Presentation on theme: "Palliative Care at the End of Life"— Presentation transcript:
1 Palliative Care at the End of Life Todd R. Cote MD, FAAHPM, FAAFPProgram Director, University of Kentucky College of Medicine/Hospice of the Bluegrass Fellowship in Hospice and Palliative MedicineChief Medical Officer, Hospice of the Bluegrass and thePalliative Care Center of the BluegrassAssistant Professor, Univ. of Kentucky College of Medicine
2 Objectives Review Definitions and History Define Principles and CultureDiscuss Treatment at the End of Life
3 Definitions: Palliative Care 2011 Palliative Care is a specialized medical care for people with serious illness.This type of care is focused on providing patients with relief from the symptoms , pain , and stress of serious illness- whatever the diagnosis.The goal is to improve quality of life for both the patients and the family.Palliative Care is 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.Palliative care is appropriate at any age and at any stage in a serious illness, and can be provided together with curative treatmentCAPC, 2011
4 Definitions: Hospice Care 2011 Palliative Care at the end of life.
5 Palliative Care and Hospice -any time in disease process-acutely-ill hospitalized pts-chronic-debilitatedHospice-6 month expected survival
6 Historical Perspective (Western) B.C. pre-Christian475 ce : First recorded hospice , Rome1400’s : Middle Ages Christian orders established networks of hospices across Europe (“Old “Hippocrates to” New” Christian)1842: Mme Jeanne Garnier started “Calvaires” (hospices)1859: Sister Mary Aikenhead founded Irish Sisters of Charity1879: Sister Mary Aikenhead opened Our Lady’s Hospice for the Dying, Dublin.: Protestant Homes( Freidensham Home of Rest, Hostel of God, St Luke’s Home for the Dying: C.S, RN, )1890 Dr Herbert Snow, Cancer Hospital , Bromptom , London, The Palliative Treatment of Incurable Cancer, with an Appendix on the Use ofthe Opium Pipe.and “Opium and Cocaine in the Treatment of Cancerous Disease.”BMJ.1899: Calvary Hospital for the Dying, New York City (after “Calvaires” concept)1905: Irish Sisters of Charity open St Joseph’s Hospice for the Dying.1909: Cancer Hospital, Bromptom , London designates 19 beds to advanced disease cancer patients1930: Bromptom Hospital for Diseases of the Chest, Bromptom Cocktail (morhine and / or diamorphone and cocaine) given to patients at Cancer Hospital next door.1935: Bromptom’s Cocktail used every 4 hours at St Lukes Home for the Dying1952: Marie Curie Memorial Foundation: Cancer Care homes1967: Dr Cicely Saunders opens St Christopher’s Hospice , Syndenham, London.1964: C.M. Parkes, psychiatrist: Bereavement Research1965: The Institute, Yale University,( Saunders, Ross, Wall) Care for the Dying.1969: Elizabeth Kubler Ross, On Death and Dying.1974 : The Connecticut Hospice, New Haven Connecticut, started as Home Care service1975: Balfour Mount started Palliative Care Service in The Royal Victoria Hospital, Montreal.1978: The Connecticut Hospice opens nation’s first inpatient hospice unit (44 beds …just like St Christopher’s Hospice)1983 :U.S. Congress: Medicare Hospice Benefit1987 :Royal College of Medicine( England) recognizes palliative medicine as a Specialty199i : Cruzan v. Director, Missouri Department of Health,1994 : Dr. Jack Kevorkian, Oregon Death and Dignity Act1995 : SUPPORT study1996 : AAHPM: Board Certification fo rHospice/Palliative Medicine1997 : Institute of Medicine Report2001 : National Report: Transforming Death in America2002 : Last Acts National Report: State-by State report on End-of-Life Care2004 : National Institute of Health : Consensus Report on End-of-Life Care in America2005 : The Terry Shiavo Case2006 : American Board of Medical Specialties(ABMS): Designation of Hospice/Palliative Medicine as a “Sub-Speciality “2007 : American Counsel of Graduate Medical Education (ACGME) begins accreditation for HPM Fellowships2010: 62 accredited HPM Fellowship Programs nationwide.
