are pursuing disease-directed treatment. www.choosingwisely.org/doctor-patient-lists/american-academy-of-hospice-palliative-medicine/
- 24. 24 Primary and SpecialtyPalliative Care Primary Palliative Care • Referrals • Feedback • Managing patients closer to home Specialty Palliative Care • Education • Support • Adding value to preexisting exemplary care
- 25.
- 26. 26 Curative or Palliative? •Morphine – No mortality benefit. • Oxygen – No mortality benefit (unless hypoxic). • Nitrates – No mortality benefit. • Aspirin – OK, now we start decreasing mortality (anti-platelet effects onset of action is 2 hours, analgesic effect is 10-15 minutes).
- 27. 27 Total Symptoms Pain • Physicalproblems (multiple) • Anxiety, anger and depression— elements of psychological distress • Interpersonal problems — social issues, financial stress, family tensions • Nonacceptance or spiritual distress Dyspnea • Physical symptoms • Psychological concerns • Social impact • Existential suffering Curr Opin Support Palliat Care. 2008; 2(2):110-3
- 28. 28 Total Suffering Social Psychological Physical •Role •Relationships •Occupation •Financial cost •Emotionalresponse •Comorbid mood disorder anxiety •Adjustment to new baseline •Cause? •Associated symptoms •Debility and fatigue Superimposed on Maslow’s Hierarchy of Needs Spiritual •Existential coping •Religious beliefs •Meaning of life/illness •Personal value Interventional Pain Service Other Specialties Pharmacy Physical Therapy Social Work Financial Navigator Occupational Therapy Chaplaincy Art & Music Therapy Social Work Psychology Psychiatry Curr Opin Support Palliat Care. 2008; 2(2):110-3 Maslow AH, A Theory of Human Motivation, 1943
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- 30. 30 Life-Limiting Illness Population •It is estimated at there is 1,200 patients with life- limiting illness for each specialty palliative care provider. – By comparison there are 141 cancer patients per oncologist. • It is estimated that 30% of hospital patients “need” a palliative care consult: – At Carle Foundation Hospital that would be a 120 patient service, currently we see about 30 in-patients per day. These numbers don’t add up either www.capc.org/about/press-media/press-releases/2016-9-9/Hospital-Palliative-Care-Programs-Understaffed/ www.ajmc.com/journals/evidence-based-oncology/2015/april-2015/how-and-why-oncologists-should-do-palliative-careor-get-some-assistance-doing-it-
- 31. 31 Chronic Non-Malignant PainPopulation • 5000 opioid-dependent chronic non-malignant pain patients in the Carle Health System. • Opioid prescriptions are written every 28 days, or 20 working days, ≈ 250 patients per day. • Active ambulatory palliative care FTEs ≈ 2. • We don’t manage chronic non-malignant pain any better than you would. The numbers don’t add up
- 32.
- 33.
