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10/10/2012
Crucial Conversations in the Continuum of Care
Home Care – Palliative ‐ Hospice
Robert Lee, MD, FAAFP, CMD
Robert Lee, MD, FAAFP, CMD
• Family Physician/Medical Director, Holston Medical Group, Kingsport, TN
• Medical Director, Holston Manor Rehabilitation Center, Kingsport, TN
• Medical Director Brookhaven Manor Rehabilitation Center, Kingsport, TN
• Medical Director, Village at Allendale ALF, Kingsport, TN
• Medical Director, Preston Place and Suites ALF, Kingsport, TN
• Medical Director, Amedisys Home Health Care, Kingsport, TN
• Associate Medical Director, Amedisys Hospice, Kingsport, TN
• Regional Medical Director, Eastern Tennessee, Amedisys, Inc., Baton
Rouge, LA
Disclosures
Organizations accredited by the ACCME require everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME does not consider Amedisys to be a commercial interest.
Program Development
Kevin Henning, MD – Nothing to disclose. Presenting Faculty
Dr. Lee – Nothing to disclose. Consultant to Amedisys
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Learning Objectives
Upon completion of this presentation, you should be able to:
1.Begin a conversation with your patients to learn their goals of care
2.Use / Apply an evidence‐based tool to guide difficult conversations with patients
3.Engage in difficult conversations around prognosis, treatment and location of care for the benefit of the patient and their family
4.Recommend care in settings consistent with the patient’s goals of care
Crucial Conversations
Median Human Life Expectancy
30,000 BC
15,000 BC
Kevin S. Henning, MD
1,000 BC
2011
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Living Longer
Time Course and Manner of Death
Sudden/Short – vast majority of deaths
Protracted – relatively rare cause of death 1940
Sudden/unexpected deaths ‐ <10% of total (e.g. sudden cardiac death, trauma)
Protracted – 90% of total Somewhat predictable decline (e.g. cancer)
Slower decline with episodic crises (e.g. HF, COPD)
2012
Living Sicker
•
79% of people over 70 have at least one or more diseases: arthritis, hypertension, heart disease, lung disease, diabetes, stroke or cancer
•
30% of seniors have three or more chronic diseases
•
80% of people over 80y/o have some ADL (Activities of Daily Living) deficit/s
•
25‐50% of community‐dwelling elderly have inadequately treated pain
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Prolonged Dying Process
•
•
•
•
Time for functional decline
Time for physical symptoms
Time for emotional symptoms
Time to think about it…
Fears, fantasies, worry in the absence of prior experience
Medical system not well‐suited to care for these problems
SUPPORT Study
(Study to Understand Prognosis and Preferences for Outcomes and Risks of Treatment)
•
9105 patients from 1989‐1994 •
Two phases
•
Patients had one of 9 serious medical illnesses
•
Admitted to 5 teaching hospitals
•
Overall six‐month mortality rate 47%
JAMA. 1995 Nov 22‐29;274(20):1591‐8.
SUPPORT Study Conclusions
•
Two‐year observational study documented shortcomings in care of seriously ill adults
•
47% of physicians were unaware of patients’ desire for no CPR
•
38% of patients who died spent 10 days in ICU
•
Family members reported 50% of patients had moderate‐
severe pain before death
JAMA. 1995 Nov 22‐29;274(20):1591‐8.
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Progress at the End of Life
Home health care shows steady growth
Hospice care more prevalent
Palliative care in hospitals more common
Home Health Statistics
Year
Outlays
($million)
Visits
(1,000s)
Clients
(1,000s)
Payment/
Client
Visits/
Client
1996
16,789
264,553
3.598
4,666
74
1997
16,723
257,751
3,554
4,705
1998
10,446
154,992
3,062
3,412
51
1999
7,908
112,748
2,735
2,892
41
2000
7,352
90,730
2,497
2,945
36
2001
8,637
73,698
2,439
3,541
30
2002
9,635
78,055
2,724
3,538
29
2003
10,149
82,517
2,888
3,524
29
2004
11,500
88,872
2,840
4,050
31
2005
12,885
95,534
3,228
3,991
30
2006
14,050
103,981
3,302
4,254
32
2007
15,677
114,199
3,383
4,635
34
2008
17,115
121,026
3,466
4,938
35
2009
18,377
125,878
3,523
5,217
36
73
Sources: Centers for Medicare & Medicaid Services. HCIS home health data
Hospice Statistics (2011)
• 2,513,000 US deaths
• 1,059,000 deaths occurred with hospice (44.6%)
• Average length of service by hospice
– 69.1 days
• Median length of service by hospice
– 19.1 days (decreasing over the last few years)
• 35.7% of hospice pts are discharged <7d of admission
• Hospice cares for 1,650,000 pts annually
• Approximately 5300 hospice locations in the US
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Patients Served by Hospice in the US 1984 to 2009
2,000,000
1,560,000 1,450,000 1,500,000
1,300,000 1,060,000 1,000,000
885,000 700,000 500,000
‐
540,000 450,000 340,000 210,000 246,000 167,000 181,000 100,000 1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2009
Source: National Hospice and Palliative Care Organization.
