Download The Case(s) for Early Palliative Care

EARLY PALLIATIVE CARE IS
PROVING TO BE AN INTEGRAL
COMPONENT OF PRACTICE
Jennie GilBhrighde, DO
Palliative and Hospice Medicine
Hospice of Southern West Virginia
September 25, 2011
THE PAIN AND PALLIATIVE
CARE SERVICE IS
OBJECTIVES
1. Function of a Palliative Care Service.
2. Research outcomes in early supportive
Palliative Care.
3.Appropriate patients for the palliative care
service.
LILLIAN W.
68 Y/O WITH CHF
HX POORLY CONTROLLED DM
BKA DUE TO CHRONIC ULCERS
HOSPITALIZED X3 IN 6 MONTHS
SOB AT REST
EF = <20%
REFUSED PACEMAKER DEFIBRILLATOR
FREQUENT PVC’S
CREATININE 3.08
SOCIAL ISSUES:
Lives alone with home nursing visits
 3 children - none who live nearby
 Recently widowed
 Daughter recently hospitalized with psych issues
 Pt tells you she is overwhelmed
 Pt appears more depressed and withdrawn

SPIRITUAL ISSUES:
Pt has been unable to attend church.
 Pt states she feels abandoned by God.
 She says she feels alone and unable to cope with
the struggle her life has become.
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What do you do?
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Where do you begin?
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What can we do to help you?
WHO DEFINITION OF PALLIATIVE CARE
An approach to and a philosophy of health care
that specializes in the relief of pain, symptoms
and stress of serious illness.
 Three cardinal principles:

Foster communication with and between patients,
families and health care providers
 Promote physical activities to maintain
independence
 Practical support for emotional, psychosocial and
spiritual well-being through a multidisciplinary
team approach.

WHAT DOES THIS LOOK LIKE IN
PRACTICE?

When do you think about consulting the
palliative care physician?
BRIEF HISTORY
1967 – Dame Cicily Saunders started St.
Christopher’s Hospice in London, for care of the
dying.
 1973 – first hospice-like inpatient unit at an
academic teaching hospital at Royal Victoria
Hospital in Montreal.
 1980’s – creation of the Medicare Hospice Benefit
 1980’s – first palliative care program at
Cleveland Clinic.
 2006 – Formal recognition as medical specialty
 2008 - ACGME accreditation for fellowship
training in palliative medicine.
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The goal is to prevent and relieve suffering and
to improve quality of life for people facing
serious, complex illness.
This is what you strive to do everyday. We can
help you to work toward this goal!
PALLIATIVE CARE:
provides relief from pain and other distressing
symptoms;
 affirms life and regards dying as a normal
process;
 intends neither to hasten or postpone death;
 integrates the psychological and spiritual aspects
of patient care;
 offers a support system to help patients live as
actively as possible until death;

offers a support system to help the family cope
during the patients illness and in their own
bereavement;
 uses a team approach to address the needs of
patients and their families, including
bereavement counselling, if indicated;
 will enhance quality of life, and may also
positively influence the course of illness;
 is applicable early in the course of illness, in
conjunction with other therapies that are
intended to prolong life, such as chemotherapy
or radiation therapy, and includes those
investigations needed to better understand and
manage distressing clinical complications.

WHAT SORT OF PATIENTS BENEFIT FROM
EARLY PALLIATIVE CARE INVOLVEMENT?
Cancer
 Chronic, progressive pulmonary disorders
 Renal Disease
 Chronic heart failure
 HIV/AIDS
 Progressive neurological conditions
 Hepatic failure
 Any chronic, progressive conditions

WHAT
OTHER TYPES OF PATIENTS
BENEFIT?
Complex and chronic pain syndromes
 Peri-operative complex pain cases
 Pts with intractable nausea and vomiting
 Pts with emotional and spiritual suffering
 Pts with delirium


Pts at end-of-life
HOSPICE AND END-OF-LIFE
Pt must be considered “terminal” (prognosis is <
6 months based on natural course of disease) and
willing to forgo curative treatment but also
Medicare coverage for life-prolonging therapies,
and Medicare’s clinical guidelines must be met
for the specific disease
 Pts at End-of –life: includes the last days to
weeks of life.

Integrated Palliative Care Along Entire
Disease Trajectory
Modifying Therapy,
Curative, restorative intent
Life
Closure
Risk
Disease
Condition
Palliative Care
Death &
Bereavement
Hospice
(6 Months)
REQUESTING A CONSULT
Attending identifies patient who would benefit
from palliative services.
 Request is made for consult.
 Palliative care consultant talks with attending to
determine needs of the attending for consult.
 Consultant interviews and examines patient to
determine areas of need.
 Consultant talks with family and with team
members to assess areas of need.
 Consultant helps by being present at, or leading,
at discretion of attending, goals of care meetings
or family meetings.

Consultant discusses recommendations with
attending.
 Attending maintains role as primary physician in
charge of patient’s care.
 Consultant can see patient one time and make
recommendations, or follow the patient with
attending, at attending’s discretion.


