1. Hospice Basics: Palliative Care vs. Curative Care

2. Goal To educate health care professional about hospice, specifically palliative care as compared to curative care in order to provide more appropriate and quality hospice care for terminally ill patients and their families.

3. Objectives Describe the history and philosophy of the hospice movement. Identify the difference between palliative and curative care. List the benefits of palliative care in the terminally ill patient. List some therapies that are palliative but may be consider curative.

4. A Bit of History Dying in the 19th Century –3% of America’s population was >65. –Life expectancy was 45-50 years. –Most people died at home.

5. …And Then Today Dying in the United States –13% of the population is > 65 years. –Approximately 75% of Americans die in health care facilities. 57% die in hospitals. 17% die in long term care facilities.

6. Hospice The origin of the word hospice was used to describe a “shelter or haven for the weary traveler” The term has come to be associated with support and care Shelter from discomfort is provided to enable dying patients to approach death in a peaceful way

7. History of Hospice 1905 St. Joseph’s 1967 St. Christopher’s in London 1969 Elizabeth Kubler-Ross – “On Death and Dying” 1974 New Haven Hospice of CT –First hospice in the US

8. Oxford’s Textbook of Palliative Medicine What is Palliative Care? “ The study and management of patients with active, progressive, far-advanced disease for whom the prognosis is limited and the focus of care is quality of life.”

9. World Health Organization Palliative Care Affirms life. Regards dying as a normal process. Neither hastens nor postpones death. Provides relief from pain & other symptoms. Integrates the psychological & spiritual aspects of care. Provides support for patient and family.

10. Hospice defines Palliative Care The aggressive treatment of physical and emotional pain & symptoms An active treatment plan, but not intended to cure the patient’s underlying disease All palliative treatments focus on enhancing a resident’s comfort & overall quality of life

11. The Goal of Palliative Care The goal of palliative care is helping patients to achieve and maintain maximum physical, emotional, spiritual, vocational and social potential, despite the progression of their terminal illness.

12. Palliative Care Realized This goal is fully realized when the patient experiences the following: Relief from pain Psychological and spiritual care A support system which assists the patient to be as actively as he or she wishes A support system to sustain the patient’s family

13. End of Life Physical Symptoms Pain and symptom management are the first priority in palliative care Unrelieved pain Shortness of breath Nausea & Vomiting Confusion Restlessness Itching Disturbed bladder and bowel function Disrupted sleep Cachexia

14. Psychosocial / Spiritual Symptoms Psychosocial and spiritual symptoms that are part of the dying process are addressed Psychosocial –Depression –Anxiety –Ineffective Coping –Ineffective Communication –Life Role Transition –Caregiver Distress Spiritual –Despair / Hopelessness –Powerlessness –Loneliness –Need for Reconciliation

15. Palliative Care vs. Curative Care Curative Care –Disease driven –Curing the disease is foremost –Doctor in charge –Disease process is primary –Few choices Palliative Care –Symptom driven –Comfort & quality of life –Patient is in charge –Disease process is secondary to person –Many choices

16. Freedom to Choose Palliative Care redirects energy Patients and Families drive the Plan of Care Patients and Families choose what is important to accomplish Physical, Psychosocial or Spiritual

17. Palliative Care Misconceptions Hospice / palliative care means “doing nothing” All treatments are discontinued All invasive interventions such as chemotherapy or radiation are stopped

18. Misconceptions Hospice / palliative care means “doing nothing” FACT: The goal is to assist the patient to achieve quality of life –Patient drives the Plan of Care –All decisions are weighed –More choices give to patient and family

19. Another Misconception “ All treatments are discontinued” FACT: All decisions about treatments (to initiate or discontinue) are weighed against the goal of palliative care.

20. Misconceptions about Invasive Interventions All invasive interventions such as chemotherapy or radiation are stopped FACT: Yes, there are such things as palliative chemotherapy and palliative radiation therapy

21. Principles for use of Invasive Palliative Interventions What does the patient want? What is the life expectancy of the patient? What is the patient’s baseline level of function? What is the goal or expected outcome of the proposed intervention? Weinreb N. Twenty Common Problems in End of Life Care, 2001

22. Patient Wishes What does the patient want? Is what the patient wants medically indicated? What is the physician’s obligation? Weinreb N. Twenty Common Problems in End of Life Care, 2001

23. Patient Prognosis Will the patient live long enough to complete the treatment? Will the patient live long enough to benefit from the treatment? Weinreb N. Twenty Common Problems in End of Life Care, 2001

24. Patient’s Functional Status Ability of patient to tolerate treatment Potential for improvement in quality of life Potential complications Discomfort to patient Inconvenience to patient Potential toxicities and side effects Weinreb N. Twenty Common Problems in End of Life Care, 2001

25. Palliative Chemotherapy Clinical Benefit Response to Chemotherapy Sustained Improvement in Pain –Decreased pain with no change in analgesia –Same level of pain with less analgesia Improvement in Performance Status Stabilization or gain in weight Weinreb N. Twenty Common Problems in End of Life Care, 2001

26. Indications for Palliative Radiation Bone pain secondary to metastases Neurological deficits associated with brain metastases Malignant dysphagia due to tumor obstruction Painful hepatomegaly Pulmonary symptoms Pelvic masses associated with pain or obstruction Weinreb N. Twenty Common Problems in End of Life Care, 2001

27. Palliative Radiation Therapy Pain, bleeding, and obstruction may be relieved Radionuclides and hemibody radiation for systemic pain Key issue relates to dosing –Short or single fractionation schemes are preferred –An increased risk of long term toxicity should not be an issue in patients near the end of life Weinreb N. Twenty Common Problems in End of Life Care, 2001

28. In Conclusion Palliative Care affirms life and attempts to relieved pain and suffering Palliative Care is symptom driven with the patient in charge Every treatment or intervention must be questioned Some treatments and therapies normally viewed as curative can be and are palliative –Chemotherapy –Radiation

29. In every sufferer, Let me see the Human Being -Maimonides

30. Hospice Basics: Palliative Care vs. Curative Care