1. A Perspective on Family Medicine and End-of-Life and Palliative Care Peter Selwyn, M.D., M.P.H. Professor and Chairman Department of Family & Social Medicine Montefiore Medical Center Albert Einstein College of Medicine Bronx, NY

2. Subspecialty Model of Care Patient #1 Patient #2 Patient #3Patient #4Patient #5 Specific Illness Illness = Continuum Patients = Episodes

3. Family Medicine Model of Care Patient/Family = Continuum Illness/ Life Event = Episodes Episodic Illness Patient/ Family Life Event Episodic Illness Life Event Chronic Disease End-of-Life Issues

4. Traditional Dichotomy of Curative and Palliative Care for Chronic Progressive Illness Curative Care (=disease-specific restorative) Palliative Care (=supportive, symptom-oriented) Diagnosis Dying Death Person with illness DISEASE PROGRESSION

5. Integrated Model Including both Curative and Palliative Care for Chronic Progressive Illness Curative Care (=disease-specific, restorative) Palliative Care (=supportive, symptom oriented) Bereavement Person with Illness DiagnosisDyingDeath Family Support services for families and caregivers Caregivers DISEASE PROGRESSION

6. Family Medicine and Palliative Care: An Ideal Paradigm Managing multiple co-morbidities Pain and symptom management /quality of life issues Family impact and context of illness Care needs of multiple family members Psychosocial factors and serious illness ‘Family values’ and goals of care Advance directives: empowerment vs. ‘taking away’ Continuity/transition/follow-up Treating the patient, not the disease Bereavement and beyond Role of the ‘clerk of records’

7. In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the NYS Public Health Law. Montefiore Palliative Care Service History *Funded by Open Society Institute Project on Death in America/Kornfield Foundation, July 2004 Consultation Service Initiated at Moses Division Palliative Care Fellowship Program* Outpatient Palliative Care Clinic MMG/FCC Inpatient Palliative Care Unit Moses Division Extended to Weiler Division 2000 20012002 2003 2004 2005 Outpatient Cancer Pain Clinic HIV Pain Clinic/ Moses ED Palliative Care Project Weiler ICU Project 1999 Cross- departmental planning process

8. In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the NYS Public Health Law. Clinical Dimensions of Palliative Care Pain and symptom management Advance care planning Psychosocial support Staff support Bereavement services Program clinical staff: - physicians (~ 3 FTE’s) - nurse practitioners (~ 2.5 FTE’s) - social workers (2 FTE’s)

9. In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the NYS Public Health Law. Patients Seen By The Palliative Care Consultation Service: January 2005 – December 2005 Data Source: CIS and Palliative Care Database Total unique patients N = 1296 Total consults N = 1453 Mean age: 69 Years

10. In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the NYS Public Health Law. Palliative Care Consultations, 2002-2005 Cumulative total of consults from 01/02-12/05: N=4,388

11. In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the NYS Public Health Law. Deaths at MMC With a Palliative Care Consultation  Objective: Appropriate Palliative Care Consultations  Measure: Percentage of inpatient deaths, all ages (No. of deaths/yr at MMC  1500) *ICD9 Codes for chronic illness include: Cerebro-vascular (436), Heart Disease (CHF) (428.0), Liver Disease (573.9, 571.9, 571.1, 571.3), HIV infection (042), Respiratory (518.81), Infection/ Parasitic (038.9, 136.9), Malignancy (199.1, 162.9, 185, 154.0, 150.9, 151.9, 170.9, 188.9, 171.9, 174.9)

12. In response to the Montefiore Quality Council, this information is provided under Section 2805-m of the NYS Public Health Law. Data are from a random sample of palliative care consultations (N=294); only the 1st reason calculated Data source: Palliative Care Database

13. Figure 1 Age Distribution of Site A Users and Community Residents Figure 2 Age Distribution of Site B Users and Community Residents *Logarithmic scale The difference between the distributions is statistically significant (  2 = 440.6, df=5, p<0.001). *Logarithmic scale The difference between the distributions is statistically significant (  2 = 181.2 df=5, p<0.001). Source: Zallman, et al. Fam Med 2003; 35(8):637-42.

14. Proposed Screening Criteria Used for Palliative Care Designation in Outpatient Primary Care 1.Would you be surprised if this patient died in the next year? 2.Has the patient had repeated or prolonged hospitalizations for the same type of illness in the past 12 months? 3.Has the patient lost > 10% of body weight unintentionally over the past year, despite intervention? 4.Is the patient dependent in > 2 activities of daily living (ADLs), or does the patient have a Karnofsky score 3? 5.After an acute episode of illness, does the patient or the family express frustration because the patient no longer returns to baseline despite optimal treatment?

15. Proposed Screening Criteria Used for Palliative Care Designation in Outpatient Primary Care (cont’d) 6.If this patient has AIDS, cancer, CHF, COPD, or dementia, would you consider him/her to be in the advanced stages of illness? If the provider answered “no” to the first question and/or “yes” to any of the others, the individual was classified as in potentially eligible for palliative care services.  Estimated prevalence in 12 month sample of ~18,000 patients: 1.7% Source: Rainone et al, in press, Am J Hospice Palliative Med, 2007.

16. Life-Threatening Illness and Death among Family Members of Users of Family Medicine Outpatient Practice Sites, Bronx, N.Y. Study subjects: Experienced death of immediate family member in prior year: - Deceased family member received care at same family medicine site: - Is aware that family medicine practice site provides end-of-life and palliative care: Currently has family member with serious chronic illness: - Family member receiving care at same family medicine site: - Patient is aware that ill family member(s) could receive care at that site: Would be personally interested in receiving end-of life or palliative care at family medicine site, if needed: N = 218 39 (17.9%) 3/39 (7.6%) 9/39 (23.1%) 56 (26.8%) 10/56(17.9%) 13/56 (23.2%) 174 (79.8%) n (%) Source: Zallman, et al, Family Medicine, 2003