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Palliative Care Vs. Curative
Medicine
Speaker:
Vicki Wilhelm, MD
Medical Director, Sentara Hospice for the Greater Peninsula
and Western Tidewater Region
www.sentara.com
Sentara Home Health &
Hospice Services
Greater Peninsula
Phone: (757)736-0700
Serving Williamsburg, Middle
Peninsula and Peninsula Region
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What is Restorative Medicine?
A cross-disciplinary approach for 21st century medicine
based on restoring organ function and repairing tissue
damage. It is not simply treating symptoms and palliating
medical conditions. It combines complementary therapies
combined with lifestyle changes with the ultimate goal to
prevent future diseases and slow down the progression of
existing diseases.
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Curative Medicine
 Seeks a cure for an existent disease or medical
condition
 Differs from preventive care which aims at preventing
the appearance of diseases through immunization,
exercise and lifestyle improvements
 Differs from symptomatic treatment which is medical
therapy of a disease that only affects its symptoms &
not it’s causes (ex. Analgesic, anti-inflammatory,
antitussives, antihistaminic, etc.)
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What is Palliative Care?
• Interdisciplinary medical care that aims to relieve
suffering and improve quality of life for families and
patients with advanced illness.
• It is offered simultaneously with all other appropriate
medical treatment.
• Palliate: From the Latin word pallium, meaning cloak
• To make less severe or intense
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Our Definition of Palliative Care
Interdisciplinary care that:
• Changes the “medical” approach from crisis intervention
to crisis prevention through advance care planning
and clarity re: the goals of care.
• Assesses and works towards the relief of distressing
symptoms and improvement of quality of life.
• Tends to the whole-person in the context of their family
and their community.
• Provides access to support for patients and their
families at any stage of illness and in any setting,
regardless of prognosis.”
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Palliative care is:
• evidence-based medical
treatment
• vigorous care of pain and
symptoms throughout illness
• care that patients want at the
same time as efforts to cure or
prolong life
It is NOT:
• “giving up”
• provided in place of
curative or lifeprolonging care
• the same as hospice
• the same as comfort
care
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What is Hospice?
Hospice is quality, compassionate
care for people with life-limiting or
life-threatening illness or injury.
Care is tailored to each patient’s
needs and wishes with the goal being
to maximize patients’ quality of life as
they travel along this last journey.
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Why is
Hospice the
Ultimate Gift?
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Goal of Hospice
The goal of hospice is to improve the quality of life
and provide comfort and dignity in death.
Hospice care neither prolongs life nor hastens death.
Hospice focuses on whole person directed
treatments with attention to “family” as part of the
experience.
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When to ask for Hospice
Services
• Early! Crisis avoidance vs. Crisis
intervention
• A proactive vs. a reactive approach:
more integrated, organized route to
wholistic care for a patient and family
and
decreases stress and anxiety for all
involved.
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ADMISSION
Admission to Hospice requires a Doctor’s order.
The Hospice staff can also provide an evaluation
for appropriateness of admission to hospice and
provide a recommendation back to the provider.
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Disease Trajectories
High
"Cancer" Trajectory, Diagnosis to Death
Function
Cancer
Death
Low
Onset of illness
Decline usually 3 months
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Disease Trajectories
High
Organ System Failure Trajectory
Function
(mostly heart and lung failure)
Death
Low
Multiple hospitalizations
Death usually follows
disease exacerbation
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Where does Hospice occur?
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At home
Independent or assisted living facilities
Long-term care or skilled care facilities
Hospital
Hospice inpatient units
Hospice House
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Dispelling Hospice Myths
 You do not need to be DNR to enter Hospice
 Hospice is not a 24-hour nurse coverage
It relies on family and coordinates support
including HHA
 Hospice patients are offered antibiotics for reversible
infections
 Medications related to the admitting diagnosis are
covered under the Hospice Benefit
 Hospice is liberal in its use of Opioids, but only in
response to symptom management
 Hospice services have been shown to prolong
survival and reduce costs at end of life.