You remain the team leader!
WHAT CAN PATIENTS EXPECT


A comprehensive history that includes all
domains – physical, mental, spiritual, emotional,
financial, including interpersonal relationships
with family members.
A team approach!
IT TAKES A NURTURING INTERDISCIPLINARY TEAM TO
PRACTICE THE NATURE OF PALLIATIVE CARE
Core Team
• Comprehensive
Assessment
• Coordinate Interventions
• Discharge Planning
Recreational Therapy
• Relaxation
• Stress Management
• Pet, Music, & Art Therapy
Treatment
Regimen
Complementary
Symptoms
Disease
Process
Clinical • Acupuncture/
Acupressure
Trials
•
Tai
Chi
Protocol
• Trigger Point Release
Individuals’
Quality of Life
Social Work
• Socioeconomic Support
• Community Resources
• Coping Skills
• Grief Counseling
• Family Support,
Co-morbidity End-of-Life Issues
• Community Transition
Concomitant
Disorder
Rehabilitation
• Functional Interventions
• Assistive Devices
• Energy Conservation
Counseling
• Pastoral Presence
Spirituality • Prayer
Psychological
Predisposition
• Hope & Peace
Suffering
Roles and
Relationships
Isolation
Level of
Function
Pharmacy
• Pharmacological Counseling
• Equianalgesia
• Adjuvant Agents
SpiritualMinistry
Economic
Burden
Grief
Emotional
State
Nutrition
• Satiety, Dysphagia
• Nausea
• Intake Modification,
TPN/Tube Feedings
ALONG WITH PHARMACOLOGIC
INTERVENTIONS COMPLEMENTARY
THERAPIES ADD BENEFIT
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Acupuncture
Acupressure
Animal Assisted therapy
Art therapy
Biofeedback
Hypnosis
Labyrinth
simulator
Mandalas
Massage
Reiki
TENs
Meditation
Guided imagery
Vibro-acustic chairs
Tai Chi
Yoga
Tea parties
Therapeutic point
EARLY PALLIATIVE CARE FOR PATIENTS WITH
METASTATIC NON-SMALL-CELL LUNG CANCER


New England Journal of Medicine, 8/19/10.
Examined the effect of introducing palliative care
early after diagnosis on patient-reported
outcomes and end of life care among ambulatory
patients with newly diagnosed disease NSCLC.
Early Palliative Care for Patients with Metastatic Non-Small-Cell Lung Cancer
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151 patients underwent randomization to receive
either early palliative care integrated with
standard oncologic care or standard oncologic
care alone.
Quality of life and mood were assessed at
baseline and at 12 week intervals.
Primary outcome was change in quality of life at
12 weeks.
Early Palliative Care for Patients with Metastatic Non-Small-Cell Lung Cancer
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Scores on Functional Assessment of Cancer
Therapy – Lung (FACT-L) with range from 0 to
136, higher scores indicate better quality of life,
(98 vs. 91.5: P = 0.03)
Fewer patients in the palliative group had
depressive symptoms. (16% vs. 38%; P = 0.01).
median survival was longer among patients
receiving early palliative care. (11.6 months vs.
8.9 months, P=0.02).
Early Palliative Care for Patients with Metastatic Non-Small-Cell Lung Cancer
IMPORTANT POINTS FROM THE STUDY
Palliative care is often only utilized late in the
course of disease.
 Previous studies have suggested that late
referrals to palliative care are inadequate to alter
the quality and delivery of care provided to
patients with cancer.
 To have a meaningful effect on patients’ quality of
life and end of life care, palliative services must
be provided earlier in the course of disease.
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In Heart failure therapy: beyond the guidelines,
published in Journal of Cardiovascular Medicine,
June 15, 2010 a review of palliative and self-care
for the treatment of CHF are discussed.
This review likens the burden of physical and
psychological symptoms in pts with CHF to
patients with advanced cancer.
Palliative care utilizes a multidisciplinary
approach.
 Palliative care is no longer limited to end-oflife care.
 It is not dependent on prognosis, and can be
delivered at the same time as the patient is
pursuing all other appropriate treatments,
including curative options.
 Palliative care specialists support the primary
team.
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Decision making
Communication
Education
Psychological and spiritual issues
Symptom management
Heart failure therapy: beyond the guidelines
DECISION-MAKING
Heart failure care and prognosis
 Interventional therapies
 CPR, code status, transition to hospice
 POA, legal issues

Heart failure therapy: beyond the guidelines
COMMUNICATION
Heart failure is a life-limiting disease. Associated
with increased risk of sudden cardiac death.
 Discussions concerning prognosis should be
initiated early in disease course.
 Frequent reassessment of goals is needed
throughout the disease course.
 Preferences for afterlife care

Heart failure therapy: beyond the guidelines
EDUCATION
Understanding of disease, treatment and
symptom control.
 Should be performed at the level of patient and
family.
 Awareness of diagnosis and expected course,
including possibility for sudden cardiac death.

