Palliative Care in Kingston
and the SE LHIN
Dr. Natalie Kondor
DFM Grand Rounds
Jan 20 2015
Outline
What is palliative care?
Why is palliative care important?
Trends in palliative care provision
Regional and local resources for palliative
care provision
FAQs
What is Palliative Care?
Palliative care is a philosophy of care that aims to help
individuals and families to:
 Address physical, psychological, social, spiritual and
practical issues
 Prepare for and manage end of life choices and the
dying process
 Cope with loss and grief
 Treat active issues and manage symptoms
 Prevent new issues from occurring
 Promote opportunities for meaningful and valuable
experiences
Why do we need palliative care?
1900
 Average age of death 46 years
 Usually a rapid death
 Leading causes: infectious disease, childbirth, accidents
Sudden Death
High
Death
Low
2015
 Average age of death 85
 Only 5% die sudden deaths, 95% decline over time
 2-4 years of decline
High
High
Cancer
Function
Low
death
Time
Dementia/Frailty
Function
Organ System Failure
Function
High
Time
Low
death
Time
death
Low
Time
Our Reality
 By 2036, seniors will account for 23-25% of the total
population
 32 % of Canadians suffer from a chronic illness
• 39% have a sufferer in their immediate family
 74% of seniors have one or more chronic conditions
 24% of seniors have three or more chronic conditions
 Chronic diseases account for 70% of all deaths
Palliative Care – Not Just End of Life
Care
The Need for Palliative Care
ESAS symptom profile for cancer patients
All Disease Sites, FY 2013/14
80%
70%
12.5%
8.2%
60%
50%
40%
6.6%
14.0%
6.4%
4.9%
14.2%
6.1%
12.8%
39.9%
39.6%
Tiredness
Wellbeing
5.0%
10.7%
12.1%
1.9%
4.9%
20%
34.3%
27.4%
32.1%
31.2%
22.6%
10%
0%
21.9%
6.3%
11.1%
30%
22.8%
Anxiety
Depression Drowsiness
Lack of
Appetite
1 - 3 (Low Severity)
26.8%
17.1%
Nausea
Pain
4 - 6 (Moderate Severity)
Shortness
of Breath
7 - 10 (High Severity)
Benefits of Earlier and Integrated
Palliative Care
Leads to better outcomes for Patients & Families:
• Reduced symptom burden
• Less anxiety and depression
• Less caregiver burden
• Better quality of life
• Less aggressive treatments
• More appropriate referral to and use of hospice
• Lower health care costs
Smith et al., 2012; Temel et al., 2010; Bakitas et al., 2009;
Myers et al., 2011; Zimmerman et al 2013
Benefits of Earlier and Integrated
Palliative Care - Improved Survival
Longer and better survival





Better understanding of prognosis
Less IV chemo in last 60 days
Less aggressive end of life care
More and longer use of hospice
$2000 per person savings to
insurers and society
Temel J, et al. NEJM 2010; Temel J, et al, JCO 2011; Greer, et al. Proc ASCO 2012
Current state of Palliative Care in Canada
 Only 16-30% of Canadians have access to formalized palliative/end-of-life
care services
 At least 25% of the total cost of palliative care is borne by families
 Approximately 70% of deaths occur in hospital
• 40% of terminally ill cancer patients visit the emergency department
within the last 2 weeks of life
• 41% of long term care home residents have at least one hospital
admission in their last 6 months of life
 96% of Canadians believe it is important to have conversations with their
loved ones about their wishes for care
• 34% have actually had a discussion
• 13% have completed an Advanced Care Plan
CHPCA Fact Sheet – Hospice Palliative Care in Canada (2014)
Building capacity for palliative care
 A palliative approach to care should be practiced by all
providers caring for people with life-threatening illnesses
o Primary, Secondary and Tertiary care settings
o Community settings
 Not a “one size fits all” approach, but key common
elements
o Person-centred care
o Inter-professional team
o Single access point
o 24/7 care to ensure continuity & coordination
o Building community capacity
Regional Implementation – Results in
Alberta
 Edmonton & Calgary: 1993 to 2000
Hospice care
Results
• Health system costs
reduced
Costs
for last
year of
life
• Acute care costs reduced
(from 83% to 63% )
Services
Introduced:
Hospices
Community
consult teams
• In-hospital days reduced
(from 39 to 27 days)
Acute care
• # of deaths in acute
hospitals reduced
• # of home deaths
increased
Fassbender K et al. Utilization and costs of the introduction of system-wide palliative care in Alberta,
1993 to 2000. Palliative Medicine. 2005:19-513-520
Regional Implementation – Results in
Ontario
 Pockets of palliative care excellence in rural & urban
areas
