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Palliative Care at the End of Life

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1 Palliative Care at the End of Life
Todd R. Cote MD, FAAHPM, FAAFP Program Director, University of Kentucky College of Medicine/Hospice of the Bluegrass Fellowship in Hospice and Palliative Medicine Chief Medical Officer, Hospice of the Bluegrass and the Palliative Care Center of the Bluegrass Assistant Professor, Univ. of Kentucky College of Medicine

2 Objectives Review Definitions and History
Define Principles and Culture Discuss 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 treatment CAPC, 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-debilitated Hospice -6 month expected survival

6 Historical Perspective (Western)
B.C. pre-Christian 475 ce : First recorded hospice , Rome 1400’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 Charity 1879: 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 patients 1930: 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 Dying 1952: Marie Curie Memorial Foundation: Cancer Care homes 1967: Dr Cicely Saunders opens St Christopher’s Hospice , Syndenham, London. 1964: C.M. Parkes, psychiatrist: Bereavement Research 1965: 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 service 1975: 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 Benefit 1987 :Royal College of Medicine( England) recognizes palliative medicine as a Specialty 199i : Cruzan v. Director, Missouri Department of Health, 1994 : Dr. Jack Kevorkian, Oregon Death and Dignity Act 1995 : SUPPORT study 1996 : AAHPM: Board Certification fo rHospice/Palliative Medicine 1997 : Institute of Medicine Report 2001 : National Report: Transforming Death in America 2002 : Last Acts National Report: State-by State report on End-of-Life Care 2004 : National Institute of Health : Consensus Report on End-of-Life Care in America 2005 : The Terry Shiavo Case 2006 : 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 Fellowships 2010: 62 accredited HPM Fellowship Programs nationwide .

7 Principles and Culture at the End of Life

8 Median Life Expectancy Over the Years
HPM 101 7/9/2009 Median Life Expectancy Over the Years Antibiotics/ Immunizations Modern Sanitation Modern Medicine Todd 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 America Consistently Americans, when asked prefer to die in their home. (85%-90%) Death in Institutions 1949 : 50% of patients 1958 : 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 101 7/9/2009 Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments Todd Coté, MD, FAAFP, FAAHPM 2

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 1993 1995 2000 2005 Lung cancer 1 Congestive Heart Failure 2 Prostate Cancer 3 7 9 Breast Cancer 4 8 10 COPD 5 Colon Cancer 6 - Pancreatic Cancer CVA Recto-Sigmoid Cancer Alzheimer’s Debility Unspecified Failure to Thrive Senile Dementia

15 Rand Group , 2001

16 The Nature of Suffering and the Goals of Medicine
HPM 101 7/9/2009 The Nature of Suffering and the Goals of Medicine The 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) Cure Todd Coté, MD, FAAFP, FAAHPM

17 The Old Model: The Cure - Care Mode
HPM 101 7/9/2009 Palliative /Hospice Care DEATH Life Prolonging Care Disease Progression DEATH Do Everything There is Nothing More We Can Do Comfort Care Only Todd Coté, MD, FAAFP, FAAHPM

18 Integrating Palliative Care
HPM 101 A New Model: Integrating Palliative Care 7/9/2009 LIKE ENSURE, WE HAVE AN OPPORTUNITY TO EXTEND THE ACCESS POINT PAST THE “SICK POINT” Disease Modifying Therapy Curative, or restorative intent Life Closure Death & Bereavement Diagnosis Palliative Care Hospice Do Everything AND Palliate Curative, Palliative and Life-Extending Efforts Comfort, Palliative Care and Dignity Todd Coté, MD, FAAFP, FAAHPM

19 Hospital –Based Palliative Care
The patient’s perspective The clinician’s perspective The hospital’s perspective

20 The patient perspective
HPM 101 7/9/2009 The patient perspective For patients, palliative care is a key tool to: relieve symptom distress: pain, nausea, dyspnea, anxiety, depression, fatigue, weakness navigate a complex and confusing medical system understand the plan of care help 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 physician handle repeated, intensive patient-family communications, coordination of care across settings, comprehensive discharge planning promote patient and family satisfaction with the quality of the care provided.

22 The hospital perspective
HPM 101 7/9/2009 The hospital perspective For hospitals, palliative care is a key tool to: effectively treat the growing number of people with complex advanced illness provide service excellence, patient-centered care increase patient and family satisfaction improve staff satisfaction and retention meet JCAHO quality standards rationalize the use of hospital resources increase capacity, reduce costs. Todd Coté, MD, FAAFP, FAAHPM

23 Growth in Hospital-Based Palliative Care Programs
HPM 101 7/9/2009 Growth 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 101 7/9/2009 U.S. Hospital-Based Palliative Care Programs (AHA Survey 2004) Todd Coté, MD, FAAFP, FAAHPM

25 US Hospice Patient Growth 1982 - 2006

26 Treatment at the End of Life Physical-Psycho-Social-Spiritual

27 HPM 101 7/9/2009 Todd Coté, MD, FAAFP, FAAHPM

28 The Concept of Total Pain

29 The Concept of Total Pain

30 2 Roads to Death THE DIFFICULT ROAD Confused Tremulous Restless
Hallucinations Normal Mumbling Delirium Sleepy Myoclonic Jerks Lethargic Seizures Obtunded THE USUAL ROAD Semicomatose Comatose Dead

31 Symptom Burden at the End of Life (Home patients, N=998)
71% : Shortness of breath 50% : Moderate to severe pain 36% : Incontinent of urine and feces 18% : Fatigue

32 Symptom Burden at the End of Life (Hospitalized patients, N=100)
81%: Fatigue 70%: Anorexia 61%: Dyspnea 58%: Dry Mouth 52%: Cough 49%: Pain 37%: Confusion 35%: Constipation 30%: Nausea 23%: Insomnia 22%: 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
Illness Snyder Framework New Goal: Search for Cure (unsuccessful) New Goal: Prolong Life (Unsuccessful) Continue search for cure Acceptance of dying Mourn lost goals Develop and Pursue Alternate Goals Develop Pathway strategies Maintain, Increase Agency Strategies Enlist Help Interdisciplinary Team

34 Healthcare Providers Strategies (Snyder)
Goals Pathways Agency Let patient choose goals (and mourn losses). Assess goals on individual basis. Encourage developing alternative goals. COMMUNICATE Re-assess Help 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)
Goals Pathways Agency -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 pathways Gum A, Snyder CR, Coping with Terminal Illness: The Role of Hopeful Thinking, J Pall Med, (2002), 5:6,

36 Major Influences on Decision-Making
Cognitive Diagnosis/Predictability Prognosis Sunk Cost Future Regret Hope Major Influences on Decision-Making Emotional Stress Guilt Doubt Fear Bad Prior Experience Anger Denial Values/Religion/Spiritual Hope Goals and Decisions Chapman GB et al. Cognitive processes and biases in medical decision making. Decision Making in Healthcare: Theory, Psychology, and Application. Cambridge Univ. Press 2000,

37 Thank you


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