Primary
Palliative Care
Capital Region
Family Medicine Conference
September 8, 2012
Objectives

Describe shared skills of palliative care and
primary care

Identify useful communication techniques

Medical Orders for Life Sustaining Treatment
Diagnosis ------- Chronic Illness ---- Death
Curative Efforts
---------------------
Life Prolonging Measures
----------------------------------------
Palliative Care
(Hospice)
----------------------------------------------------------------
Russell Portenoy, MD
All of hospice
is palliative
care, but not
all of
palliative
care is
hospice
Palliative
Care
Hospice
“ The American College of Chest
Physicians strongly supports the
position that palliative and end-of-life
care of the patient with an acute
devastating or chronically progressive
pulmonary or cardiac disease and
his/her family should be an integral part
of cardiopulmonary medicine.”
Chest 2005 / VJ Vanston AAHPM 2010


40% report acute and chronic pain at levels
similar to patients with cancer
23% report neuropathy, fatigue, depression,
sleep disturbance
“Diabetes care management should include
not only good cardiometabolic control, but
also symptom palliation across the disease
course.”
J General Internal Medicine Aug 2012
Newly dx’d ambulatory metastatic non-small cell lung cancer
MGH
Standard treatment vs. Standard treatment + palliative care
Intervention group
better QOL scores
lower rates of depression
2.7 month survival benefit
less chemotherapy
Temel, et al NEJM Aug. 2010
Hospital based interdisciplinary teams – MD, NP, RN, SW, PC
89% of hospitals > 300 beds
Palliative Care Skill Set
Advance care planning
Symptom Managment
Establishing patient-centered / realistic goals of care
Appropriate level (setting) of care
Coordination of care
Palliative Care Information Act
2/2011
Public Health Law section 2997-c requires the "attending
health care practitioner" to offer to provide patients with a
terminal illness with information and counseling regarding
palliative care and end-of-life options appropriate to the
patient, including:
Prognosis;
Range of options appropriate to the patient;
Risks and benefits of various options;
Patient's "legal rights to comprehensive pain and
symptom management at the end of life."
http://www.health.ny.gov
Case Study
88 year old female
Dementia, HBP, osteoporosis, hyperlipidemia,
anemia, arthritis, impaired nutrition
Assisted living facility
June 2008
sent to ER for increased confusion - uti
MRI/Neuro consult/ EEG/ carotid US
Discharge meds: Iron, Nexium, Norvasc, Fosamax,
Zocor, Folic Acid, Levaquin, Aricept, Aspirin
Sept 2008
Sent to ER for lethargy
Hematemesis and aspiration pneumonia
GI consult EGD – severe esophagitis
Pulmonary consult CT, thoracentesis
IV antibiotics
Discharge meds: Zocor, Aricept, Nexium,
Cardiezem, Norvasc, Fosamax
November 2008
Sent to ER for lethargy and anemia
Contracted, minimal verbalization
4 stage III-IV pressures sores
Urinary tract infection
Family contacted
HC Proxy and Living Will
Comfort and Returning to Community
Stopped Fosamax, Zocor
Started RTC pain medicine, Wound care
Allowed to eat as tolerated
NonHospital DNR
Hospice referral
Quality in healthcare is defined as:
Patient-centered
Timely
Beneficial
Equitable Safe Efficient
National Quality Forum www.qualityforum.org
Institute for Healthcare Improvement www.ihi.org
Medicine used to be simple,
inexpensive, and relatively safe.
Now its complex, effective, and
potentially dangerous.
Sir Cyril Chantler
Hospitalization-Associated
Disability
Covinsky, Pierluissi, Johnston
JAMA
October 2011
“occurs in approximately one-third of patients
older than 70 years of age and may be
triggered even when the illness that
necessitated the hospitalization is successfully
treated.”
Patient vulnerability and capacity to recover
Age
Poor mobility
Cognitive function
ADLs Social functioning Depression
Geriatric syndromes (falls, incontinence)
Severity of Illness
Hospitalization Factors
Environment
Restricted mobility
Enforced dependence Undernutrition
Little encouragement of independence
Covinsky, Pierluissi, Johnston
Polypharmacy
JAMA October 2011
Don’t underestimate your role
Let the patient set the agenda
Encourage discussion and completion of
advance directives
“Hope for the best but be prepared for the
worst”
Goals of Care Shift –Time for
Discussions
43% 1 year mortality rate after hospitalization for AECOPD