8 Median Life Expectancy Over the Years HPM 1017/9/2009Median Life Expectancy Over the YearsAntibiotics/ImmunizationsModern SanitationModern MedicineTodd Coté, MD, FAAFP, FAAHPM
9 Death in America Approx. 2.4 Million Deaths/ Year* Approx. 1.5 Million Medicare Hospice Benefit recipients / year**? Approx Million Individuals could benefit from Hospice/year? Eventual Hospice Penetration: Approx. 75%*National Registrar (2002)**NHPCO ( 2008 National Dataset)
10 Death in AmericaConsistently Americans, when asked prefer to die in their home. (85%-90%)Death in Institutions1949 : 50% of patients1958 : 61%1980 : 74%2001 : 77% (53% in acute care hospitals, 24% in nursing homes)Estimation: 2010: 40% of Deaths in America will occur in a Nursing Home.- 1.6 million Americans live in Nursing Homes.- 90% of these people are over the age of 65.- 5.3 million SNF residents projected by 2030.
11 Walker Percy MD, Love in the Ruins 1971 “If you listen carefully to your patients they will tell you not only what is wrong with them but what is wrong with you.”Walker Percy MD, Love in the Ruins 1971
12 Study to Understand Prognoses and Preferences for Outcomes and HPM 1017/9/2009Study toUnderstandPrognoses andPreferences forOutcomes andRisks ofTreatmentsTodd Coté, MD, FAAFP, FAAHPM2
13 Death in America Heart disease: 28.5% Malignant neoplasm: 22.8% Cerebrovascular disease: %COPD: %Accidents: %Diabetes: %Pneumonia: %CDC ( 2002)
14 Hospice Top 10 Admission Diagnoses Diagnoses in 1993199520002005Lung cancer1Congestive Heart Failure2Prostate Cancer379Breast Cancer4810COPD5Colon Cancer6-Pancreatic CancerCVARecto-Sigmoid CancerAlzheimer’sDebility UnspecifiedFailure to ThriveSenile Dementia
16 The Nature of Suffering and the Goals of Medicine HPM 1017/9/2009The Nature of Suffering and the Goals of MedicineThe relief of suffering and the cure of disease must be seen as twin obligations of a medical profession that is truly dedicated to the care of the sick. Physicians’ failure to understand the nature of suffering can result in medical intervention that (though technically adequate) not only fails to relieve suffering but becomes a source of suffering itself.Cassell, Eric, NEJM 1982;306:Comfort(Suffering)CureTodd Coté, MD, FAAFP, FAAHPM
17 The Old Model: The Cure - Care Mode HPM 1017/9/2009Palliative/HospiceCareDEATHLife Prolonging CareDisease ProgressionDEATHDo EverythingThere is NothingMore We Can DoComfort Care OnlyTodd Coté, MD, FAAFP, FAAHPM
18 Integrating Palliative Care HPM 101A New Model:Integrating Palliative Care7/9/2009LIKE ENSURE, WE HAVE AN OPPORTUNITY TO EXTEND THE ACCESS POINT PAST THE “SICK POINT”Disease Modifying TherapyCurative, or restorative intentLifeClosureDeath &BereavementDiagnosis Palliative Care HospiceDo Everything ANDPalliateCurative, Palliative andLife-Extending EffortsComfort, Palliative Care and DignityTodd Coté, MD, FAAFP, FAAHPM
19 Hospital –Based Palliative Care The patient’s perspectiveThe clinician’s perspectiveThe hospital’s perspective
20 The patient perspective HPM 1017/9/2009The patient perspectiveFor patients, palliative care is a key tool to:relieve symptom distress:pain, nausea, dyspnea, anxiety, depression, fatigue, weaknessnavigate a complex and confusing medical systemunderstand the plan of carehelp coordinate and control care options“Goals of Care”provide practical, emotional and spiritual support for exhausted family caregivers.allow simultaneous palliation of suffering along with continued disease modifying treatments (no requirement to give up curative care).Todd Coté, MD, FAAFP, FAAHPM
21 The clinician perspective For clinicians, palliative care is a key tool to:manage day-to-day pain and distress of highly symptomatic and complex cases, 24/7, thus supporting the treatment plan of the primary physicianhandle repeated, intensive patient-family communications, coordination of care across settings, comprehensive discharge planningpromote patient and family satisfaction with the quality of the care provided.
