1. Introduction to Palliative Care
Erin Fitzgerald, MD
Jessica A Alle Corliss, LCSW
Monica M. Sandoval, MD
Department of Palliative Medicine

2. Objectives Define Palliative Care Outline Palliative Care at UNMH
Define Hospice
Discuss when to consult Palliative Care

3. Myths about Palliative Care
MYTH 1: It hastens death “they will order the Morphine drip”
MYTH 2: It means doctors have given up, “there is nothing else to do”
MYTH 3: Its for old or dying people
“ means I am dying”
MYTH 4: Palliative care means no more treatment “same as hospice”
Palliative care is still widely misunderstood by many
Barrier to timely PC referrals

4. The goal is not to hasten death nor o prolong dying process.
What is Palliative Care?
Provided by an interdisciplinary team
1 team together makes 1 care plan
Can be provided in conjunction with life prolonging treatment
No need to choose between tx plans
Appropriate at any age and any stage of illness.
The goal is not to hasten death nor o prolong dying process.
“Specialized medical care for people with serious illness. This type of care is focused on providing relief from the symptoms and stress of a serious illness. The goal is to improve quality of life for both the patient and the family.”
QUALITY OF LIFE
RELIEF OF SUFFERING

5. PALLIATIVE CARE DOMAINS Care of the dying patient
Framework
Disease Management
Care of the dying patient
Psychological
Patient +
Family
Functional status
Social, Cultural & Ethical
Physical Aspects of Care – pain, dyspnea, nausea/vomiting, fatigue, constipation, performance status, medical diagnoses, medications (add/wean/titrate)
Psychological Aspects of Care – anxiety, depression, delirium, cognitive impairment; stress, anticipatory grief, coping strategies; pharm/non-pharm treatment; patient/family grief/bereavement;
Social Aspects of Care – family/friend communication/interaction/support; caregiver crisis
Spiritual Aspects of Care – spiritual/religious/existential; hopes/fears; forgiveness;
Cultural Aspects of Care – language, ritual, dietary, other.
Care of the Imminently Dying – presence; recognition and communication to patient/family education/normalization; prognosis (eg hours to days; very few days; etc)
Ethical & Legal Aspects of Care – decision maker; advance directives
Spiritual
Focuses on the “illness”, not just the “disease”
What is this patient’s and family’s experience of the disease, and how can we help them all live as fully as they can in whatever time they have?

6. Each patient is unique and their path is their own
How does palliative care help you and your patients? *
Unacceptable pain or symptom distress
Team/patient/family needs help with complex decision-making
Goals of care & Advance Care Planning
Prognostication
Team support
Emotional, spiritual and psychological support
May improve survival *
Fewer hospital days
Less likely to die in an ICU
How can we help?
“No agenda”
Each patient is unique and their path is their own
Early Palliative Care for Patients with Metastatic Non–Small-Cell Lung Cancer led to significant improvements in both quality of life and mood and longer survival (~2.5 months).
NEJM Temel et al. 2010

7. Shared Decision-Making Model

8. Bringing Palliative Care Upstream
Primary Palliative Care Skills
Basic pain and symptom management
Code status
Communication
Goals of care
Palliative care can be delivered by specialist working with primary providers
Palliative care be delivered by clinicians who are not specialist, internist, doctors, nurses, oncologist….etc and other clinician that are caring for seriously ill patients,

9. OUR SPECIALIST Great Support Great Medicine Accurate Diagnosis
Suitable for all categories business and personal presentation
Suitable for all categories business and personal presentation.
Suitable for all categories business and personal presentation.
*Patient seeing the world outside like a fantasy that he longs to be part of
*Contrasting with sense of immobility
*Points to the struggles of many patients with neurological diseases

10. What is Hospice?
Interdisciplinary team provides care
Patients with a limited life expectancy and who choose to focus on quality of life rather than exclusively on length of life
Intensive pain and symptom management, and patient/family support
Two MDs certify prognosis < 6 months if “disease runs its usual course”
It is a philosophy, not a place
Hospice is a health care benefit and a philosophy of care.
Medicare (Part A) benefit since 1983.
FOCUS ON COMFORT AND RELIEF FROM SUFFERING
NOT ON LIFE PROLONGATION

11. Palliative Care or Hospice care: What’s the difference?
Hospice: 2 MDs certify that prognosis is <6 months if illness runs its natural course; treatments are comfort focused, not curative
Palliative Care: No prognostic requirement; inpatient consultation service to help alleviate suffering in patients with serious or life threatening illness
All hospice care is palliative care
But not all palliative care is hospice care

12. Inpatient Consultation Outpatient Consultation
UNMH Palliative Care Team
Inpatient Consultation
Our Team:
Physicians
Advance Practice Providers
Social Workers
Chaplain
Arts-in-Medicine
Administrative Assistant
Outpatient Consultation
Bereavement Services
Physicians (All Board Certified in Palliative Medicine) plus:
Marr and FitzGerald: Internal Medicine
Neale: Geriatrics
Camarata: Family Medicine
Finlay: Medical Oncology
Fahy: Surgical Oncology
Doezema: Emergency Medicine
Sandoval: Geriatrics
ANPs: Harlow, Marsh, Knight, Acosta
SW: Lee and Alle-Corliss
Pastoral Care: Ferguson
Arts-in-Medicine: Repar and team
Call for information or referral

14. Who is appropriate for a palliative care consultation?1
Unacceptable pain or symptom distress with serious/life threatening illness
Who is appropriate for a palliative care consultation? 2
Team/Patient/Family Needs help with complex decision making & determination of goals of care 3
Advance Care Planning/ Tube Feedings discussions
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Prognostication 5
Patient, Family or Team support