Palliative Care at UCH Pager: 303 266-7629 October, 2010

Common Misconception of Palliative Care Curative or Life Prolonging Treatment Bereavement care Relief of suffering, hospice Death

Hospice: One Form of Palliative Care

Palliative Care Goals of Care Next Steps? Pain and Symptom Management Quality of Life Palliative Care Advance Directives Next Steps? Approach Difficult Decisions Hospice Care 4 4

Palliative Care is not Hospice Care, End of Life Care, or the “Death Panel”

Palliative Care Vs Hospice Initiated Disease progresses Terminal phases Prognosis Months - YEARS Days-Weeks- Months Focus Quality of life living with illness; Symptom Mx during last days; Prevent suffering Communication Clarify goals of care Preferences about end of life care We do specialize in both, but may focus our approach based on what is going on with the patient. For Focus: In EOL care, concepts of pall care spill over. 6

Palliative Care: Not an “Either-Or” Traditional Care Model “Curative” Care “Palliative” Care Integrated Care Models

“Cancer” Trajectory, Diagnosis to Death Possible hospice enrollment High Possible hospice enrollment Function Low Death Often a few years, but decline usually < 2 months Onset of incurable cancer Time

Organ System Failure Trajectory High (mostly heart and lung failure) Function Low Death ~ 2-5 years, but death usually seems “sudden” Begin to use hospital often, self-care becomes difficult Time

Dementia/Frailty Trajectory High Function Low Death Onset could be deficits in ADL, speech, ambulation Quite variable - up to 6-8 years Time

Palliative Care Comprehensive Multidisciplinary Promotes quality of life for patients living with a serious, chronic or terminal illness Interventions focus on improving symptoms and enhancing the quality of life. Good chronic disease management Appropriate and expected transition to end of life. Decrease unnecessary suffering Relieve the burden rather than adding to it.

How PC Can Help You Figure out the next steps Guide you and your family with difficult decisions Clarify the goals of care Assist you and your family with transition to end-of-life care

Decision Making Finding out about options Weighing options Keeping the control Partnering with healthcare Weighing options Risks Benefits Burdens If you want to know the options – ask directly. This will allow you to keep the control instead of having things spin out of control. Make your physicians and other healthcare providers realize that you want a partnership – you’re not along for the ride that they dictate you should be on. Risks: side effects, risks of a procedure – disadvantages – what may I see if things don’t go as planned or perfectly? Benefits: ask them to tell you WHY you should do it. Advantages? Ask specific questions that you WANT and don’t want to know: QOL, Quantity of Life? Burdens: how is this going to effect my family? 13

Appropriate Palliative Care Consults: Pain or symptom control Clarifying family and / or patient goals of care. Family meeting coordination. Facilitating communication among patients, families, and health care providers Planning and helping the family transition to the next appropriate level of care. Not just for a hospice referral.

When Else Should I Advocate for Palliative Care? CARING CRITERIA: (Fischer, et.al. 2006) Patients who: C: Primary diagnosis of Cancer A: 2 or more admissions for a chronic illness within the year R: Resident in a nursing home I: ICU with MOF NG: Noncancer hospice guidelines Not just for end of life, but if a patient is nearing end of life, the PCCS can assist and should be consulted as well for pain, symptom management and goal clarification. NG: (life limiting condition, decreased performance status, decline in function, dependence on most ADLS, low serum albumin). FINALLY, ASK YOURSELF THE FOLLOWING: Are they suffering? Do they have a lot of needs? Are their needs being met? Do they have a chronic disease? Do they have symptom distress?

Actual consult is dependant on the primary team’s question: What do you understand about the course of your disease? Performance status questions Goals Symptom Distress Quality of Life Support system Advance Directives Wishes for End-Of-Life Care See pall care assessment

Hospice Appropriate when patient, family and healthcare providers believe that curative therapy will not be beneficial and will not change the outcome Care focus has shifted to comfort and symptom management Therapies that are paid are those related to symptoms attributed to the terminal illness.

How Does Palliative Care Differ from Hospice Care? Both emphasize physical comfort, pain relief, symptom management, spiritual, psychological, social, and bereavement needs Hospice care: limited to the end stages of disease (months) Philosophy of providing treatments that necessitate comfort but not life prolonging treatments Palliative care: provided throughout the course of a serious, advanced illness Good chronic disease management Hospice and palliative care are responses to these inadequacies in the prevention and relief of symptoms and distress in people approaching death. The term “hospice” has at least 3 somewhat different uses that can be confusing and even misleading: 1) a discrete site of care, such as a free-standing facility, 2) an organization or program that provides, arranges, and advises on a wide range of medical and supportive services for dying patients and their loved ones, and 3) an approach to care for dying patients based on clinical, social, and metaphysical or spiritual principles. 18

The Palliative Care Consult Team at the University of Colorado Hospital 266-7629 Our Team: Sub Specialty Jean Kutner, MD Internal Medicine Jeanie Youngwerth, MD Internal Medicine / Hospitalist Harri Brackett, RN, MS Oncology & Palliative Care CNS Kathy Bunzli, RN, MS Critical Care Stacy Fischer, MD Geriatrics Dan Matlock, MD David Nowels, MD Family Medicine Interdisciplinary Consultative Service Palliative Care Board Certified Physicians Advance Practice and Certified Palliative Care Nurses Unit based Social Work and Pastoral Care Services Resident and Fellow education

Can Therapy Help Palliative Care Patients? Pain control Improved strength Improved functional status Maintain enrollment in clinical trials Improved quality of life

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