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Palliative Care Cardinale B. Smith, MD, MSCR Assistant Professor Division of Hematology/ Medical Oncology Tisch Cancer Institute Brookdale Department of.

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Presentation on theme: "Palliative Care Cardinale B. Smith, MD, MSCR Assistant Professor Division of Hematology/ Medical Oncology Tisch Cancer Institute Brookdale Department of."— Presentation transcript:

1 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 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 Palliative /Hospice Care Disease-focused Care (Aggressive Care) Disease-focused Care (Aggressive Care) Old Model: Two types of care

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

6 Death & Bereavement Disease Modifying Therapy curative or restorative intent Life Closure Diagnosis A New Vision of Care Palliative Care Hospice

7 Palliative Care

8 Palliative Care Is 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 Palliative Care Is NOT 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

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

11 Lifetime Risk of: Palliative Care – Relevance In Context 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 Parkinsons:1:40

12 The Reality of the Last Years of Life: Death Is Not Predictable (slide adapted from Joanne Lynn, MD, Rand Health/CMS) Time

13 Hospital Palliative Care: The 5 Main Principles 1.Clinical Quality 2.Patient and Family Preferences 3.Demographics 4.Education 5.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 % 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. Academic Medical Centers % of 5176 patients reporting moderate to severe pain between days 8-12 of admission Colon Cancer60% Liver Failure60% Lung Cancer57% COPD44% CHF43% 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 ones 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.1999


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 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 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 SpecialtyNumber of Fellowship Positions Number of Fellowship Programs Number of Providers Cardiology ,901 Medical Oncology ,000 Palliative Care and Hospice ,400 Deficiencies in Medical Education

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 27 th in life expectancy 37 th in overall quality of healthcare system (WHO)

33 Im afraid weve had to move him to expensive care

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

35 Costs and Outcomes Associated with Hospital Palliative Care Consultation 8-hospital study Live DischargesHospital Deaths CostsUsual Care Palliative Care PUsual Care Palliative Care P Total Per Day $1,450$1,171<.001$2,468$1,918<.001 Directs Per Admission $11,1240$9, $22,674$17, Laboratory$1,227$803<.001$2,765$1,838<.001 ICU$7,096$1,917<.001$15,542$7,929<.001 Pharmacy$2,190$2,001.12$5,625$4, Imaging$890$949.52$1,673$1, Died in ICUXXX18%4%<.001 Adjusted results, n>20,000 patients Morrison et al. Arch Internal Med (16)

36 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 U. Michigan- Hospice of Michigan Palliative Care Reduces Hospital Costs (patients with complete data as of July 1, 2002, at Medicare prices, excludes Rx)


40 How Palliative Care Reduces Length of Stay and Cost Palliative care: 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 dont 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 clinicians 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 ( ) Gelfman LP, Morrison RS. J Palliat Med, 2008

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

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