Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Residency Education in Palliative Care A Longitudinal Community Medicine Project Sergio Urcuyo, MD PGY-1 Contra Costa Regional Medical Center Why Palliative Care? From the Beginning What is palliative care? (WHO) “The active total care of a patient whose disease is not responsive to curative treatment” “The goal of palliative care is the achievement of best possible quality of life for patients and their families “ “Palliative care affirms life and regards dying as a normal process, and neither hastens nor postpones death. “ “Many aspects of palliative care are also applicable early in the course of the disease in conjunction with disease modifying treatment, such as chemotherapy, radiotherapy, and surgery. “ Hospice Hospice is derived from the Latin word hospitum which means a place where guests are received with hospitality and lodging Hospice as we know it dates back to 17th century France The first hospice in the USA was started in 1974 in New Haven, CT The word Hospice can now be used to describe a philosophy of care, an organization, or a specific site Hospice and Palliative Care Similar philosophies Palliative care can be started as early as is appropriate Hospice needs to start with a good faith estimation of less than 6 months to live Palliative care is often instituted in any setting (including acute care) Hospice is usually instituted in someone’s residence, a nursing home, or a prison “Where” matters 70% of deaths occur in hospitals 16% of deaths occur in nursing homes 17% of deaths occur at home Home deaths are more common in malignancies 1999 Medicare study 30% of all deaths among the elderly with malignancies occurred after transfer to a hospital 50% of those occurred within 96 hours of transfer. Nursing Homes and Hospice Nursing homes are eligible for hospice reimbursement under Medicare Then why do 70% of nursing homes not have hospice patients? Omnibus budget passed in 1987 encourages rehab and acute care over comfort care through higher reimbursement Why do we care? By 2030 20% of the population of the US will be over age 65 More than 50% of malignancies occur in this age group 67% of cancer deaths occur in this age group This age group as higher rates of functional loss, caregiver stress, and institutionalization AHRQ Study on Preparedness 50% of terminal patients had an advanced directive 12% of advanced directive patients had received input from their physician in its creation 65-76% of physicians were not aware of the existence of patients’ advanced directives So, advanced directives will solve all of our issues, right? AHRQ Study, continued ADs helped in less than 50% of decisions ADs became active too late to make a diference Language in ADs was too non-specific Surrogates named were often not present or too emotionally distraught to help Physicians were only 65% accurate in predicting patient preferences – they tended toward under treatment Surrogates were more likely to over-treat even after discussing it with the patient Bad Doctor! How do we be good doctors? Journal of Family Practice in February 2002 Not a RCT Looked at where PCPs had success in end-oflife care Results showed that the relationships and role playing were more important than their skills and knowledge Results identified 3 roles played… The Consultant The expert in diseases and the dying process Will make decisions based on medical facts when families can’t Families to make decisions when able Do we let families take all the responsibility for turning off the ventilator? Do we act paternalistically because we ‘know better’? The Collaborator Information hub between patient, family and medical team to ensure all parties have the same understanding Combines the consultant’s skills with an understanding for the family’s experience Example: Letting a 30 yr old with terminal brain cancer go fishing The Guide Understands The facts The family wishes And how to get there Example: A family who is resistant to hospice gets listened to by a thoughtful MD who realizes that they feel that way because the family understands hospice as “giving up” on the patient. The Pink Elephant I’m already good with patients, So can I leave now? Not yet… The study said it took doctors 2 decades to get good at this And the medicine is still important Question 1 A 62 year-old male with metastatic lung cancer presents with skeletal metastases to the lumbar spine with no cord compression or nerve impingement. His pain is not relieved with over-the-counter medications he has tried at home. He has not been on opioids. Other than lung cancer, he does have chronic kidney disease; he’s been told he might soon need dialysis. His serum creatinine is 6.2. Which of the following opioids is the most appropriate