Caring, Curing and Comforting September 13, 2018 Wendy Knowlton DO, HCMD Jason Heffernan MD Bonnie Blachly RN

Objectives Describe medicine’s shifts over the last 100 years Myths about hospice and palliative care. Why palliative care? Comfort along the journey; describe models that integrate comfort before, during, and after curative therapy

“My dear, Americans are the only people who think death is an option.” -- Barbara Walker Leicester, England

How Americans Died in the Past Early 1900s Average life expectancy 47 years old Only one person in 25 survived to age 60 Childhood mortality high

How Americans Died in the Past Prior to antibiotics, people died quickly infectious disease accidents Medicine focused on caring, comfort Sick more often cared for at home

Medicine advances Improved sanitation, public health, antibiotics, other new therapies increasing life expectancy 2016 average 78.6 yrs Drop from 78.7 yrs in 2015 Potential of medical therapies “fight aggressively” against illness, death prolong life at all cost

Medicine’s Shift in Focus Science, technology, communication Marked shift in values “death denying” society Death viewed as “the enemy” Mortality rates are used to rank hospitals Physicians have sense of failure if patient not “saved” “Didn’t know it was this bad”; Mobility of Americans puts distance between many younger and older family members

End of Life Care in U.S. Today Modern health care only a few cures live much longer with chronic illness dying process also prolonged To die of old age is a death rare, extraordinary, and singular . . . a privilege rarely seen. Montaigne, Of Age, 1575

Obstacles Professional culture values saving lives through advanced technology more highly than compassionate care at end of life Uncertainties in prognostication Inadequate training of caregivers in palliative medicine Fragmented, organ-oriented care

Everybody anticipating death deserves the option of hospice philosophy of care… Everyone facing serious illness deserves the option of discussing their hopes and goals…

Myth #1 Hospice is only for patients who are actively dying. Fact: Hospice is about maximizing the quality of a person’s life. Many families and patients wish that hospice had been invited sooner due to increased comfort outside the hospital.

End of life Caregiving in the United States A National Profile Of End-Of-Life Caregiving In The United States. Article Link: https://www.healthaffairs.org/doi/10.1377/hlthaff.2017.0134 “Palliative care provides an added layer of support for seriously ill patients and their families, and it is available at any point in such an illness.” “In contrast, hospice care is limited to the last months of life and may begin too late to fully benefit caregivers who have already experienced tremendous strain related to their caregiving” - Kelley AS , Morrison RS . Palliative care for the seriously ill . N Engl J Med . 2015 ; 373 ( 8 ): 747 – 55

Myth #2 Palliative care is the same as hospice. Fact: Palliative care is a specialty, a support system for people with serious illness who may still be pursuing treatment and who have a life expectancy greater than six months. All hospice care encompasses a palliative approach.

Myth #3 Palliative care means “giving up” and “dying”. Fact: Mortality rate for anyone alive is 100%. Palliative care is a team approach. We talk about pros and cons of treatments We talk about symptom management We want help close gaps in understanding illness and treatment options with the goal of shared decision making We will bring up when it is time to consider hospice

Which patient has a serious illness? Which patient is a hospice patient?

Comments and Questions - Thank you!