Growth of Hospital Palliative Care Programs
>60% of All
Hospitals
# of Palliative Care Programs
1700
1500
1300
>80% of All
Hospitals with
>300 Beds
1100
900
700
500
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
The Hospital is Still King
$750,602,099,000.00
Expenses for US hospitals in 2010
About 75% of all deaths occur in facilities
Hospitals
Nursing homes
20% of all deaths occur in ICUs
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Why do patients go to the hospital?
For many decades.....it’s where people who are sick go
The doctors and nurses are there
The medicine is there
The lab and X ray is there
The operating room and ICU is there
Often, this choice is completely logical and consistent with goals of care
But, what if your goal is:
Having your illness treated in a safe home environment
Rehabilitation
Intensive symptom management
Allowing your family to care for you
Spending precious time with loved ones
Many goals of care can be accomplished at home with:
Home health care
Palliative care
Hospice care
Home visit care
Private duty care
Hospital at home
IF….we ask about goals of care and patients and families understand there is an alternative
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What Does a Home Health Care Patient Look Like?
Homebound, not bedbound
Homebound implies considerable tasking effort to leave Infrequent, short visits to doctor, church or barber are OK
Skilled nursing need includes teaching, management and observation Acute benefit with goal of staying at home
What Does a Hospice Patient Look Like?
A prognosis measured in months, not years
A patient who wants to focus on palliation
No homebound need
No need for skilled care
No need to be DNR or “ready to die”
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Prognostic Disclosure to Cancer Patients near the End of Life
•
326 cancer patients admitted to 5 hospice programs in Chicago by 258 physicians
•
37% of physicians provided a frank estimate of prognosis
•
40% of physicians provided a discrepant prognosis (70% of which were overoptimistic)
•
23% of physicians would not communicate prognosis
Christakis NA, Lamont EB. Extent and Determinants of Error in Doctors’ Prognoses in Terminally Ill Patients: Prospective Cohort Study. BMJ 2000;320:469‐73.
When the Prognosis is ….. Short
Helping patients understand the prognosis is a critical medical task
Ethically imperative
Allows grief to begin
Allows patients to achieve their goals of care
Goals of Care
Traditionally, medical providers ignore learning about a patient’s goals of care
Knowing patients’ goals is crucial when they are in the last few years of life
Stay at home?
Rehabilitation? Pain‐free?
Avoidance of institutions?
Connect with family members?
Resolve spiritual issues?
Understanding goals can help patients navigate the continuum of care
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Goals of Care
How much treatment burden are you willing to accept?
Surgery
Intensive care unit with monitors, ventilators
Hemodialysis
Sedation or other side effects of efforts to reduce treat pain, nausea or delirium
In what setting do you want to be treated?
Hospital
Home
Nursing home
Hospice inpatient unit
Goals of Care
What is important to you at this point?
Relief of pain?
Cure or prolonged life?
Connection with family members?
Cases in Point:
□ “Kelsey”‐ 87 y/o WF with HTN, CHF, CAD, DM, s/p CVA with rt. hemiparesis, renal insufficiency; recently discovered to have a “blood dyscrasia” and hematology w/u ordered
□ Daughter of “Donald” upset that her elderly father is hollering and losing weight and just not acting right. ‘They’ said “He just had a UTI!”
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Modern Ethical Constructs
(when breaking bad news)
Consensus between philosophers, medical ethicists, and religious leaders on four ethical principles (principle‐based ethics)
Beneficence
Non‐maleficence
Autonomy
Justice
Beneficence
Promote the patient’s well‐being
Hippocratic principle
What does that mean?
Do ventilators promote a terminally‐ill patient’s well‐
being?
Do gastrostomy tubes contribute to well‐being in a dementia patients?
