1. Nathan Goldstein, MD Mount Sinai School of Medicine
The Case for Palliative Care
Palliative Care
Cardinale B. Smith, MD, MSCR
Assistant Professor Division of Hematology/ Medical Oncology Tisch Cancer Institute
Brookdale Department of Geriatrics & Palliative Medicine Hertzberg Palliative Care Institute
Icahn School of Medicine at Mount Sinai

2. Palliative Care
Specialized medical care for people with serious illnesses.
Focused on providing patients with relief from the symptoms, pain, and stress of a serious illness - whatever the diagnosis.
The goal is to improve quality of life for both the patient and the family.
Provided by a team of doctors, nurses, and other specialists who work with a patient's other doctors to provide an extra layer of support.
Appropriate at any age and at any stage of a serious illness, and can be provided together with curative or disease directed treatments.

3. Palliative Care in Practice
Nathan Goldstein, MD
Mount Sinai School of Medicine
The Case for Palliative Care
Palliative Care in Practice
Expert control of pain and symptoms
Uses the crisis of the hospitalization to facilitate communication and decisions about goals of care with patient and family
Coordinates care and transitions across fragmented medical system
Provides practical support for family and other caregivers (+ clinicians)

4. Old Model: Two types of care
Palliative /Hospice Care
Disease-focused Care
(“Aggressive Care”)

5. The Cure - Care Model: The Old System
DEA TH
Life Prolonging Care
Palliative/
Hospice
Care
Disease Progression

6. Nathan Goldstein, MD Mount Sinai School of Medicine
The Case for Palliative Care
A New Vision of Care
LIKE ENSURE, WE HAVE AN OPPORTUNITY TO EXTEND THE ACCESS POINT PAST THE “SICK POINT”
Disease Modifying Therapy
curative or restorative intent
Life
Closure
Death &
Bereavement
Diagnosis
Palliative Care
Hospice

7. Palliative Care

8. Nathan Goldstein, MD Mount Sinai School of Medicine
The Case for Palliative Care
Palliative Care Is
Palliative Care Is NOT
Excellent, 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
Not “giving up” on a patient
Not in place of curative or life-prolonging care
Not the same as hospice or end-of-life care
Use clinical examples!
Talk about why you went into it – Mr. Santana
Talk about what you do every day.

9. Consumer Knowledge of Palliative Care
95% of respondents agree that it is important that patients with serious illness and their families be educated about palliative care.
92% of respondents say they would be likely to consider palliative care for a loved one if they had a serious illness.
92% of respondents say it is important that palliative care services be made available at all hospitals for patients with serious illness and their families.
CAPC/ACS Public Opinion Survey, 2011

10. Significance of Palliative Care
More patients with serious illness not imminently dying, but living with chronic and debilitating conditions
Surveys of patients and families have identified top needs:
Relief of suffering
Practical support needs
Open communication
Opportunities to relieve burdens and strengthen relationships with families
Thankfully we have turned many diseases into chronic illnesses but this comes at a cost……..

11. Palliative Care – Relevance In Context
Lifetime Risk of:
Heart disease: 1:2 men; 1:3 women (age 40+) Cancer: > 1:3 Alzheimer's: 1:2.5 – 1:5 by age 85 Diabetes: 1:5 Parkinson’s: 1:40

12. The Reality of the Last Years of Life: Death Is Not Predictable
Nathan Goldstein, MD
Mount Sinai School of Medicine
The Case for Palliative Care
The Reality of the Last Years of Life: Death Is Not Predictable
In part, it because there are different functional trajectory that patients take prior to death.
For Edna, she will have multiple excerbations and most likely on the day of her death she will be about the same .. in that she will die of an Arrythmia.. while a patient with Cancer will have a functional decline in the las 6-8 weeks of life..Edna has actually been this way for two years..
Given this inherent ambiguity, it is our argument for these diseases that we need to learn how to prepare patients for their deaths while still pursuing life-extending treatment. We need to learn how to manage patients with what seem to be contradictory goals. To achieve this, health care providers must openly negotiate with patients about goals of care and incrementally make transitions to limit the use of aggressive, life saving treatments. At all times, we should attend to the patient’s comfort. Perhaps we should hold ourselves to the standard that we must recognize when medical treatment is over burdensome and no longer beneficial in the patient’s eyes. Perhaps, we should promise patients that, at worst, “I will only over treat you once.”
Time
(slide adapted from Joanne Lynn, MD, Rand Health/CMS) 29

13. Hospital Palliative Care: The 5 Main Principles
Clinical Quality
Patient and Family Preferences
Demographics
Education
Finances

14. Why palliative care? 1. The Clinical Imperative
The need for better quality of care for people with serious and complex illnesses.