22 The hospital perspective HPM 1017/9/2009The hospital perspectiveFor hospitals, palliative care is a key tool to:effectively treat the growing number of people with complex advanced illnessprovide service excellence, patient-centered careincrease patient and family satisfactionimprove staff satisfaction and retentionmeet JCAHO quality standardsrationalize the use of hospital resourcesincrease capacity, reduce costs.Todd Coté, MD, FAAFP, FAAHPM
23 Growth in Hospital-Based Palliative Care Programs HPM 1017/9/2009Growth in Hospital-Based Palliative Care Programs( AHA Annual Survey, )Todd Coté, MD, FAAFP, FAAHPM
24 U.S. Hospital-Based Palliative Care Programs (AHA Survey 2004) HPM 1017/9/2009U.S. Hospital-Based Palliative Care Programs (AHA Survey 2004)Todd Coté, MD, FAAFP, FAAHPM
30 2 Roads to Death THE DIFFICULT ROAD Confused Tremulous Restless HallucinationsNormalMumbling DeliriumSleepyMyoclonic JerksLethargicSeizuresObtundedTHE USUAL ROADSemicomatoseComatoseDead
31 Symptom Burden at the End of Life (Home patients, N=998) 71% : Shortness of breath50% : Moderate to severe pain36% : Incontinent of urine and feces18% : Fatigue
32 Symptom Burden at the End of Life (Hospitalized patients, N=100) 81%: Fatigue70%: Anorexia61%: Dyspnea58%: Dry Mouth52%: Cough49%: Pain37%: Confusion35%: Constipation30%: Nausea23%: Insomnia22%: Vomiting(von Gunten, J P Symptom Management 1998;16:Fainsinger R, Miller MJ, et.al. J Palliat Med 1991; 7: 5-11.)
33 Snyder Framework Pursuit of Chosen Goals Dx of Life-threatening IllnessSnyder FrameworkNew Goal:Search for Cure (unsuccessful)New Goal:Prolong Life (Unsuccessful)Continue search for cureAcceptance of dyingMourn lost goalsDevelop and Pursue Alternate GoalsDevelop PathwaystrategiesMaintain, IncreaseAgency StrategiesEnlist HelpInterdisciplinary Team
34 Healthcare Providers Strategies (Snyder) GoalsPathwaysAgencyLet patient choose goals (and mourn losses).Assess goals on individual basis.Encourage developing alternative goals.COMMUNICATERe-assessHelp patient identify pathways , sub goals, obstacles.Provide interventions for cure, prolongation, improved QOL.Support the patient/family’s pathways.Work together with individual, family and other healthcare providers.Do all you can for pain and symptom management.Encourage, support, be sensitive.Appropriate humor.Ask and remind of past goal successes.Gum A, Snyder CR, Coping with Terminal Illness: The Role of Hopeful Thinking, J Pall Med, (2002), 5:6,
35 Patient/Family Strategies (Snyder) GoalsPathwaysAgency-Mourn losses of valued goals.-Recognize one’s worth.-Recall past goals/achievements/relationships.-Develop alternative goals important to self, communicate and enlist others help.-Describe goals clearly and measure progress.-Enhance goals by agency and pathways-Use positive , active strategies and actively confront.-Believe in personal control.-Break goals into sub goals.-Practice plans.-Develop alternative pathways.-Learn new skills.-Communicate.-Enhance by new goals and agency-Manage pain and symptoms-Exercise-Rest-Plan during peak of day-Be compliant-Expect and plan for difficulties-Positive, self –motivating talk.-Develop social support-Appropriate Humor-Enhance by new goals and pathwaysGum A, Snyder CR, Coping with Terminal Illness: The Role of Hopeful Thinking, J Pall Med, (2002), 5:6,
36 Major Influences on Decision-Making CognitiveDiagnosis/PredictabilityPrognosisSunk CostFuture RegretHopeMajor Influences on Decision-MakingEmotionalStressGuiltDoubtFearBad Prior ExperienceAngerDenialValues/Religion/SpiritualHopeGoalsandDecisionsChapman GB et al. Cognitive processes and biasesin medical decision making. Decision Making in Healthcare: Theory, Psychology, and Application. Cambridge Univ. Press 2000,