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PALLIATIVE CARE AT STANFORD James Hallenbeck, MD Medical Director, Stanford Hospice, VA Hospice Care Center.

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Presentation on theme: "PALLIATIVE CARE AT STANFORD James Hallenbeck, MD Medical Director, Stanford Hospice, VA Hospice Care Center."— Presentation transcript:

1 PALLIATIVE CARE AT STANFORD James Hallenbeck, MD Medical Director, Stanford Hospice, VA Hospice Care Center

2 Definitions Palliative Care Palliative Medicine Hospice Supportive Care

3 The Need SUPPORT Study Studies on Communication Stanford Study

4 SUPPORT STUDY % of DNR orders written with 2 days of death 40% of patients/surrogates had discussed CPR with physician –Of 60% who had not done so, 41% wanted to ~ 50% wanted a DNR status, but did have it 50% of patients reported as being in 7/10 or greater pain in last three days of life N= 9105 SUPPORT JAMA 1995; 274:

5 Tulsky Study on Advance Directive Discussions Conversations averaged 5.6 minutes Physicians spoke 66% of the time Used vague language Patients values rarely explored Tulsky JA et. al. Opening the black box: how do physicians communicate about advance directives? Ann Intern Med 1998 Sep 15;129(6):441-9.

6 Stanford Survey 1998 Staff and families identified communication as the area most needing improvement –35% of staff felt inexperienced communicating with dying patients and families (residents 64%) Broad support for a consultation team –61% of physicians surveyed felt that a consultation team would be moderately or extremely helpful –47% of attendings, 64% of residents stated that they would often or always use a consultation team in care of dying pts 617 Stanford Clinicians, 35 families

7 Stanford- What We Do Not Know... Annual # of hospital deaths by age, insurance status COD and LOS by DRG, Location of death –In most hospitals LOS for patients who die in hospital 2-3 X for those discharged alive Cost per case by DRG for deceased vs. alive Audits of quality of symptom relief, documentation of patient preferences Site-specific data

8 The Context JCAHO ABIM AAMC ACGME New Policy and Regulatory Mandates...

9 Palliative Medicine Evolving as a Medical Subspecialty American Board of Hospice and Palliative Medicine- > 600 physicians boarded since 1996 A Push for ACGME Accreditation Currently approximately 16 fellowships nationwide –VA Palo Alto HCS has 2 one-year fellows

10 Palliative Care Services being Integrated into Healthcare Systems Consultation teams and/or dedicated beds more common –~ 50% of California hospitals surveyed have or are planning dedicated services –VA Palo Alto HCS: 30 dedicated beds, consult team –UCSF: Comfort Care Suites, consult team –Santa Clara Valley Med: 2 dedicated beds, evolving consult team

11 Growing Public Demand for Expert Palliative Care Bill Moyers September Public Television Special on Death and Dying in America Sept Numerous associated events: –KQED f/u special on associated issues in the Bay Area –Community Action Groups Community meeting at VA Palo Alto HCS on September 27, sponsored by community hospices

12 Models for Success McGill University- Consult Service –Demonstrated average length of stay halved for terminally Northwestern Memorial Hospital –Consult and inptatient service since 1994 –Average 55 consults a month –Followed for an average of 2 days (range 2-10) –Revenue 1.5 million in 1996, excluding donations exceeded direct costs of ~ 1 million

13 Models for Success Oregon Health Sciences University Consult Service (of 67 serial consults) –66% Cancer, 34% Non-cancer –59% receiving life-prolonging treatment –41% hospice/palliative care only –20% died during hospitalization –Symptoms addressed: pain, nausea, constipation, delirium… –65% received assistance in EOL care decision making Bascom PB. A hospital-based comfort care team: consultation for seriously ill and dying patients. Am J Hosp and Palliat Care. 1997

14 Models for Success Philadelphia VA: Consult team for Cancer Patients (of 75 patients studied) – 164 medical problems identified –31 patients inadequate pain relief –Other problems: skin care, oral care, nutrition nausea, constipation mental status –15 patients referred for hospice- no documentation of wishes regarding resuscitation –36 patients required psychosocial counseling

15 Philadephia VA Study Of 22 patients followed in Medical Oncology Clinics: –21 had one or more problems identified by consult team Principally financial, social or spritual 11 patients reported inadequate pain relief Abrahm JL et al. The impact of a hospice consultation team on the care of veterans with advanced cancer. J. Pain Symptom Manage. 1996; 12:23-31.

16 What are Our Choices? Status Quo Palliative Care geared to meet JCAHO minimum standards- a process of quality improvement A minimalist Palliative Care service A comprehensive interdisciplinary palliative care consult team A comprehensive Palliative Care service, bridging venues of care

17 From Consult Team to Palliative Care Service Establish an interdisciplinary consult team –Attendings, fellow, elective resident/students, nurse, social worker, chaplain Coordinate with others working in related areas –Stanford Hospice, Pain Service, Pediatrics, Ethics Center, VA Hospice Care Center Consider identifying dedicated beds, outpatient clinic in later years

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