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Palliative Care
Interdisciplinary Curriculum
A Joint Initiative of the
Palliative Medicine Faculty & Staff of
We gratefully acknowledge the support of
Award Number R25CA134309 from the National Cancer Institute
The content is solely the responsibility of the authors and does not necessarily represent the official
views of the National Cancer Institute or the National Institutes of Health
Palliative Care is…
Hospice Care is…
Frank D Ferris, MD, FAAHPM, FAACE
Palliative
Care
Interdisciplinary
Curriculum
Objectives
• Modern illness experience
• What are palliative & hospice care
• Value of early referral
Main Message
Early referral to
palliative & hospice care,
delivers higher value & safety…
Success of
Modern Medicine…
Illness in the
Past . . .
Health Status
Prior to Antibiotics
Sudden, Unexpected
• infections
• accidents
• adults lived into
their 60s
Death
Time
Adapted from Lunney JR et al. JAMA, May 14, 2003—Vol 289, No. 18 2387-92
Health Status
1940s - 1980s
Prolonged Dying
• predictable
decline
Decline
Death
Time
Adapted from Lunney JR et al. JAMA, May 14, 2003—Vol 289, No. 18 2387-92
Illness in
2016 . . .
Disease, Aging in 2016
• Sometimes cured
• Most often controlled
 Life expectancy 20 - 30 yr.
Canada ≈ 81.8 yr.
USA ≈ 79.7 yr.
World ≈ 68.3 yr.
Cancer
Health Status
Decline with
dependence for
2 – 3 months
Death
Time
Adapted from Lunney JR et al. JAMA, May 14, 2003—Vol 289, No. 18 2387-92
Kit, 58 year old
Peripheral lung mass on
routine chest x-ray
• Wants best treatment
for her cancer
• Wants to be
comfortable,
with family
Kit: Surgery
• Subtotal
pneumonectomy
• Adenocarcinoma
• Metastatic workup:
No evidence other cancer
• Post-thoracotomy
pain syndrome
Opioids + adjuvants to control pain
What does Kit need ?
Multiple Issues Cause Suffering
Disease Management
•Diagnosis
•Prognostication
•Management
Physical
•Pain, dyspnea &
other symptoms
•Function, fluids, nutrition
Loss, grief
•Emotional
responses
•Bereavement
End of life / death
management
•Last hours of living
•When death occurs
Psychological
•Anxiety
•Depression
•Distress
Social
•Family dynamics
•Financial
•Legal
Practical
•Caregiving
•Teamwork
•Volunteers
Spiritual
•Hope
•Meaning, value
•Existential
Who is Affected
Martha, 76, Pulmonary Fibrosis …
Dr. Charles von Gunten, OhioHealth
What does Martha need ?
What are the Clinicians thinking ?
Debrief… Martha…
Dr. Charles von Gunten, OhioHealth
What does Martha need ?
What are the Clinicians thinking ?
Organ Failure
Health Status
e.g., CHF, COPD, Renal, Liver
Decline with
dependence for
months – years
Crisis
Death
Time
Adapted from Lunney JR et al. JAMA, May 14, 2003—Vol 289, No. 18 2387-92
Health Status
Dementia
Decline with
dependence for
years
Death
Time
Adapted from Lunney JR et al. JAMA, May 14, 2003—Vol 289, No. 18 2387-92
Why Did Kit and Martha
come to the Healthcare system ?
Normal path of life with an anticipated future
Illness path with
an uncertain future
Help me fix
my broken story
( Brody )
Patients & Families Want…
• Live life the way they want to
‘ Fix ’ disease, or not
Prevent and relieve suffering, or not
Don’t do treatments they don’t want
• Negotiate goals for
1. Life
2. Medical care
Death in North America
• 90% want to die at home ( NHO Gallup survey )
• 25 % die at home
• 75 % die in institutions
( Teno et al, 1997 )
2 / 3 in hospitals
1 / 3 in nursing homes
• 90% believe it is a family responsibility
to provide care to a loved one
What do You
want your illness
experience to be ?
Patterns of Functional Decline
at the End of Life
1 – Organ Failure
3 – Cancer
2 – Dementia
4 – Sudden
Death
Lunney JR et al. JAMA, May 14, 2003—Vol 289, No. 18 2387-92
Where Would You Like
to Receive Your Care
When You are Dependent ?
1. Acute care
2. Long-term care
3. Home
Palliative Care is…
Palliative Care is…
• Prevent & relieve suffering
• Promote quality of life and death
• Any diagnosis
• Any time there is need
Adapted From: Ferris FD, Balfour HM, Bowen K, Farley J, Hardwick M, Lamontagne C,
Lundy M, Syme A, West P. A Model to Guide Hospice Palliative Care.
Ottawa, ON: Canadian Hospice Palliative Care Association, 2002.
