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Transforming health care globally… through palliative care www.PalliativeMed.org www.IPCRC.net.

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Presentation on theme: "Transforming health care globally… through palliative care www.PalliativeMed.org www.IPCRC.net."— Presentation transcript:

1 Transforming health care globally… through palliative care

2 Public Health Perspective on Palliative Care: Transforming Healthcare in Sweden Frank D. Ferris, MD, FAAHPM, FAACE Institute for Palliative Medicine at San Diego Hospice University of California San Diego University of Toronto

3 Imagine...

4 What do You Want Your Illness Experience to be ?

5

6 Where would you like to receive your care? 1.Acute care 2.Long-term care 3.Home

7 Swedish Life Expectancy Age 0 World Bank Data 2009 = 81.4

8 How many are ? Likely to die 2030s – 2040s…

9 How will you achieve your goals ? Who will provide your care ?

10 Transforming health care… through palliative care

11 Objective… A Road Map to Build Palliative Care ( PC ) Capacity in Sweden…

12

13 Success & Challenges…

14 Mortality as an Indicator of Need ( 2008 est., x 1,000 ) All CausesCancerAIDS World World Late Presentation Low Resources Limited or No Treatment

15 Palliative Care Service Development Globally (from the International Observatory on End-of-Life Care of Lancaster, UK) No activity yet identified Capacity building activity Localized provision Approaching integration Source of Map: Wright et al., J. Pain Sym. Manag. 35:469 (2008) Bar graph created from data in this publication # Countries 99 / 144 LMICs have no services

16 Mortality as an Indicator of Need ( 2008 est., x 1,000 ) All CausesCancerAIDS Sweden 91,5 22,1-- Sweden 91,5 22,1-- 8 % of all dying, 30% dying of cancer receive PC USA USA % receive hospice care ( 2010 ) Many more receive non-hospice palliative care

17 Sweden Vital Statistics… Population9,3 M10,6 M % 65+18,3 %25,8 % % 80+5,5 %9,4 % Dependency ratio28,144,6 Crude death rate1012 per 100 K Deaths93 K127 K Due to cancer25 K> 32 K

18 Sweden Vital Statistics

19 Palliative Care in Sweden 2012 In K deaths all causes 93 K deaths all causes > 60 % benefit from PC ≈ > K deaths from cancer > K deaths from cancer > 80 % benefit from PC >

20 Causes of Death 1. 1.Cardiovascular39,4 % 2. 2.Cancer26,5 % 3. 3.Neurological 3,4 % 4. 4.Injuries3,7 % 5. 5.Respiratory 5,8 % 90 % of patients receiving PC have cancer !

21 Setting of Death North America 23 % own home 23 % own home 77 % die in institutions ( Teno et al, 1997 ) 77 % die in institutions ( Teno et al, 1997 ) 2 / 3 in hospitals 1 / 3 in nursing homes Sweden 5 – 10 % own home 5 – 10 % own home 40 – 50 % nursing homes 40 – 50 % nursing homes

22 1993  2002 ‘ One Voice ’

23 2002 National Model Canadian Hospice Palliative Care Association Consensus Consensus Common language Norms of practice English et Français English et Français

24 Palliative Care… Prevents & relieves suffering Improves quality of living and dying Any diagnosis From: Ferris FD, Balfour HM, Bowen K, Farley J, Hardwick M, Lamontagne C, Lundy M, Syme A, West P. A Model to Guide Hospice Palliative Care. Ottawa, ON: Canadian Hospice Palliative Care Association, 2002.

25 …Palliative Care… PresentationPresentationDeathDeath Therapies to modify disease Bereavement Care 6m6m End-of-life / Hospice Care Therapies to relieve suffering and / or improve quality of life Palliative Care

26 ...Palliative Care Help to Eat well Eat well Sleep well Sleep well Maintain function Maintain function Minimize stress Minimize stress  Live better  Live longer

27 Needs of Patients / Families

28 Process of Providing Care

29 “ The Model… …is the most important document in the history of hospice palliative care in Canada ” “ The Model is implicit in all hospice palliative care in Canada – it’s like the hard drive in every computer, invisible but supporting everything. ”

30 CHPCA Model  Impact Patient / family care Patient / family care National Health Accord  Access to medications for home PC Education EducationPalliumEFPPEC Research Research Canadian Institutes for Health Research

31 2012 ‘ One Voice ’

32 2012 National Guidelines

33 The Challenge… , how will Sweden apply the Guidelines to  PC funding, skills & services…

34

35 Human Rights Watch “ Pain & PC are Human Rights ” IndiaKenyaUkraine

36 Unrelieved Pain is Medical Torture

37 Call to Action… How will Sweden Ensure PC human right Ensure PC human right Include in health policy with funding Include in health policy with funding - cancer, elders, all diagnoses

38

39 WHO proposed: Opioid use is an indicator of PC capacity…

40 Global Morphine-Equivalent Opioid Consumption, Pain Policy Studies Group, Madison, WI

41 Sweden has many medications & opioids for palliative care… and all medical uses…

42 > 80 % of global morphine consumed by 7 countries with 80% of world’s population ), consume < 10 % of global morphine 2. Canada Austria 177 Substitution Therapy 23 Countries > Global Mean 131 Countries < Global Mean 3. USA Sweden 20

43 10. Sweden 20

44 2. Canada USA Sweden 31.5

45 5. Sweden 31.5

46

47 Call to Action… How will Sweden increase per capita opioid use ?

48 Call to Action… How will Sweden avoid medication stock-outs ?

49

50 Call to Action… Train ALL healthcare professionals to provide palliative care…

51 For Palliative Medicine ( PM ), Sweden Needs… Assumption Each Palliative Medicine specialist Each Palliative Medicine specialist 60 % clinical & 40 % teaching 300 new patients / year 30 year career cycle

52 Palliative Care PresentationPresentationDeathDeath Therapies to modify disease Bereavement Care 6m6m End-of-life / Hospice Care Therapies to relieve suffering and / or improve quality of life Palliative Care

53 …For only End of Life Care, Sweden Needs K deaths 93 K deaths 60 % benefit from PC PM Specialists Have 68 Have 68 Need 186 Need K deaths 127 K deaths Need 254 new ! Need 254 new !

