Presentation on theme: "Nathan Goldstein, MD Mount Sinai School of Medicine"— Presentation transcript:
1 Nathan Goldstein, MD Mount Sinai School of Medicine The Case for Palliative CarePalliative CareCardinale B. Smith, MD, MSCRAssistant Professor Division of Hematology/ Medical Oncology Tisch Cancer InstituteBrookdale Department of Geriatrics & Palliative Medicine Hertzberg Palliative Care InstituteIcahn School of Medicine at Mount Sinai
2 Palliative CareSpecialized 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, MDMount Sinai School of MedicineThe Case for Palliative CarePalliative Care in PracticeExpert control of pain and symptomsUses the crisis of the hospitalization to facilitate communication and decisions about goals of care with patient and familyCoordinates care and transitions across fragmented medical systemProvides practical support for family and other caregivers (+ clinicians)
4 Old Model: Two types of care Palliative /Hospice CareDisease-focused Care(“Aggressive Care”)
5 The Cure - Care Model: The Old System DEA THLife Prolonging CarePalliative/HospiceCareDisease Progression
6 Nathan Goldstein, MD Mount Sinai School of Medicine The Case for Palliative CareA New Vision of CareLIKE ENSURE, WE HAVE AN OPPORTUNITY TO EXTEND THE ACCESS POINT PAST THE “SICK POINT”Disease Modifying Therapycurative or restorative intentLifeClosureDeath &BereavementDiagnosisPalliative CareHospice
8 Nathan Goldstein, MD Mount Sinai School of Medicine The Case for Palliative CarePalliative Care IsPalliative Care Is NOTExcellent, evidence-based medical treatmentVigorous care of pain and symptoms throughout illnessCare that patients want at the same time as efforts to cure or prolong lifeNot “giving up” on a patientNot in place of curative or life-prolonging careNot the same as hospice or end-of-life careUse clinical examples!Talk about why you went into it – Mr. SantanaTalk 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 conditionsSurveys of patients and families have identified top needs:Relief of sufferingPractical support needsOpen communicationOpportunities to relieve burdens and strengthen relationships with familiesThankfully 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, MDMount Sinai School of MedicineThe Case for Palliative CareThe Reality of the Last Years of Life: Death Is Not PredictableIn 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 QualityPatient and Family PreferencesDemographicsEducationFinances
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 admissionColon 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 controlAvoid inappropriate prolongation ofthe dying processAchieve a sense of controlRelieve burdens on familyStrengthen relationships with loved onesSinger et al. JAMA 1999;281(2):
20 “Difficult” Conversations Improve Outcomes Multisite, longitudinal study of 332 patient-family dyads37% of patients reported having prognosis discussion at baselineThese patients had lower use of aggressive treatments, better quality of life, and longer hospice staysFamily after-death interviews showed better psychological coping for those with conversations as compared to those withoutWright et al. JAMA (14):
21 What Do Family Caregivers Want? Study of 475 family members 1-2 years after bereavementLoved one’s wishes honoredInclusion in decision processesSupport/assistance at homePractical help (transportation, medicines, equipment)Personal care needs (bathing, feeding, toileting)Honest information24/7 accessTo be listened toPrivacyTo be remembered and contacted after the deathTolle et al. Oregon report card
23 Families Want to Talk About Prognosis Qualitative interviews with 179 surrogate decision makers of ICU patients93% of surrogates felt that avoiding discussions about prognosis is an unacceptable way to maintain hopeInformation is essential to allow family members to prepare emotionally and logistically for the possibility of a patient's deathOther themes:moral aversion to the idea of false hopephysicians have an obligation to discuss prognosissurrogates look to physicians primarily for truth and seek hope elsewhereApatira 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, 2003Anderson GF. NEJM 2005;353:305CBO 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 team100% of cancer centers report a palliative care team
27 Nathan Goldstein, MD Mount Sinai School of Medicine The Case for Palliative CareVermont, 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 SpecialtyNumber of Fellowship PositionsNumber of Fellowship ProgramsNumber of ProvidersCardiology77917525,901Medical Oncology48613014,000Palliative Care and Hospice234854,400
30 Improvements in Education 2007 Board Certification in Palliative CareMedical 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 spending27th in life expectancy37th 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 studyThe Case for Palliative CareLive DischargesHospital DeathsCostsUsual CarePalliative CarePTotal Per Day$1,450$1,171<.001$2,468$1,918Directs Per Admission$11,1240$9,445.004$22,674$17,765.003Laboratory$1,227$803$2,765$1,838ICU$7,096$1,917$15,542$7,929Pharmacy$2,190$2,001.12$5,625$4,081.04Imaging$890$949.52$1,673$1,540.21Died in ICUX18%4%Adjusted results, n>20,000 patientsMorrison et al. Arch Internal Med (16)
36 Nathan Goldstein, MD Mount Sinai School of Medicine The Case for Palliative Care8 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 DischargesMorrison 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 CareNeed hospice cost per day for both groupsDollar costs for each bar for hospitalizationDollar costs for each bar totally
40 How Palliative Care Reduces Length of Stay and Cost Clarifies goals of care with patients and familiesHelps families to select medical treatments and care settings that meet their goalsAssists with decisions to leave the hospital, or to withhold or withdraw treatments that don’t help to meet their goals
42 What Does All this Mean from the Patient Perspective? For patients, palliative care is a key to:relieve symptom distressnavigate a complex medical systemunderstand the plan of carehelp coordinate and control care optionsallow 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 timehelp to handle repeated, intensive patient-family communications, coordination of care acrosssettings, comprehensive discharge planningProvide Symptom Controlassists with controlling pain and distress for highlysymptomatic and complex patients, 24/7 -thus supporting clinician’s treatment planPromote Satisfactionincreases 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 illnessprovide excellent patient-centered careincrease patient and family satisfactionimprove staff satisfaction and retentionmeet accreditation and quality standardsrationalize the use of scarce hospital resourcesincrease 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 deliveryLack of research funding to support needed researchNeed for public advocacy and public and professional education
46 Research Publications: Oncology and Palliative Care (2003-2005) Gelfman LP, Morrison RS. J Palliat Med, 200846
47 SummaryPalliative 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