 Community capacity building initiatives across Ontario
have created innovative programs
 A recent analysis of community based, specialist
palliative care teams found:
o Reduced acute care use
o Reduced hospital deaths at the end of life
What’s Next in Ontario
 The Provincial HPC Steering Committee & the Clinical
Council are now active
 HPC now a priority for system transformation in all LHINs
 All LHINs have committed to:
o 10% reduction in one or more of the following areas:
Overall palliative-related ALC days
Inpatient days per capita among patients that died in
hospital;
Palliative-related avoidable hospitalizations (repeat ER
visits/readmissions)
o Implementing regional HPC programs
 Work underway to develop palliative care indicators
Palliative Care In Our Region - SE
LHIN Regional Priorities
Strengthen capacity of local communities in providing hospice
palliative care
• Increase capacity in providing palliative care in all care settings
especially primary care
• Support the uptake of common palliative care plans, guidelines and
tools
• Promote use of shared information among care settings
Create regional mechanisms to enable early identification of patients
who would benefit from hospice palliative care
• Implement the adapted Gold Standards Framework for Early
Identification
Increase the understanding and implementation of Health Care
Consent and Advance Care Planning
Strengthen caregiver support including bereavement
Palliative Care in Our Region Resources
 Inpatient Consult Services
 Community Palliative Care Services
• CCAC – Nursing, PSW, SW, OT, PT, Dietician
• Physicians
 Inpatient Palliative Care Units
• SMOL PCU, Brockville PCU
 Community Hospices
• Inpatient, ambulatory
 Outpatient Ambulatory Clinics
• KRCC, Advanced dyspnea management clinic
 Hospice Palliative Care Nurse Practitioners
Community Palliative Care Services
 For patients with PPS < 50%
 FamMD makes CCAC referral
 FamMD +/- colleague follows patient at home and
provides 24/7 call coverage
 FamMD refers to community palliative care physician for
concurrent care or transfer of care
 Patients are seen same day to within 2 weeks depending on
urgency
 On referral, helpful to indicate whether you are requesting
community, PCU assessment or clinic visit. If unsure, feel free to
phone to suss out which might be most appropriate (548-2485)
 Helpful to indicate urgency, PPS, decline in PPS, symptom
issues, whether want concurrent vs. transfer of care
Palliative Care Unit – at SMOL
 13 beds – 10 private and 3 semi-private rooms
 All referrals are to go through the palliative care
office and are directed to the intake physician
who manages a running list
 Wait time often less than 2 weeks, can be as
soon as same day
 Patients at home get priority over patients
waiting at KGH
 Prognosis less than 3 months
 If survive longer, may get transferred to LTC
Palliative Care Clinic at KRCC
 Referrals from specialists (often oncologists),
Family MD
 For symptom management for ambulatory
patients (PPS =/>50%)
 For cancer-related symptoms or symptoms
related to cancer therapy
 Patient continues to receive primary care from
Family MD
Palliative MD is generally 1st contact regarding symptom
management issues
Hospice Palliative Care Nurse
Practitioners
“Would you be surprised if this patient
were to die in the next 6-12 months?”
No
What is your comfort level in providing
palliative care at home for this patient?
Yes
Do not refer at this time
I am comfortable and able to provide
home palliative care independently
I would like to provide home palliative
care but lack time and/or comfort/skill
level to do so independently
I do not wish and /or am not able to
provide home palliative care
Do not refer at this time
Consider referral to either:
1. HPC NPP for shared care where you
/your physician group provide(s) call
coverage
or
2. Queen’s Community Palliative
Medicine for consultation or shared care
with call coverage to be determined
Consider referral to Queen’s
Community Palliative Medicine to
assume care and provide call coverage
Some FAQs
What is a PPS and why is it important?
Do I have to have CCAC involved to care
for my patient at home?
 Yes – the short answer
 Why:
CCAC is the “umbrella” organization that
designates one of the nursing agencies to be the
first call to patients/families
Coordinate and provide OT/PT/SW support,
equipment (hospital beds, nebulizer machines etc)
Supplies needles, syringes, dressings, sc sets,
catheters, some personal care items, etc.