with pCO2 > 50
17-20% 1 year mortality from dx of CHF
25-30% 1 year mortality rate following Hip Fracture
2 month median survival when majority of day in bed or
chair in patients with metastatic cancer
What Do Patients with Serious Illness
Want?
Pain and symptom control
Avoid inappropriate prolongation of the dying
process
Achieve a sense of control
Relieve burdens on family
Strengthen relationships with loved ones
Singer et al. JAMA 1999;281(2):163-168.
D Meier , CAPC 2009
Factors that Influence Hope
Decrease Hope
Feeling diminished as a
person
Abandonment and
isolation
Lack of direction
Uncontrolled pain and
discomfort
Increase Hope
Feeling valued as a person
(reminiscence)
Meaningful relationships
(humor)
Realistic goals
Pain and symptom relief
Oxford Textbook of Palliative Medicine
http://www.oncotalk.info/
Robert Arnold, MD
Director of the Institute of Doctor-Patient Communication at the University of Pittsburgh
http://www.oncotalk.info
James Tulsky, MD
Director of the Center for Palliative Care at Duke University
http://www.oncotalk.info/
Communication Techniques
Sit Down
Maintain eye contact
“Active” Listening
Pause
Manage emotion
Normalize feelings
Reflect patient’s own words
Factual Questions / Expression of Emotion
Fire a “warning shot”
Hospitalizations During Last 6 months of Life Medicare Patients 2007
Percent of Decedents Admitted to ICU/CCU
During the Hospitalization in Which Death Occurred
2007 Medicare Patients
20% of all deaths
in the US
occur in the ICU
or shortly after an
ICU stay
Angus CritCareMed 2004
The
4
Stages
of
Man
Advance Care Directives
For All Adults
Health Care Proxy Form
Living Will
Organ Donation
(optional)
For Those Who Are
Chronically Ill or
Near the End of Their Lives
Nonhospital Do Not Resuscitate
(DNR) Order
Medical Orders for Life
Sustaining Treatment
(MOLST) form
POLST/MOLST
Communication
Documentation
System Responsiveness
Core Elements of MOLST
Actionable medical orders
Advanced, chronic progressive illness
Limit or request all medically treatments
Direction about resuscitation status
Other types of intervention – future
hospitalizations, tube feedings
POLST Research findings
Oregon
Effectively communicates requests for DNR, comfort
measures
Frail elderly make reasonable choices
Not all or none
(JAGS, J Gerontol Nurs 2000-2004)
Oregon, W Virginia, Wisconsin
Less likely to receive unwanted hospitalization and medical
interventions
(Hickman, JAGS July 2010)
POLST 2006
Paradigm of communication, documentation, and system responsiveness
Paradigm of communication, documentation, and system responsiveness
POLST Paradigm Program 2006 POLST.org
POLST 2012
http://www.ohsu.edu/polst/programs/state+programs.htm accessed 4/2012
Slide courtesy of P Bomba, MD April 2012
State of N ew Y ork
D epartm ent of H ealth
N onhospital O rder N ot to Resuscitate
(D N R O rder)
Person's N am e:___________________________________
D ate of Birth: _____/_____/_____
D o not resuscitate the person nam ed above.
Physician's Signature ____________________
Print N am e _________________________
License N um ber ____________________
D ate _____/_____/_____
It is the responsibility of the physician to determ ine, at least every 90 days, w hether this
order continues to be appropriate, and to indicate this by a note in the person's m edical
chart.
The issuance of a new form is N O T required, and under the law this order should be
considered valid unless it is know n that it has been revoked. This order rem ains valid and
m ust be follow ed, even if it has not been review ed w ithin the 90 day period.
D O H -3474 (2/92)
Accepted in outpt
settings but…
Does NOT include
DNI
Does not cover
additional Rx’s
1 in 20 children
will experience
the death of a parent
by the time they graduate
from high school.
Free Bereavement Resources
Does NOT have to be a Hospice patient
Wave Riders
K -3rd grade 4th -8th grade
Teens
At schools during the day; referrals thru school
social worker
At Local Hospice office
Kids
Parents/guardians are in their own group ..how to
help their children and to support themselves in their
grief.
1.
2.
3.
Decrease isolation
Normalize grief
Provide a framework for remembrance and
meaning-making
Resources
compassionandsupport.org
MOLST, advance directives, patient/family friendly
eperc.mcw.edu/EPERC/FastFactsandConcepts
pain and symptom management, ethics,
communication skills