15. Everybody with serious illness spends at least some time in a hospital...
98% of Medicare decedents spent at least some time in a hospital in the year before death.
15-55% of decedents had at least one stay in an ICU in the 6 months before death. Average length of stay in the ICU is 2-11 days.
Dartmouth Atlas of Health Care 1999 & 2006

17. Symptom Burden of Patients Hospitalized With Serious Illness at 5 U. S
Symptom Burden of Patients Hospitalized With Serious Illness at 5 U.S. Academic Medical Centers
% of 5176 patients reporting moderate to severe pain between days 8-12 of admission
Colon Cancer 60%
Liver Failure 60%
Lung Cancer 57%
COPD 44%
CHF 43%
Desbiens & Wu. JAGS 2000;48:S

18. Why palliative care? 2. Concordance with patient and family wishes
What is the impact of serious illness on patients’ families?
What do persons with serious illness say they want from our healthcare system?

19. What Do Patients with Serious Illness Want?
Pain and symptom control
Avoid inappropriate prolongation of
the dying process
Achieve a sense of control
Relieve burdens on family
Strengthen relationships with loved ones
Singer et al. JAMA 1999;281(2):

20. “Difficult” Conversations Improve Outcomes
Multisite, longitudinal study of 332 patient-family dyads
37% of patients reported having prognosis discussion at baseline
These patients had lower use of aggressive treatments, better quality of life, and longer hospice stays
Family after-death interviews showed better psychological coping for those with conversations as compared to those without
Wright et al. JAMA (14):

21. What Do Family Caregivers Want?
Study of 475 family members 1-2 years after bereavement
Loved one’s wishes honored
Inclusion in decision processes
Support/assistance at home
Practical help (transportation, medicines, equipment)
Personal care needs (bathing, feeding, toileting)
Honest information
24/7 access
To be listened to
Privacy
To be remembered and contacted after the death
Tolle et al. Oregon report card

23. Families Want to Talk About Prognosis
Qualitative interviews with 179 surrogate decision makers of ICU patients
93% of surrogates felt that avoiding discussions about prognosis is an unacceptable way to maintain hope
Information is essential to allow family members to prepare emotionally and logistically for the possibility of a patient's death
Other themes:
moral aversion to the idea of false hope
physicians have an obligation to discuss prognosis
surrogates look to physicians primarily for truth and seek hope elsewhere
Apatira et al. Ann Intern Med. 2008;149(12):861-8

24. Why palliative care? 3. The demographic imperative
Hospitals need palliative care to effectively treat the growing number of persons with serious, advanced and complex illnesses.

25. Chronically Ill, Aging Population Is Growing
The number of people over age 85 will double to 10 million by the year 2030.
The 23% of Medicare patients with >4 chronic conditions account for 68% of all Medicare spending.
US Census Bureau, CDC, 2003
Anderson GF. NEJM 2005;353:305
CBO High Cost Medicare Beneficiaries May 2005

26. Hospital Based Palliative Care Programs in the United States
63% of all hospitals and 85% of mid-large size hospitals report a palliative care team
100% of cancer centers report a palliative care team

27. Nathan Goldstein, MD Mount Sinai School of Medicine
The Case for Palliative Care
Vermont, Maryland, Minnesota, Nebraska, Oregon, Washington – GOOD JOB!
Nation moves from a “C” grade to a “B” in less than 5 years

28. Why palliative care? 4. The educational imperative
Every doctor and nurse-in-training learns in the hospital.

29. Deficiencies in Medical Education
Specialty
Number of Fellowship Positions
Number of Fellowship Programs
Number of Providers
Cardiology
779
175
25,901
Medical Oncology
486
130
14,000
Palliative Care and Hospice
234 85
4,400

30. Improvements in Education
2007 Board Certification in Palliative Care
Medical school licensing requirement:
“Clinical instruction must include important aspects of … end of life care (average 14 hours).”

