1. Inpatient Palliative Care: What is it and Why it’s Important Lyra Sihra MD Associate Medical Director Gentiva Hospice

2. Objectives Describe the role of palliative care in the hospital setting Explain how palliative care is accessed by physicians in the hospital Describe why palliative care is becoming important to hospitals Explain why hospice is confused with inpatient palliative care

3. A Few Statistics From 2000 to 2009 ◦ % of deaths in the hospital decreased from 32.6 to 24.6 ◦ More decedents had ICU stays ◦ Hospice use increased from 21.6% to 42.2% ◦ Short hospice stays (3 days or less) increased from 22.2% to28.4% What does this mean? Longer intensive care unit stays with more life sustaining treatments until patient is near death and Transition of hospice to avoid death in the hospital

4. According to the World Health Organization: Palliative Care is the active total care of patients at the end of their lives What is Palliative Care?

5. How Does Inpatient Palliative Care Work? Most commonly palliative care is delivered via a consult team ◦ Physician, advanced nurse practitioner, social worker, chaplain Some hospitals have inpatient units but this is rare Physicians call for a consultation

6. What are the Roles of Inpatient Palliative Care? Pain and non-pain symptom management Communication ◦ Goals of care ◦ Advanced directives Emotional support and management of complex family dynamics Evaluate use of life sustaining treatments Hospice referral and discharge planning

7. What is the Evidence for Inpatient Palliative Care? Palliative Care consultations are effective in improving quality of life at end of life Family perceptions of inpatient care are improved Proven to decrease intensive care utilization

8. What are the problems with access? Physicians don’t know about palliative care or are afraid to access palliative care How can at risk patients be identified? ◦ Screening ◦ Checklists ◦ Who is responsible for screening?

9. Suggested Primary Criteria Would you be surprised if this patient were to die in 6 months? Frequent admissions (more than one admission for the same condition within several months) Admissions prompted by difficult to control physical or psychological symptoms Complex care requirements (tube feeds,vent) Decline in functional status, weight loss

10. Palliative Care Statistics The number of palliative care teams have increased from 600 in 2000 to more than 1600 66% of hospitals with more than 50 beds have palliative care teams 81% of hospitals with more than 300 beds have palliative care teams Prevalence of palliative care teams is lowest in Southern region of US at 52%

11. Why are Hospitals Interested? Hope to decrease length of stay ◦ No firm evidence ◦ Sometimes palliative care increases length stay ◦ Prospective payment system Improve Mortality Statistics (V code) Decrease 30 day re-admissions The Joint Commission Advance Certification for Palliative Care

12. Inpatient Palliative Care and Hospice Why is there such a misunderstanding? ◦ Physicians believe that palliative care and hospice are the same thing ◦ Physicians believe that life prolonging treatments, although “palliative” can be continued in the hospice setting ◦ Poor understanding of hospice philosophy

13. References JAMA release. Feb 5, 2013 Weissman DE, Meier DE: Identifying patients in need of a palliative care assessment in the hospital setting. J. Palliat Med 2011;14:1-7 Casarett D et al: The optimal delivery of palliative care. Arch Internal Med 2011;171(7) 649-655 Casarett D et al:Do palliative consultations improve patient outcomes? J Am Geriatric Soc 2008;56:593-599 Cassel B et al: Palliative care consultation and hospital length of stay. J Palliat Med: 2010;13:761-767 Doyle D et al: Oxford Textbook of Palliative Medicine:New York: Oxford University Press, 1998 Center to Advance Palliative Care in US hospitals: 2012 Snapshot. www.capc.org