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

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

3. Hospice: One Form of Palliative Care

4. 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

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

6. 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

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

8. “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

9. 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

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

11. 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.

12. 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

13. 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

14. 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.

15. 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?

16. 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

17. 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.

18. 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

19. 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

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

21. References
Beltran, J.E. (1997). A model for comprehensive palliative care. The Talbert Journal of Health Care, (Spring /Summer),
Chapple, H.S. (1999). Changing the game in the intensive care unit: Letting nature take its course. Critical Care Nurse, 19(3),
Clark, A.P. (2002). Can we improve the quality of dying in hospitals? Clinical Nurse Specialist, (16)4,
Dowdy, M.D., Robertson, C., & Bander, J.A. (1998). A study of proactive ethics consultation for critically and terminally ill patients with extended lengths of stay. Critical Care Medicine, 26(2),
Faber-Langendoen, K. & Lanken, P. (2000). Dying patients in the intensive care unit: Forgoing treatment, maintaining care. Annals of Internal Medicine, 133(11),
Ferrell, B.R. & Coyle, N. (2002). An overview of palliative nursing care. Lipponcott’s Case Management, 7(4),
Lilly, C.M., DeMeo, D.T., Sonna, L.A. et al. (2000). An intensive communication intervention for the critically ill. American Journal of Medicine, 109(6),
Lorig, K. (1996). Chronic disease self-management. American Behaviorial Scientist, 39(6),
Nelson-Marten, P., Braaten, J., & English, N. (2001). Promoting good end-of-life care in the intensive care unit. Critical Care Nursing Clinics of North America, 13(4),
SUPPORT Principal Investigators. (1995). A controlled trial to improve care for seriously ill hospitalized patients: The study to understand prognosis and preferences for outcomes and risks of treatments (SUPPORT). JAMA, 274(20),
Wenrich, M.D., Curtis, R.J., Shannon, S.E., et al. (2001). Communicating with dying patients within the spectrum of medical care from terminal diagnosis to death. Archives of Internal Medicine, 161(6),