1. Palliative Care Consultation Team An Introduction Basics of Pain Management 11.30.09

2. What is Palliative Care?

3. One definition: “comprehensive, interdisciplinary care, focusing primarily on promoting quality of life for patients living with a serious, chronic, or terminal illness and for their families…assuring physical comfort and psychosocial support. It is provided simultaneously with all other appropriate medical treatments.” Billings, J Palliative Medicine, 1999

4. California HealthCare Foundation Spreading Palliative Care in Public Hospitals Initiative Focus on providing culturally sensitive care We have one of six implementation grants statewide

5. California public hospitals lag private hospitals in palliative care

6. CCRMC data Review of data from patient deaths, January - June 2009 How many patient deaths after > 30 days in the hospital? In which unit do most patient deaths occur? What are the major causes of death among our patients?

7. Length of stay for patients who ultimately died

8. Location at time of death

9. Causes of death at CCRMC, January-June 2009

10. The CCRMC Palliative Care Consultation Service A multidisciplinary team which will collaborate with CCRMC staff in providing palliative care to our patients An integrative service Available for inpatients in our first year Expanding to the ED in our second year

11. Multidisciplinary Clinicians (Hellman-Wylie, Steinhart, Freedman, Akin, Tzvieli, Kuruvilla, McCormick…and you?) Social work (Linda Russell) Pharmacists (Katherine Dial, Sharon Sihota) Interpreters Psychiatry consult-liaison staff (Liat Porat, John Echols) Nursing education (Marianne Bunce) Residents (Matt Foster, Sergio Urcuyo) Any resident on elective block who wants to join us for consultations is welcome

12. When do I consult? Terminal illness with distressing symptoms Chronic illness with distressing symptoms Patient/family prefer to be at home rather than hospital Prolonged critical care course with poor prognosis Lack of clarity in goals of care

13. When do I consult? Chronic illness with frequent hospitalizations Patient/family lack understanding of diagnosis and prognosis Advance care planning - choosing a DPOA, completing an advance directive You just don’t have time to find out what is going on….

14. What will we do? Review referred cases and arrange family meetings Support relationship of primary team with patient and family Explore social history Review current medications and other orders Establish advance directives Arrange home or hospice services Co-follow patients with you

15. Our Challenges Palliative care for an ethnically diverse population Integrative care - effective collaboration between two teams Education throughout the institution - nursing staff, residents, and others

16. Attitudes toward care at the end of life vary by race and ethnicity CHCF sponsored survey of 1,800 California adults in 2006 Which comes closer to your view? –“Doctors and nurses should always do everything possible to save a life.” –“Sometimes there are circumstances where a patient should be allowed to die.”

17. Attitudes toward care at the end of life vary by race and ethnicity

18. Culturally appropriate palliative care Interpretation - Interpreters trained to act as cultural brokers, not simply translators Cultural humility Strength of provider-patient therapeutic relationship key to navigating gaps in understanding

19. Our Challenges Integrative care - effective collaboration between two teams –Primary team included in meetings whenever possible –Encourage residents to lead meetings Education throughout the institution - nursing staff and other disciplines –Inclusion of the bedside nurse in meetings with patients and families. –Continuing education sessions for nursing staff –Educational programs with other disciplines? (RTs, etc.)

20. Palliative care team is available Monday - Friday, 8 am - 5 pm Call schedule available on amion.com with password “ccrmc” Think of palliative care broadly, not just in terminal illness We will learn as we go - please give us feedback so that we can do just that