1. Will This Admission Help? Leonard Hock, D.O., CMD Covenant Hospice

2. Chronic patients in Acute Care Emergency rooms serve chronic patients About 50% of hospital admissions come from the Emergency Department ER physicians and staff often recognize patients at the door –Frequent fliers –Gomers Exasperation and frustration with limited choices in the ER

3. Sick People Get Admitted The options of care are limited in the ER Sick people get admitted An acute process in a chronic patient is usually seen as an acute action point. Case management in the ER usually means “get an ICU bed right away.” Once in the ER, living wills and advanced directives are secondary to care.

4. Admissions Myths Best care for the patient. Families expect admission. Admissions equal census and that’s good for the hospital.

5. Will this admission help? Help? Improve the condition? Lengthen life? Improve quality of life? Respect the patient’s wishes? Be the best option of care?

6. Family Expectations 80% of Americans believe every death is due to a medical failure. Then, what they need is education about the facts. Not the numbers, but the facts about the person they love. What is the diagnosis, the prognosis the likely outcome for this person.

7. Admissions and Census When patients can have a diagnosis, a treatment and a likely improvement they should be admitted. When the diagnosis is terminal, treatment is futile and improvement not achievable, the admission will be frustrating, risky, long and expensive.

8. Are there options? Safety first –For the patient –For the hospital Get the facts –Previous decisions –Previous declarations –Living will, advanced directives, hospice pt.

9. Options Admit. Admit with limits and endpoints. Return to home or nursing home with treatment and follow up. Involve hospice as an option of care.

10. Evidence Based Decisions Previous admissions with no improvement Multiple chronic disease processes Overwhelming multi system failure End-stage disease that is finally end-stage Data consistent with terminal condition Family input consistent with end-of-life

11. A Study

12. C.A.R.I.N.G. Cancer Admissions Resident ICU Non cancer Guidelines –Fischer et al, Journal of Pain and Symptom Management, April ‘06

13. C.A.R.I.N.G. Simple Retrievable No testing required Part of basic medical history Useful On-the-spot decision making

14. Cancer Primary Cancer diagnosis? Active diagnosis of cancer?

15. Admissions Two (2) or more admissions to the hospital for a chronic illness within the last year.

16. Resident of a nursing home Being a nursing home resident identifies that there is some debility, frail state or chronic disease.

17. ICU Recent ICU admission with Multiorgan Failure (MOF).

18. Non Cancer Non cancer diagnosis on Hospice service.

19. Guidelines Used in the Emergency Dept. prior to admission. Identify patients with limited life expectancy. On-the-spot decision making –To have the discussion about options of care.

20. Results 49% of Medical Service admissions met one or more of the CARING criteria. 26% of Medical Service admissions died within one year. Age mattered.

21. Results As expected, the more CARING criteria met, shorter was the length of life. The highest valued indicator was Chronic Disease on Hospice service. The lowest was Nursing Home resident.

22. Another Study

23. ICU Palliative Care ICU admit from a regular hospital admission (avg. 10 days). > 80 y/o with two (2) serious co morbid diagnosis. Active metastatic cancer. Status post cardiac arrest. CVA requiring mechanical ventilation. Norton et al, Proactive Palliative Care in the ICU, Critical Care Medicine, 2007

24. Outcomes 26% of ICU admissions met criteria. With palliative/hospice referral the ICU stay was one week shorter without a difference in mortality. Quality of life and symptom control was the focus of care. $50, 000 per patient saved.

25. Opportunities Quick and easy to remember criteria. Highly predictive of death in one year. Helps identify futile hospital admissions. Admissions that are often long expensive and do not add days or quality to life. A time to start or continue the discussion about options of care.

26. Options of Care Aggressive diagnosis and treatment Regular or routine care Palliative Care –Symptom relief Hospice Care –Symptom relief at the end-of-life Where and how?

27. Thank you