Patient not eligible for CADD pumps or SRKs
without CCAC involvement
Do I have to have CCAC involved to care
for my patient at home?
How to get CCAC support:
Fill in a CCAC Service Requisition
Can simply write: “please see for palliative
symptom assessment and management” and
the ball will start rolling
How many hours of CCAC PSW and
nursing support can my patient receive?
 Not 24/7 bedside care!
 CCAC’s “End-of-Life” Program
PPS less than 30
Life expectancy/need for 30 days or less
PSW - Up to 360 hrs allotted for 30 days or 12 hrs per
day
Nursing – visits as often as needed up to 4 times per
day
 Option of hiring PSW support and nursing
privately but lack of manpower and expensive
$60-80/hr for nurse
$30-40/hr for PSW
Compassionate Care Benefits





Family member at risk of dying within 26 weeks
Doctor completes application form
EI program
Benefits for up to a maximum of six weeks
To be eligible for compassionate care benefits, you must
be able to show that:
your regular weekly earnings from work have
decreased by more than 40 percent; and
you have accumulated 600 insured hours of work in
the last 52 weeks, or since the start of your last claim
(this period is called the qualifying period).
 The basic benefit rate is 55 percent of your average
insurable earnings, up to a yearly maximum insurable
amount ($48,600 in 2014). This means that, in 2014, you
can receive a maximum payment of $514 per week.
Compassionate Care Benefits
Do I have to refer my palliative patient at
home to the community palliative care team?
 No!
 If Dr. You is comfortable with and readily
available to provide symptom management and
end of life care to your patients at home, you can
do it
 You or a colleague covering for you must be
available to be called 24/7
 The Queen’s palliative care team has a
physician available to call for advice 24/7 (5482485 or ask for the PC doctor on call through the
KGH operator if after-hours)
Why do referrals to community palliative
care need to come from the Family MD?
 Specialists (eg. CTU resident discharging patient
home, oncologist at KRCC) can refer patient to
community palliative MD but must get
confirmation of agreement (verbal or in writing)
from patient’s Family MD
 To ensure Family MD is aware of situation and
give opportunity for Family MD to decide
whether prefer they vs. community PC follow pt
at home
 If a patient does not have a Family MD, any MD
can refer to community palliative care
What is a Symptom Response Kit and
how do I order one?
What is a Symptom Response Kit and
how do I order one?
Palliative Care Facilitated Access List
Can Bloodwork be done at home?
 Yes, but not urgent b/w
 Order on LifeLabs req and write HOME VISIT in the
“additional clinical information” area
 LifeLabs will come to patient’s home usually “within the
next week” – may be as soon as next day depending on
geography
 Results available day after b/w is done
 Costs the patient approximately $35 per visit
 Occassionally home care nurse can do b/w with an order
but only if b/w obtained via a PICC (generally don’t do
peripheral venipuncture anymore) and if b/w taken
immediately to lifelabs by nurse or family member
Can my patient receive IVF or blood
transfusions at home?
 Patients can receive fluid hydration at home –
set up by the nurses through CCAC
Requires faxed order to CCAC
NS is easiest to obtain (vs. 2/3 1/3, NS with KCl, etc)
IVF – can order if pt has IV access eg. PICC or Port-aCath. CCAC provides pump for administration
Hypodermoclysis – fluids run sc through a sc set by
gravity, generally overnight/over 8 hours
 Blood transfusions cannot be done at home, can
be done through ER or KRCC as outpatient (with
pre-orders)
What is a Yellow Folder?
SE LHIN initiative for “expected death at
home”
Contains information on who/when to call
for what situation
Contains SRK Rx
Contains DNR confirmation form
What is a DNR Confirmation Form and
does my DNR patient need one?
Does an MD need to pronounce and
complete the death certificate?
 In Ontario, in the case of an expected death and
the death is caused by the expected cause then
a nurse (RN or RPN) may pronounce
 A physician or NP’s order is required for this to
occur and the funeral home should be aware and
agreeable
 Once pronouncement has happened, the funeral
home will retrieve the body with or without the
death certificate
 A physician or NP is required to submit an
original copy of the death certificate to the
funeral home as soon as possible (usually within
24 hours)
Summary
Palliative care is growing in scope and
importance
By 2036, 25% of Canadians will be seniors
and many of them will need some form of
palliative care
Tools and resources are readily available
for primary care practitioners to provide
this care to their patients