54 PC Skills... 1° Basic Skills All Healthcare Professionals 1° Advanced Skills Cariology, Geriatrics, Oncology, Etc. 2° Expert skills Palliative Care Consultants / Teams 3° Academic Palliative Care

55 Educational Interventions… A stepwise process…

56 as a Model…

57 Time ( yr )  Sensitization Courses ( Basic & Advanced ) Visiting Scholars ( Expert Identification ) Fellowships ( Experts ) Leadership ( Leaders ) Scholars in Residence ( Education & Research )

58 IPM Education

59 More tomorrow…

60 Research

61 Call to Action… Develop new palliative care knowledge & translate it into practice…

62 Swedish Registry Online access Online access All deaths in Sweden All deaths in Sweden Quality improvement Quality improvement

63 Methylnaltrexone Time to Laxation p < J.Thomas et al. J Clin Oncol 2005; 23: 16S ( Abstract )

64 New Engl J Med 358 ( 22 ); 2332 May 29, 2008

65 Innovative Research Rapid management of depression Rapid management of depressionMethylphenidateKetamine New class of antinausea medication New class of antinausea medication Effectiveness of educational strategies Effectiveness of educational strategiesIn-countryFellowshipLeadership

66 IPM Research

67

68 Palliative Care Service Development Globally (from the International Observatory on End-of-Life Care of Lancaster, UK) No activity yet identified Capacity building activity Localized provision Approaching integration Source of Map: Wright et al., J. Pain Sym. Manag. 35:469 (2008) Bar graph created from data in this publication # Countries 99 / 144 LMICs have no services

69 Call to Action… Expand PC services to all patients / families in Sweden in need… and demonstrate effectiveness…

70 PC Specialty Services…

71 San Diego Hospice… Founded Dr. Doris Howell Founded Dr. Doris HowellCommunity-ownedNot-for-profitAcademicEducationResearchAdvocacy Campus 1991 Campus 1991 Gift of Joan Kroc SDHIPM 2009 SDHIPM 2009

72 Palliative Care in the US PresentationPresentationDeathDeath Therapies to modify disease Bereavement Care 6m6m End-of-life Care Therapies to relieve suffering and / or improve quality of life Non-Hospice Palliative Care Hospice Care

73 …San Diego Hospice… ≈ 850 staff ≈ 750 volunteers Budget ≈ $89 million 60 % non-cancer 60 % non-cancer Hospice Care Prognosis < 6 months Non-Hospice Care Any time ≈ 4,500 new patients per year ≈ 1,500 new consults per year

74 Acute Care Home ER DAYCAREDAYCAREDAYCAREDAYCARE Elder Care, Nursing Homes Specialized Free-standing PC Units Inpatient Unit ICUs Outpatient Clinic / Office Other eg, Jails

75 … San Diego Hospice… Avg. Census > 1,000 patients / day Avg. Census > 1,000 patients / day Home care11 branches500 – 550 / d Long-term care 4 branches300 – 350 / d 3 Acute inpatient units 36 beds Pediatric team 25 – 30 / d Ambulatory outpatient clinic Team 7 – Px < 7 days Triage Nurses Extended care – nights, weekends

76

77 Outcomes… San Diego vs. Los Angeles San Diego County Los Angeles County Use of Hospice Care 70 % ( US ≈ 39 % ) 25 % Cost of Hospice Care 50 % higher than San Diego County Last 2 yrs of life< $29,000> $43,000 San Diego County Use of Hospice Care 70 % ( US ≈ 42 % ) Cost of Hospice Care Last 2 yrs of life< $29,000

78 PC ‘ Inside ’… Oncology… Cardiology… Elder care… Etc….

79 Building relationships with hospitals…

80 San Diego Hospice 4 hospital-based consult services each seeing 10 – 20 / day 4 hospital-based consult services each seeing 10 – 20 / day UCSD Cancer Center La Jolla UCSD Hillcrest Scripps Mercy Hospital Scripps Chula Vista Hospital Ambulatory outpatient clinics Ambulatory outpatient clinics AIDS case management ≈ 120 / d AIDS case management ≈ 120 / d

81 Building relationships with specialty associations…

82 ASCO

83

84 ASTRO

85 Public / Media Awareness

86 Call to Action… Increase public & media awareness & access…

87 What % of Swedish population knows about PC…

88 PC = Best kept secret…

89 Are you prepared to talk about the death of your loved one ?

90 PC Adds ‘ Days to Life & Life to Days ’

91 Let’s Campaign PC Pain = entry point  Increase public awareness  Create demand for PC  Change political will

92

93 Opportunities for Sweden ?

94 What Experience... your patients & families, your loved ones, and ultimately yourselves ?

95 “ The standards of practice we create and the people we train will look after us when it’s our turn to receive care… ” Will Sweden be ready ?

96

97 Call to Action in Sweden  Policy Human right National policies & funding  Education 1°, 2°, 3°  Services All diagnoses Whenever, wherever patient / family need care  Palliative care knowledge Translate into practice  Public / political awareness & access Living, not dying Campaign to Create demand  Political will Pain = entry point

98 You must be the change you want to see in the world Gandhi You must be the change you want to see in the world Gandhi


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