1. Palliative Care: Emergency Room Interaction
Pippa Hawley, UBC and BCCA, Vancouver
July 2016

2. Objectives Discuss words used when talking about palliative care
Present a visual model to help you describe it’s various aspects to patients, families, colleagues and the public
Give you confidence in knowing what to say when your patient is seriously ill

3. Historical Understanding of Palliative Care
ACTIVE (“CURATIVE”) TREATMENT

4. CHPCA Model ~yr 2000 Focus of Therapy to modify disease care Hospice
Palliative Care
Bereavement
This is still referred to as the ”new” model in many references

5. What Patients See (Google Images search )

7. “This is Not For Me” Too little palliative care too late
No time for advance care planning
Low expectations for symptom management
Expectation of suffering
Caregiver burden
High cost (taxpayers and families)

8. WHO Definition
Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.

9. WHO Definition Continued…
………early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications.

10. Integration of Palliative Care with Disease Management
There is now clear evidence that Specialist Palliative Care Consultation….
Improves quality of life of patients
Improves quality of life of care-givers
Reduced dysfunctional grief
Increases the chance of death occurring in the chosen location (home or hospice vs hospital)

11. Integration of Palliative Care with Disease Management
Reduces risk of inappropriate interventions, e.g..
ICU admissions where no advance care planning has been done
chemotherapy within last days/weeks of life
Reduces costs to health care system
ER admissions
Acute bed stays
Doctor visits

12. Mass. General Study
Increased survival; Temel et al RCT of mandatory US Cancer centre-based PSMPC clinic referral at diagnosis of metastatic lung cancer vs discretionary referral by oncologist
Median Survival
11.6 vs. 8.9 months
p<0.02
2. NEJM 2010;363:

13. Integration of Palliative Care with Disease Management
PC is most valuable when integrated early in the course of illness, particularly in care for chronic illness where a palliative approach to care is most appropriate
PC is shifting from focus on cancer to focus on all diseases with differing illness trajectories and care needs
Prognostication is getting harder with new disease-modifying medical advances
There is no longer a “right time” for palliative care referral

14. A New Model of Integrated Palliative Care
Disease
Management

15. A New Model of Integrated Palliative Care
Chemotherapy
Radiotherapy
Transfusions
Palliative
Care
Disease
Management
Hormone therapy
Anti-nausea drugs
Antibiotics
Targeted therapy
Surgery

16. A New Model of Integrated Palliative Care
Survivorship
Cure
Rehabilitation
Palliative
Care
Disease
Management
Symptom Management
Advance Care Planning
Palliative Care Unit
Control
Hospice
Bereavement
End of Life Care

17. Goals for Bowtie Model
Accurately describe the current WHO definition of palliative care, for our patients, their families and our colleagues
Emphasize that a definite and inevitably fatal course is not a prerequisite for eligibility
“If you get over this we will all be thrilled”
“If you don’t, you will have had access to the best possible care, all the way along”

18. Specialist Palliative Care
Specialist Palliative Care is provided by a specially-trained team of doctors, nurses, social workers and other specialists who work together with a patient’s primary care team to provide an extra layer of support for people with serious illness. It focuses on providing relief from the symptoms and improving quality of life for both the patient and the family. It is appropriate at any age and at any stage of a life-threatening illness and can be provided along with curative-intent treatment.

19. Specialist Palliative Care Services
Unable to take care of all of clinical needs
Often rationed arbitrarily according to prognosis
We are not very good at prognostication
Barriers to access including DNR status: this should be a goal, not a requirement
Mis-use of the word “palliative” as a euphemism for many concepts, e.g “dying”, “incurable”, “close to death”, “suffering greatly” etc.
No wonder patients don’t want it!

20. Hospice
Care that focuses on relieving symptoms and supporting patients with incurable illness that have a life expectancy of weeks to months. In most cases hospice care is provided to a patient in his or her own home. It also can be provided in freestanding hospices, hospitals, nursing homes and other long-term care facilities.

21. Palliative Medicine
The medical specialty focusing on the knowledge and skills which make up the physician’s role in providing specialist palliative care, including teaching and research.