- 34. 34 Chronic Inflammatory Pain 1stLine • NSAID + PPI see tables following • Selective COX-2 Inhibitors celecoxib 200 mg daily or 100 mg every 12 hours • Acetaminophen 1000 mg TID 2nd Line • 2 agonists tizanidine 2-12 mg PO TID • Serotonin-norepinephrine reuptake inhibitors (SNRIs): duloxetine 60-120 mg PO daily venlafaxine 75-112 mg PO BID • Tricyclic antidepressants (TCAs): amitriptyline 25-150 mg PO QHS nortriptyline 25-150 mg PO QHS 3rd Line • Corticosteroids Require an extensive risk to reward discussion with patient • Strong Opiates < 50 mg MEDD Pharmacological Management BJA, 2001; 87(1):3–11 Up-To-Date
- 35. 35 Chronic Nocioceptive Pain 1stLine •Topical agents: capsaicin 0.025% - 0.075% topically TID lidocaine 5% topically TID 2nd Line •Acetaminophen acetaminophen 1000 mg TID 3rd Line •NSAID + PPI see tables previous •Selective COX-2 Inhibitors celecoxib 200 mg daily or 100 mg every 12 hours 4th Line •Serotonin-norepinephrine reuptake inhibitors (SNRIs): duloxetine 60-120 mg PO daily venlafaxine 75-112 mg PO BID •Tricyclic antidepressants (TCAs): amitriptyline 25-150 mg PO QHS nortriptyline 25-150 mg PO QHS 5th Line •Strong Opiates < 50 mg MEDD Pharmacological Management Up-To-Date If signs/symptoms of muscle spasm: • cyclobenzaprine 5 mg PO TID • tizanidine 2 mg PO TID • baclofen 5 mg PO TID
- 36. 36 Neuropathic Pain 1st Line •Calciumchannel 2 ligands: gabapentin 300-1200 mg PO TID pregabalin 100-150 mg PO BID •Serotonin-norepinephrine reuptake inhibitors (SNRIs): duloxetine 60-120 mg PO daily venlafaxine 75-112 mg PO BID •Tricyclic antidepressants (TCAs): amitriptyline 25-150 mg PO QHS nortriptyline 25-150 mg PO QHS 2nd Line •Topical agents: capsaicin 0.025% - 0.075% topically TID lidocaine 5% topically TID •Tramadol tramadol 100 mg PO TID tramadol ER 100-200 mg PO BID 3rd Line •Strong Opiates < 50 mg MED oxycodone methadone Possibly Effective •N-methyl-D-aspartate (NMDA) antagonists dextromethorphan-quinidine 30-30 mg PO BID •Muscle relaxants tizanidine 2-12 mg PO TID Pharmacological Management www.uptodate.com/contents/image?imageKey=PC%2F58265&topicKey=ANEST%2F2785&search=peripheral%20neuropathic%20pain&rank=1~150&source=see_link Finnerup NB et al, Lancet. 2015 Feb; 14: 162-173. Shaibani AI et al, Pain Med. 2012 Feb;13(2):243-254. Semenchuk MR, Sherman S, J Pain. 2000;1(4):285-92
- 37.
- 38. 38 HCPOA Surrogate decision makers 1.the patient's guardian of the person 2. the patient's spouse 3. any adult son or daughter of the patient 4. either parent of the patient 5. any adult brother or sister of the patient 6. any adult grandchild of the patient 7. a close friend of the patient 8. the patient's guardian of the estate. Choosing a surrogate • Choose the person who would make the decision you would make for yourself if you were able to. • And tell them you chose them and talk about your health and wishes. (755 ILCS 40/) Health Care Surrogate Act
- 39. 39 Talk Early. TalkOften. • Anticipate trajectory of disease so that you can have continuing conversations about goals-of-care and advance directives. • Making decisions empowers patients and decreases burden on family because these conversations have already occurred.
- 40. 40 Speaking and TranslatingCaring Goals of Care • Identify what is important to and priorities for the patient. • Identify what they hope to achieve by receiving care. • Identify what they fear will happen because of the disease. • Life review and legacy building are separate, equal, but not independent parts of care. Plan of Care • Representation of the goals of care in the form of – Documentation • Advanced Directive • Living Will • HCPOA – Orders • POLST • Code Status – Medications • Starting and stopping – Services • Social Work • Chaplaincy • Hospice • Home Health National Committee for Quality Assurance: Goals to Care
- 41. 41 S.M.A.R.T. Goal • Specific –What does the patient mean to accomplish with this goal? • Measurable – What observable shows we are meeting the stated goal? • Agreed Upon – Are the patient, family, and provider all on the same page? • Realistic – Is this possible – physiologically, clinically, financially, humanly, etc.? • Time-Bound – When will this be observable? General goals cannot be translated into a plan of care Management Review. AMA FORUM. 70 (11): 35–36 National Committee for Quality Assurance: Goals to Care
- 42. 42 Unclear Goals =Unplannable Caring Goals of Care • “I’m going to beat this [disease]!” • “My family won’t let me go to a nursing home.” • “We’re going to fight this!” • “I’m going to get my miracle.” Plan of Care • These are general, usually not agreed upon, often unrealistic, and do not meet a timeline consistent with life expectancy. • The plan of care in these case is to explore: – “Tell me what this means to you.” – “Help me understand more about this by telling me how you feel about…” And get a family meeting with all the key partners in the patient’s care both family and providers. vitaltalk.org
- 43. 43 It Is AllGoing Downhill Disease Trajectories bioethicsarchive.georgetown.edu/pcbe/images/living_well_graph.gif
- 44.