Historical Perspective
Anti-disease Therapy
Presentation
End-of-Life
Care
6m Death
Bereavement
Care
Palliative Care 2016  2026
End-of-Life Care
Anti-disease Therapy
Palliative Care
Presentation Therapies to
6m Death
relieve suffering and / or Bereavement
Care
improve quality of life
Domains of Care
Disease
management
Physical
Loss, grief
End of life /
death
management
Psychological
Social
Practical
Spiritual
Interdisciplinary Care
Spiritual
counselor
Volunteers
Nurse
Family
Doctor
Patient
Social
worker
Community
Physio
therapist
Psychologist
Pharmacist
Bereavement
counselor
ICUs
Acute Care
Office
Home
Inpatient Unit
Other, eg, Jails
Long-Term
Care
Inpatient Unit
Specialized
Units
D
A
Y
H
O
S
P
I
T
A
L
Fact
Our ability to relieve the pain, symptoms
and the distress of serious illness has
never been greater
Goals of Palliative Care
Help to
• Eat well
• Sleep well
• Maintain
function
• Reduce
stress
 Live better
 Live longer
“ Add life to days
and days to life ”
Hospice Care is…
Hospice Care is…
Anti-disease Therapy
End-of-Life / Hospice Care =
Enhanced Palliative Care
Hospice Care
Presentation Therapies to
6m Death
relieve suffering and / or Bereavement
Care
improve quality of life
In the USA
Since 1982, Hospice Care is
• Medicare insurance benefit
• Carved out of Medicare Part A
• Adopted by
Medicaid
Commercial insurers
Eligibility
• 2 physicians certify
Referring physician
Hospice medical director
“ I believe the patient has
a prognosis of ≤ 6 months
if the illness runs its normal course ”
‘ More likely than not ’
= 51 % probabililty
Benefit Periods
Initial Certification
2 physicians
Referring
Hospice Medical Director
90 d
90 d
F
2
F
60 d
F
2
F
60 d
F
2
F
60 d
Recertification
1 physician
Hospice Medical Director
F
2 Unlimited
F
60 d
Medicare Hospice Benefit includes…
• Patients & their families
• Treat & prevent issues that cause
suffering
• Promote quality of life during illness &
bereavement
Facilitate transitions
Achieve full potential – finish life story
Rebuild lives
Medicare Hospice Benefit includes…
• Services
Skilled nursing
Medical counseling
Chaplaincy
• Medications /
therapies
• Medical equipment
• Supplies
Healthcare Aides
Volunteers
24 hr Triage
Bereavement support
≥ 13 months
• Palliative Medicine
physicians
…Medicare Hospice Benefit in Central Ohio
• Routine care ~ $150 / day
• Respite care ( 5 days ) ~ $150 / day
• Continuous care ( crises ) ~ $800 / day
Home
Extended care facility
• General Inpatient Care ( GIP ) ~ $800 / day
Hospice
Hospital
Value of early
Palliative Care…
Quality
Value =
Cost
Safety = minimize risk of harm
& don’t Rx without benefit
Key Elements of Palliative Care
• Communication & negotiation of
goals of life & care
• Symptom management
• Distress
How Much Palliative Care ?
Acute
Last Days
of Life
Recurrence
Chronic
Presentation
Increased
Debility
Respite
Death
Impact of COPD Pilot Program
Hospitalizations per 1000 patient exposure
days
39 % Reduction in Re-hospitalizations
COPD Pilot Program Hospitalization Density
Pre Index Discharge vs. Post Index Discharge
10.00
9.48
9.00
8.00
7.00
6.00
6.69 6.77
7.24
6.57
5.76
5.00
4.00
3.00
2.00
1.00
0.00
Enrolled 50
patients
(p=.03)
Not enrolled 202 patients
(p=.91)
Pre
Post
All Patients
(p=.31)
2010
Benefits of Early Palliative Care
 Survival
• Longer
• Better
• Understanding
prognosis
• Goals of care
 Less IV chemo in
last 60 days
  Quality of Life
• Improved mood
American Society of Clinical Oncology
recommends…
Concurrent palliative care for
seriously ill cancer patients – from the beginning
2012
Palliative Care at Kaiser,
Los Angeles
• 484
Seriously ill,
inpatient
palliative care
consult
• 10 % readmitted
within 30 days
Enguidanos et al, J Palliat Medicine 2012; 15(12): 1356
Value of early
Hospice Care…
‘ Excellent ’ Quality of
EOL Care
80
n = 1578
percent
70
60
50
40
Excellent
30
20
10
0
Home
Care
Hospice
NH
Hospital
Teno et al JAMA 2004; 291: 88-93
Outcomes in Last Place of Care
percent
n = 1578
Teno et al JAMA 2004; 291: 88-93
Cost with Hospice Care
• Significant
savings
when compared
with
no hospice care
Kelley AS et al, Health Affairs 2013; 552: 561
Inescapable Conclusion
• Hospice is the highest value in EOL care
Value =
 Quality
 Cost
• Stop making hospice a choice
• Systemwide quality measure
How do we get everyone to incorporate
palliative care into practice early ?
Fully Integrate Palliative Care
Ambulatory
Outpatient
Clinics
Hospital
Consultation
Services
Specialty
Inpatient Long-term
Care
Units
Home
Care
Value for Martha
Hospice Care for 2 years…
Value for Kit…
Kit: 6 Months
• Recurrence in axillary
lymph nodes
• Chemo: partial response
• XRT: partial response
• Chemo: stable disease
• Resection ?
• Progression
Kit: 21 months
• Hospice care 3 months
• Oncologist attending
• Resolution
• Gifts
• Surprises
Main Message
Early referral to
palliative & hospice care,
delivers higher value & safety…
What Experience . . .
your patients & families,
your loved ones, and
ultimately yourselves?
“ The standards of practice we create
And the people we train
Will look after us
When it’s our turn to receive care…
Will Ohio be ready for you ? ”
Gandhi… You need to be the change
you want to see in the world…
Kobacker House
Columbus, Ohio
Palliative Care
Interdisciplinary Curriculum
A Joint Initiative of the
Palliative Medicine Faculty & Staff of
We gratefully acknowledge the support of
Award Number R25CA134309 from the National Cancer Institute
The content is solely the responsibility of the authors and does not necessarily represent the official
views of the National Cancer Institute or the National Institutes of Health