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Interdisciplinary Hospice Team
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Patient and family
The patient’s primary physician
Hospice physician
Nurses
Certified nursing assistants
Chaplains
Social workers
Music Care Services
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The Medicare Hospice Benefit
Criteria
– Eligible for Part A of Medicare
– Terminally ill with a life expectancy of 6 months or less
Coverage
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Physician services
Medical care through the hospice Medical Director
Case management
Medical appliances and supplies
Medications related to the terminal illness and palliation of symptoms
Speech therapy
Short-term inpatient and respite care
Physical and occupational therapy
Dietary counseling
Homemaker and home health aide services
Counseling and social work services
Spiritual care
Volunteer participation
Bereavement services
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Prognosis
Important factors to consider
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Co-morbid illnesses
Rate of decline
Nutritional status
Functional status
Cognitive status
Age and gender
Number of hospitalizations in past year
Will to live
Other (psychosocial, emotional and spiritual)
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The Prognosis
A study in 2000 by Christakis and colleagues [10] found that:
• Prognostic accuracy generally erred on the side of optimism.
Only 20% of physicians’ prognoses were accurate within 33%
of actual survival time
– 63% were over-optimistic about life expectancy
– 17% underestimated survival time
• As the duration of the doctor-patient relationship increased,
prognostic accuracy decreased.
• In general, there was an 8-fold overestimation of life
expectancy for patients who died within 30 days of the
prognostic determination.
[10] Christakis NA, Lamont EB, BMJ 2000;320:469-472
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Medicare Hospice Benefit Eligibility
• Patients must be eligible for Medicare Part A,
and
• The patient’s doctor and hospice medical director
certify that s/he may have six months or less to live if
their illness runs its normal course,
and
• Patient chooses a Medicare approved Hospice
program,
and
• Patient signs a statement choosing hospice care
instead of other Medicare-covered treatment options
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What does Medicare pay for?
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Physician and Nurse Services
Medical Equipment
Medical Supplies
Medications for pain and symptom
management
• Health Aide Services
• Social Worker Services
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Additional Medicare coverage
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Physical and Occupational Therapy
Speech Therapy
Dietary Counseling
Short Term In-Patient Care
Grief and Loss Counseling for patient and
for patient’s family
• Short Term Respite Care (small co-pay
applies)
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A patient can continue to qualify for
hospice if they are showing documented
signs of decline and at the time of
recertification they still appear to have
less than six months of life expectancy.
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Hospice Medicare benefit
does not cover:
• Treatment intended to cure terminal illness
• Prescription drugs to cure illness rather than for
symptom control or pain relief
• Room and board
• Care from providers not arranged by the hospice
team, including
• Emergency Room care
• Inpatient facility care
• Ambulance transportation
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Important Reminder…
Medicare will still pay for covered
benefits for any health problems
that are not related to the
terminal illness.
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Timing of Referrals to Hospice and Palliative
Care is Late
Median length of stay in hospice = 10 days
42% of hospice patients receive care for < 1
week before death
4.8% 180 days or more
Median LOS in hospitals before palliative
care consultation = 18 days (CDC Nat’l
Center for Health Statistics 2004)
www.nhpco.org & Mount Sinai Hospital Palliative Care Consult Service data
CDC National Center for Health Statistics 2004
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Does hospice provide help to the
family after the patient dies?
Yes, hospice provides continued contact and support for
family and friends for a minimum of 13 months following
the death of a loved one.
Team members of Sentara Hospice include professional
chaplains and counselors specifically trained to provide
bereavement support.
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Why does it take several doctors to treat a patient but only 1 nurse?
8/31/08
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Sentara Home Care
&Hospice Services
200 Enterprise Drive
Newport News, VA 23603
Phone: (757) 736-0700
Fax: (757) 969-6610
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