- 45. 45 Years – Months– Weeks – Days Birth Actively Dying Death J Pain Symptom Manage. 2014 Jan; 47(1): 77–89. Diagnosis Treatment New Problem
- 46. 46 DNAR is a(Small) Part of Goals of Care Birth Actively Dying (B) Death (A) (C) www.polstil.org Diagnosis Treatment New Problem
- 47. 47 POLST A. “If youhad no heart beat and are not breathing, that is you are dead, what do you think would be the best thing to do? Try to bring you back, which is a Full code, or knowing that you have a number of progressive health conditions feel that a natural death is right at that time, which is Do Not Attempt Resuscitation?”
- 48. 48 POLST Continued B. Ifthey choose Full Code in A, then the only appropriate selection in B is “Full Treatment” If they chose DNAR, “If you are dying, that is your lungs and heart cannot get oxygen to your organs, what would like us to do, take you to the hospital and try to correct the situation, even using life support (Full Treatment) or using everything short of that (Selective Treatment), or try to keep you comfortable at home and only moving you to keep you comfortable (Comfort- Focused Care). No matter what you chose if you are feeling ill you can always elect to see your physician or come to the hospital.”
- 49. 49 POLST Continued C. Ifthey elected Comfort Care in B the only appropriate selection is No medically administered nutrition. If they elected Selective Treatment in B then any option is appropriate. If they elected Full Treatment only Long-term or Trial period of medical nutrition is appropriate. “Would you want artificial nutrition, that is a tube in the nose or in the belly that supplies nutrition?”
- 50. 50 POLST Continued D. Makesure the patient or surrogate and witness sign it. E. Make sure that you sign the POLST to complete it. I make a copy to be scanned in and return the original to the patient. I tell them to place it on their fridge.
- 51. 51 Advance Care Planning •CPT Code 99497 – Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate • CPT Code 99498 – each additional 30 minutes (List separately in addition to code for primary procedure) Billing Frequently Asked Questions about Billing the Physician Fee Schedule for Advance Care Planning Services , www.cms.gov, July 14, 2016
- 52.
- 53. 53 In-Patient Palliative Care •Since January 2017, the in-patient service has been 7 days a week, 365 days a year during regular business hours. • Minimum staffing for the service is three (3) providers, one of whom is a physician, except on weekends and holidays. • Follow-Up Orders – on patients we already see – on patients that receive other care here at the main campus who would benefit from ambulatory palliative care follow-up If they are sick enough to be in the hospital and need a palliative care consult, they need that consult in-patient.
- 54. 54 Ambulatory Palliative Care •Clinic staffed Monday – Friday during regular business hours. • To refer place order in EPIC – Type “amb pal” – Clinical coordinator or RN will call patient to set-up appointment • Embed Clinics: – Oncology (5 days/week)
- 55. 55 Telepalliative Care • CarlePalliative Care Services now offers telephone and telehealth consultations. • Patients and families must be made aware that our service may require them to be seen in-person prior to initiating or continuing symptom management, particularly when prescribing opioids. • If the referring service is willing to write all prescriptions for symptom management it will be less likely that in-person visits will be necessary. The positives of a pandemic
- 56. 56 THANK YOU QUESTIONS. CONCERNS.COMMENTS.