31. Why palliative care? 4. The fiscal imperative
Hospital and insurers of the future will have to efficiently and effectively treat serious and complex illness in order to survive.

32. Healthcare Spending and Quality
U.S. leads the world in per capita spending
27th in life expectancy
37th in overall quality of healthcare system (WHO)

33. I’m afraid we’ve had to move him to expensive care

34. National Health Expenditure Growth 1970-2003
HCFA, Office of the Actuary, National Health Statistics Group, 2003

35. Nathan Goldstein, MD Mount Sinai School of Medicine
Costs and Outcomes Associated with Hospital Palliative Care Consultation 8-hospital study
The Case for Palliative Care
Live Discharges
Hospital Deaths
Costs
Usual Care
Palliative Care P
Total Per Day
$1,450
$1,171
<.001
$2,468
$1,918
Directs Per Admission
$11,1240
$9,445
.004
$22,674
$17,765
.003
Laboratory
$1,227
$803
$2,765
$1,838
ICU
$7,096
$1,917
$15,542
$7,929
Pharmacy
$2,190
$2,001
.12
$5,625
$4,081
.04
Imaging
$890
$949
.52
$1,673
$1,540
.21
Died in ICU X
18% 4%
Adjusted results, n>20,000 patients
Morrison et al. Arch Internal Med (16)

36. Nathan Goldstein, MD Mount Sinai School of Medicine
The Case for Palliative Care
8 Hospital Study: Costs/day for patients who died with palliative care vs. matched usual care patients

37. Cost Savings – Medicaid in NY State
Cost savings/Day for Live Discharges
Morrison et al. Health Affairs :454-63

38. Nathan Goldstein, MD Mount Sinai School of Medicine
U. Michigan- Hospice of Michigan Palliative Care Reduces Hospital Costs (patients with complete data as of July 1, 2002, at Medicare prices, excludes Rx)
The Case for Palliative Care
Need hospice cost per day for both groups
Dollar costs for each bar for hospitalization
Dollar costs for each bar totally

40. How Palliative Care Reduces Length of Stay and Cost
Clarifies goals of care with patients and families
Helps families to select medical treatments and care settings that meet their goals
Assists with decisions to leave the hospital, or to withhold or withdraw treatments that don’t help to meet their goals

41. Aug ;363(8):733-42

42. What Does All this Mean from the Patient Perspective?
For patients, palliative care is a key to:
relieve symptom distress
navigate a complex medical system
understand the plan of care
help coordinate and control care options
allow simultaneous palliation of suffering along with continued disease treatments (no requirement to give up life prolonging care)
provide practical and emotional support for exhausted family caregivers

43. What Does All this Mean from the Clinician Perspective?
For clinicians, palliative care is a key tool to:
Save time
help to handle repeated, intensive patient-family communications, coordination of care across
settings, comprehensive discharge planning
Provide Symptom Control
assists with controlling pain and distress for highly
symptomatic and complex patients, 24/7 -thus supporting clinician’s treatment plan
Promote Satisfaction
increases patients’ and families’ satisfaction with the quality of care provided by the clinician

44. What Does All this Mean from the Hospital Perspective?
For hospitals, palliative care is a key tool to:
effectively treat the growing number of people with complex advanced illness
provide excellent patient-centered care
increase patient and family satisfaction
improve staff satisfaction and retention
meet accreditation and quality standards
rationalize the use of scarce hospital resources
increase bed/ICU capacity, reduce costs

45. But………. Disparities in access to palliative care
Lack of a solid evidence base to guide clinical care and care delivery
Lack of research funding to support needed research
Need for public advocacy and public and professional education

46. Research Publications: Oncology and Palliative Care (2003-2005)
Gelfman LP, Morrison RS. J Palliat Med, 2008 46

47. Summary
Palliative care improves quality of care for our sickest and most vulnerable patients and families.
Serious illness is a universal human experience and palliation is a universal health professional obligation.

48. ‎"When we honestly ask ourselves which people in our lives mean the most to us, we often find that it is those who, instead of giving advice, solutions, or cures, have chosen rather to share our pain and touch our wounds with a warm heart and tender hand. The person who can be silent with us in a moment of despair or confusion, who can stay with us in an hour of grief and bereavement, who can tolerate not knowing, not curing, and face with us the reality of our powerlessness, that is a person who cares.”
-Henri Nouwen