agent to administer in repeated doses? a. Dolophine b. Morphine c. Meperidine d. Fentanyl Answer A or D Dolophine (Methadone) and Fentanyl are thought to be the safest opiods in renal failure because they are not renally cleared. This patient will likely need long-term and aroundthe-clock pain control, so while methadone is not fast acting it is an option for the overall pain strategy Question 2 A patient with metastatic colon cancer is discharged with oral immediate release morphine. How often can the patient take the immediate release oral opioid if pain is severe and unrelenting? a. 30 minutes b. 60 minutes c. 2 hours d. 4 hours Answer B – Every 60 minutes The peak effect for oral morphine is 60 minutes, so administration of another dose before then is premature Interestingly, the peak effect of IV morphine in 6 minutes. A quick note on pain 66% of dying patients experience pain 33% of people experience pain in last 24 hrs of life. Consequences of persistent pain include Depression Social isolation Sleep disturbance Impaired ambulation Increased health care use and costs Pain is not the most common symptom but is the most distressing and feared symptom by patients and families Question 3 A 66 year old woman with end-stage renal failure presents with generalized weakness. She has refused dialysis and plans to enroll in a hospice program. She was unable to get out of bed, so her family had her brought to the hospital by ambulance. She can be awakened easily by voice and desires alertness “till her last moments”. Which of the following medications represents the best choice for secretion management (“death rattle”) in this patient if and when it occurs? a. Scopolamine b. Glycopyrrolate c. Atropine 1% eye drops SL d. Atropine IV Answer B – Glycopyrolate Because glycopyrolate does not cross the bloodbrain barrier, it can be used to treat secretions (and the “death rattle”) with minimal effect on mental status. Atropine and scopolamine are more likely to cause delirium even though they are all anticholinergics The Medicine – Symptom Mgmt Nausea and Vomiting Fatigue Cachexia-Anorexia Dehydration Depression Suicidal Ideation Derlirum Dyspnea Insomnia Don’t we do this already? Ury Et. Al in Journal of General Internal Medicine: Can a Pain Management and Palliative Care Curriculum Improve the Opioid Prescribing Practices of Medical Residents? Study based on data showing how opiods are incorrectly prescribed Prospective chard review showed a sustained improvement in how residents prescribed opiods How did they begin Ury Et. Al. performed a needs assessment at St. Vincent’s Hospital (800 bed tertiary center with a 100 resident IM program) Interviewed families, patients, attendings, residents Results showed Little medical school education on palliation Discomfort amongst residents over important issues on palliation Enthusiasm amongst residents about improving their knowledge Do we just focus on the medicine? After several intravenous administrations of morphine and lorazepam for severe dyspnea, a patient with advanced pulmonary fibrosis becomes drowsy, his oxygen saturations drop, his respirations become shallow, he becomes bradycardic, and goes into cardiac arrest. The patient has elected an advance care plan that includes no life sustaining measures. You should: A. be sure the nurse is counseled for administering the medication too rapidly B. initiate CPR and ACLS, so as not to be charged with assisted suicide C. report the incident to risk management and write it up as an adverse event D. consider the principle of double-effect The “answer” D – Consider the “double effect” The principles Close to death, you will have to relieve symptoms of suffering If the intent of the clinician was the “good effect” The potential bad effects of the meds where considered The dose and administration were “reasonable” The double-effect would be cited as evidence that the clinical team is not practicing euthanasia or assisted suicide and is not at fault in the patient’s death Who came up with that nonsense? The defense lawyers? The double effect is attributed to Thomas Aquinas, the 13th Century Roman Catholic philosopher. Is everyone ok with that? New York Times Article from Dec 26, 2009 So, how do we improve? A. Consult palliative care B. Consult Palliative Care and sign off C. Consult Palliative Care, sign off on the patient, and take a vacation D. Learn more about it My project Stage I Stage II Assessment Survey the residents and the incoming interns Tool will be a modified version of the EPEC-EM Implementation Work with Julie Freedman et. al. to develop a curriculum that will include lunchtime conferences, PBLs, etc. Stage III Evaluation (did I waste my time?) Re-assess everyone and see how (or if) we improved Thanks for listening