The treatment, considered alone, is ethically‐neutral
Non‐maleficence
Avoid doing harm
Hippocratic principle
Examples
• Failing to provide adequate symptom relief
• Destroying hope
• Providing unnecessary sedation
• Failing to D/C burdensome treatments
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Autonomy
• Patient self‐determination
• Patients may refuse therapy
• Even when that decision is inconsistent with the care provider’s values
• Does not extend to the right to demand any and all treatment
• Does not outweigh other ethical principles
Justice
• Fair allocation of resources, new principle compared to traditional medical ethics
• Neither society nor physicians are obligated to provide futile treatments (even if funded and desired by the patient)
Example
• Is it just to hospitalize a patient with heart failure who can be effectively treated at home?
Therapeutic Decision Making
Will the proposed therapy meet the patient’s goals in an ethically sound manner?
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Outstanding Clinicians in the Continuum of Care
• Caring for patients during the last few years of life requires a special clinician
Being a medical hero and sharing
good news is easy
Breaking bad news is hard and
requires advanced skill
Breaking Bad News
•
Most clinicians avoid it
•
Nearly all haven’t been trained
•
Skilled communicators develop stronger therapeutic relationships
•
Solid communication allows patients to achieve their goals of care
•
Patients and families can avoid unwanted, non‐beneficial care plans
Bad News Defined
•
Communicating feeling of no hope
•
Threat to person’s mental or physical well‐being
•
Risk of upsetting an established lifestyle
•
Limiting an individual’s choices in his or her life
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Breaking Bad News Really ….. Sucks
• Feeling responsible for patients’ misfortune
• Perceptions of personal failure
• Unresolved personal feelings about death and dying
• Concern over patients’ response to the news
Training: • Formal training in breaking bad news is rare
• Clinicians may think that clinical experience, ability to be sympathetic or empathic may give sufficient skill
SPIKES Protocol for Breaking Bad News
Setting
Perception
Invitation
Knowledge
Empathize
Summary and strategy
Setting
Establish patient rapport:
• Privacy (find a comfortable room out of the hall way)
• Patient or family comfort (comfortable seating for all)
• Uninterrupted time (turn off cellphones, and pagers)
• Sitting at eye level
• Inviting desired significant others (who are the decision makers and those with input?)
Understand the family dynamics
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Perception
Elicit the patient (or family member’s) perception of the problem (What is your understanding of your loved one’s condition? Or, What have your doctors told you?)
Invitation
Obtain the patient (or family member’s) invitation to disclose the details of the medical condition. (Some cultures or family dynamics do not allow bad news to be explained to the patient or certain family members)
Knowledge
• Provide knowledge and information to patient or family member (Do you have the chart, diagnostic reports, etc.?)
• Small chunks (allow time to digest)
• Check for understanding frequently
• Avoid medical jargon (use analogies where applicable)
• Connect the ‘dots’
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Empathize
• Empathize, validate, and explore emotions expressed by the patient or family member (run toward them not away from them)
• “I know (or I can tell) this news is upsetting to you” • Avoid closed‐ended responses • Avoid “I understand” (do you really?)
• Instead, “I appreciate how you are upset about this, what is most upsetting to you”? • Or, “Tell me how this makes you feel”
Empathy “Empathy is what happens to us when we leave our own bodies…and find ourselves either momentarily or for a longer period of time in the mind of the other. We observe reality through her eyes, feel her emotions, share in her pain” ~Khen Lampert, 2005~
Empathy is Critical
• …during difficult conversations
• Arguably not necessary when sharing good news
• Without it defensiveness dominates
• With it trust builds and a therapeutic relationship can develop
• Conveys to the patient/family that you have their best health interest at heart
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Summarize and Strategize
Summarize the conversation
Discuss next steps
(What are we going to do next? Stop/Start certain meds, procedures, consults, draw boundaries?)
Advising Patients in Care Planning in the Continuum of Care
1. Understand the patient’s goals of care
2. Discuss prognosis
3. Explain the benefit and burden of therapy
4. Provide active advice on the care plan
Medications
Therapies
Place of care
Form of care delivery
Teaching the Art of Crucial Conversations
Teach the basics
• Being compassionate and caring isn’t sufficient
• SPIKES model (framework for the conversation)
• Model it for your staff and colleagues
• Ask about personal experiences with clinicians
• Use role playing exercises
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Crucial Conversations in the Continuum of Care
When patients are in the last years of life healthcare providers
need to be skilled at several things:
• Understanding patients’ goals of care in light of patient’s composite of health status and prognosis
• Being skillful in engaging in difficult conversations about prognosis and therapy
• Being willing to guide patients to therapy and modes of care that meets their goals in an ethical fashion
Questions
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