Heart failure therapy: beyond the guidelines
ADDRESSING PSYCHOLOGICAL AND
SPIRITUAL ISSUES
Mental health concerns
 Financial concerns
 Interpersonal relationships
 Spiritual support
 Transition to hospice care

Heart failure therapy: beyond the guidelines
SYMPTOM MANAGEMENT
Symptom control/Pain – opioids can be used
safely, NSAIDS contraindicated.
 Quality of life
 Disease modifying interventions
 Sleep disordered breathing (seen in 1/3 to 2/3 pts)
 Dyspnea
 Anxiety/depression
 Limited exercise capacity

Heart failure therapy: beyond the guidelines
COST OF CARE
Call for multidisciplinary palliative care brings
concern about cost effectiveness.
 Data suggest that this approach is financially
feasible and suggests that it may in fact reduce
costs.
 May prevent recurrent hospitalizations by
helping patients and families manage the
symptoms better.

INTEGRATING PALLIATIVE CARE IN SEVERE
COPD

COPD: Journal of Chronic Obstructive
Pulmonary Disease, 5:207-220, 2008.
By 2020 COPD will likely to account for over 6
million annual deaths worldwide, which will
make it the 3rd leading cause of death.
 COPD is the seventh leading cause of disability.

Integrating palliative care in severe COPD
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Diagnosis is often delayed because patients may
not perceive dyspnea until approx 40% of their
lung function is lost.
Current medical and surgical treatments, other
than oxygen therapy, have not altered mortality
and are limited to symptom treatment,
illustrating the need for early attention to
palliative care in the management of COPD.
Integrating palliative care in severe COPD

Pts with severe COPD (GOLD Stages III and IV)
are similar to cancer patients, and experience
the same symptom burdens and decreased
quality of life through physical, psychological,
spiritual and social impairments.
Integrating palliative care in severe COPD
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COPD patients receive less palliative care in
comparison to lung cancer patients.
Pain is nearly as prevalent as in patients
with lung cancer (21% vs. 28%), and is often
undertreated due to the misperception that
opioids and sedatives may hasten death.
Less than 50% of COPD patients experience
relief from dyspnea during their last 6 months of
life.
Integrating palliative care in severe COPD
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Anxiety, depression and pain are interdependent,
and exacerbated by each other. All three are
present in up to 90% of COPD patients.
Anxiety and depression contribute to decreased
quality of life independent of COPD severity.
Depression is linked to increased mortality,
hospital readmission and longer length of stays.
Integrating palliative care in severe COPD
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Poor appetite and inadequate nutrition are
secondary to depression, dyspnea and fatigue
with the result of lost weight, including muscle
mass.
Muscle mass is important in maintaining
exercise tolerance, which can maintain
independence, maintain ability to perform ADL’s
and contributes to overall quality of life.
Integrating palliative care in severe COPD
Severe COPD results in multiple hospital
admissions during the last year of life.
 Admission for acute exacerbation portends a 2
year survival of 49%.
 More patients with COPD as opposed to lung
cancer receive mechanical ventilation (70% vs.
19.8%), tube feeding (38.7 vs. 18.5%) and CPR
(25% vs. 7.8%).
 Less pts with COPD die at home (15.8%) as
compared to pts with cancer (35%) and CHF
(23%).
 Enrollment in hospice often happens late for
patients with COPD.
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RECOMMENDATIONS FROM PALLIATIVE
CONSULT ORDERED FOR LILLIAN
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Supported treatment plan. Recommended low dose
opioid to help manage dyspnea.
Social worker spoke with patient and children, and a
goals of care meeting was arranged.
Hospital chaplain contacted pt’s minister who came in
and arranged a visit from 2 members of her Sunday
school class.
Pt named son as POA, and decided to sign advance
directives and DNR.
Pt agreed to plan of discharge to local nursing home
for rehab.
Pt agreed to continue with counseling outpatient.
A GOOD PARTNERSHIP!!!

Patient and family were grateful to you, their
attending physician, for helping to manage the
many complex issues as well as her symptoms
and disease!
BRINGING IT ALL TOGETHER
Supported by evidence based medicine
 Provides support, and interdisciplinary approach
 Family education.
 Manage symptoms and provide suggestions for
interventional and/or complementary treatment.
 Assist with transition to hospice and end-of-life.

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Your Palliative Care Specialist is here for you!
“THERE IS NO INCONSISTENCY BETWEEN
THE ABILITY TO ACHIEVE GREAT
DIAGNOSTIC AND THERAPEUTIC
VICTORIES AND THE ABILITY TO PROVIDE
COMFORT WHEN THOSE VICTORIES ARE
BEYOND REACH.”
Sherwin B. Nuland, M.D.
TIME Magazine, 2000
Questions?
REFERENCES
Berger, A., Shuster, J. and Von Roenn, J.
Principles and Practice of Palliative Care and
Supportive Oncology, 3rd ed. 2007.
 Thompson, et al. Heart therapy: beyond the
guidelines. Journal of Cardiovascular Medicine,
06/15/10.
 Termel, et al. Early Palliative Care for Patients
with Metastatic Non-Small-Cell Lung Cancer.
New England Journal of Medicine, 2010;363:73342.
 Hardin, K., Myeres F. and Louie, S. Integrating
Palliative Care in Severe Chronic Obstructive
Lung Disease. COPD: Journal of Chronic
Obstructive Pulmonary Disease, 2008:5,207-220.
