1. Assessing prognosis and patient preferences at admission: A research proposal Stephen Workman General Internal Medicine Dalhousie University Halifax Nova Scotia

2. Outline Genesis of this proposalGenesis of this proposal –Philosophy of end of life care currently End of life care and the medical teaching unitEnd of life care and the medical teaching unit –Institutional statistics # deaths/service# deaths/service ATLOSATLOS Total bedsTotal beds ComparatorsComparators Educational research proposalEducational research proposal

3. Genesis of this proposal CTU Morbidity and mortality rounds held each month – –25-30 deaths per month – –Often death seems (very) probable at admission – –(Progressive disease, no clear reversible cause) Goals of care often not determined until late – –Delay in starting palliative care – –Patients / family members may trigger the initiation of palliative care

4. 3 Palliative/curative models of care delivery curative Palliative curative Palliative 1. Sequential ( current) 2. Exclusionary 3. Complementary Curative

5. EOLC at a 1000 bed teaching center: A Major Commitment 1250 deaths (2003-2004) – –Average terminal length of stay: 20 days (median 18) – –Last six months of life: 25 days – –MTU35 days 25,000 bed days / 365,000 total available – – 7% of total beds – –30% of deaths preceded by SCU admission 14,000 bed days in hospital for medicine patients, 1612 on palliative care ward

6. # deaths per service

9. A comparison to 77 US Centres QEII

10. Research proposal Goal: To address death and dying and the need to provide EOLC based upon risk not certainty – –(NNT vs NNP) – –Ensure patients who get aggressive treatment truly desire it. – –Include palliative goals before death is certain. Approach – –Utilize a decision aide that addresses EOLC in a structured manner – –Explicitly consider prognosis and treatment options. – –Assess patient preferences for treatment and treatment goals as part of the history and physical – –Address emotional responses and fears if they should arise

11. Intervention Have the resident in the ED estimate prognosis and assess patient preferences for treatment and treatment goals in the history and physicalHave the resident in the ED estimate prognosis and assess patient preferences for treatment and treatment goals in the history and physical –Exclude patients at discretion of resident/admitting MD (Palliative only or clearly full code) Complete a flow sheet (example) at or around the time of admissionComplete a flow sheet (example) at or around the time of admission

12. Six steps Likert scale to estimate prognosisLikert scale to estimate prognosis Assess treatment optionsAssess treatment options Assess for prior advance care plansAssess for prior advance care plans Assess patient preferences*Assess patient preferences* ‘FIFE’ on an as need basis‘FIFE’ on an as need basis Record treatment plan or full code by defaultRecord treatment plan or full code by default

13. Step 1. Would you be surprised if this person died within 6 months? Yes__No__ Could the patient die this admission? (Mark estimate or range) Step 2 Treatment goals appropriate for this patient: (Choose One or more) 1.___Comfort as primary goal of care 2.___Comfort plus ‘ward based’ treatments to prolong life. 3.___As above plus (CPAP BiPAP)___Intubation___ for respiratory support 4.___As above plus CPR and admission to an ICU. 5.___Other: Describe_________________________________________________ Step 3 Are patient preferences previously documented? No____ Yes___ Old chart___Living Will___Other________________________ Plan documented: Full code___No code____Palliative ___Other_________________________________ Do you believe preferences need to be reassessed?Yes___No___ Very likelyunlikely

14. Step 4 Patient ___proxy___ preferences and goals Are family members present? Yes___No___ 1. Assessment deferred for 24__48__ hours___Indefinitely___ 2. Reason for deferral—patient request___Family not present___ Other_________________________________________________ 3. Patient__Proxy___ preferences for treatments and goals of care 1. ___Comfort as primary treatment goal 2. ___Comfort measures plus ward based medical treatments. 3. ___Comfort + ward treatments + (BIPAP or CPAP)__ INTUBATION___ 4. ___Full medical treatment including CPR and admission to an ICU 5. ___Other_______________________________________________ 6. ___Patient / proxy wishes to defer decision making Aware___Not aware___ of ‘full code by default’ Step 5: Patient / family evidence of distressYes___No___ FIFE* (feeling ideas fear expectations)Done-___Not done___ Step 6 Outcome: Goals NOT established: is this recorded in chart? Yes____No___ Goals established___ and recorded___: In chart___In orders___ Describe goals________________________________________ ___________________________________________________________

15. STEP 1: Prognosis* (Conrev data) (+) High functional class, Independent for ADL’s, clearly reversible illness component (-)Bedridden, functional class 4, low albumen, decline despite medical treatment, lack of reversible cause for progressive worsening, permanently depressed level of consciousness, persistent hypothermia, recurrent/recent hospital admissions, cachexia, low blood pressure chronically STEP 4: Assessing treatment preferences: Low probability of dying I routinely ask patients about the kinds of treatment they would like if they became very sick…Hospital policy is that if you became very sick suddenly whatever treatments are necessary to keep you alive would be used including CPR, Life support. Have you thought about the kinds of treatment you would like if you became very sick? What do you understand about your / your mothers illness? Do you want to talk about the kind of treatments you would want if you became critically ill? Would you want to go to the ICU or receive CPR Moderate / high probability of dying Consider talking about death as a possible/probable outcome “Have you thought that you / your mother could die from this illness / during this admission? What do you hope we can do for you during this admission? What do you hope for the future UNDECIDED PATIENTS Patients who are undecided should be informed of hospital policy (Full code by default) STEP 5: FIFE (Fears Ideas Feeling Expectations) Some patients may have anxiety or fears about their illness. If distress appears to be present FIFE important How do you feel about….? Would you like to talk about your worries? Is there anything you are worried or afraid of? What do you hope we can do for you STEP 6:Developing a care plan Address emotions Educate about unrealistic expectations Describe what can be done in terms of comfort and improving survival. (Improving comfort may improve survival as well) Reassure ‘low risk patients’ Be sure to address fears about death and dying for ‘high risk’ patients.

16. Safety measures Not part of the chartNot part of the chart Defer at leisureDefer at leisure Risk stratify patientsRisk stratify patients Consider both goals and treatment preferencesConsider both goals and treatment preferences FIFE when in doubtFIFE when in doubt

17. Outcomes Descriptive statistics as providedDescriptive statistics as provided Chart reviewChart review –Time to palliative care / care transition –Identification of goals of care –Time to end of life care discussions –Quality of end of life care

18. Questions For me?For me? For youFor you –What do you think are the major hurtles facing this reasearch? –Which steps most likely to be problematic –Risk vs benefit? –Need for resident training? –Suggestions?