Practice Support Program
End of Life
Learning Session 1
1
Acknowledgements
• Practice Support Program End of Life Committees:
Dr. Cathy Clelland, Chair, Sheila Balson, Andy Basi, Sherry Bar, Dr. Doris
Barwich, Dr. Clifford Chan-Yan, Louise Donald, Dr. Ian Courtice, Dr.
Romayne Gallagher, Dr. Neil Hilliard, Pamela Hinada, Dr, Bruce Hobson, Dr.
Marcus Hollander, Judy Huska, Pauline James, Dr. Marnie Jacobsen, Dr.
Helena Kadlec, Liza Kallstrom, Dr. Douglas McGregor, Dr. Chris Rauscher,
Pat Porterfield, Della Roberts, Christina Southey
• BC Hospice Palliative Care Association Learning
Centre for Palliative Care: Hospice Palliative End-ofLife Primary Care Provider Education Project
• Fraser Health End of Life Care Program: Advance Care
Planning Initiative
• Gold Standards Framework
(http://www.goldstandardsframework.nhs.uk)
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Why we are here
(25 minutes, including patient/family
voice and the module aim)
3
Session opening
• Introductions
• Housekeeping
• Personal experience with PSP End of Life
4
Module aims
To improve the care of patients and families
living with, suffering and dying from life-limiting
and chronic illnesses by:
 Identifying patients early who could benefit from a palliative
approach to care
 Enhancing GP & Specialist confidence and communication skills
to enable Advance Care Planning (ACP) conversations.
 Improving the experience of health care providers, patients and
families:
o Assessing patient and family needs from a palliative perspective.
o Improving the experience of the patient, family, physician, MOA and
healthcare providers in End of Life care.
o Improve physician confidence related to End of Life
care (e.g. care planning, forms).
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Module aims
To improve the care of patients and families living with,
suffering and dying from life-limiting and chronic
illnesses by:
 Improving collaboration:
o Identifying and referring appropriate patients to specialty palliative
care and others for consultation and services.
o Understanding provider needs, clarifying roles, tools and resources
for practice support and collaboration.
“Integration
o Improving collaborative care planning, coordination and
in Action”
communication with patients/caregivers and physicians and other
local health care and community providers.
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PSP End of Life Care Algorithm
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Case study: Mr. James Lee and his wife
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Patient/Family’s voice video
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End of Life Care:
Expanding the scope
(30 min. for this section plus Palliative
approach to life-limiting disease
section)
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Changing face of dying
We are living longer. By 2025:
• 30% of the population >65.
• 33% increase in deaths over
2004.
• 2/3 will die with 2 or more chronic
diseases after months or years in
state of “vulnerable frailty”.
• Only 20% of us will die with a
recognizable terminal
(“palliative”) phase.
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Cause of deaths in Canada
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End Stage Organ Failure:
Approaching End of Life
Terminal
Phase
Function
High
Low
Begin to use hospital more
often, self-care more difficult
Death
Time ~ 2-5 years.
Death usually seems “sudden”
Modified from Lunney JR et al. JAMA 2003: 289: 2387.
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Ambiguous dying
“There will not be a distinct terminal phase.
The week we die will start out like any other and some unpredictable
calamity will occur. Amongst those of us with advanced heart failure,
we will have had a 50-50 chance to live for six months on the day
before we died”
Joanne Lynn:
Sick to Death and Not Going to Take it Anymore (2004)
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The Palliative Approach
to life-limiting illness
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Canadian Hospice Palliative Care Association:
Model of care (2002) www.chpca.net
Disease-modifying therapy
Bereavement
Care
Palliative Approach to Care
Diagnosis of
life-limiting
illness
Death
Illness trajectory
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WHO definition of palliative care
Palliative care is an approach that improves the
quality of life of patients & their families facing the
problem associated with life-threatening illness,
through the prevention and relief of suffering by
means of early identification, impeccable
assessment & treatment of pain and other
problems, physical, psychosocial and spiritual.
http://www.who.int/cancer/palliative/definition/en/
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The Palliative Approach:
Living Well; Dying Well; and Bereavement
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Palliative Approach
Guided by person centered goals of care:
1. Pain and symptom management.
2. Psychosocial care for person.
3. Psychosocial care for family.
4. Spiritual care.
5. Disease management.
6. Preparing for and managing dying.
7. Bereavement.
(Canadian Hospice Palliative Care Association: Norms, 2002)
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Patient journey in comprehensive
heart failure care
Copyright ©2009
Goodlin, S. J. J.A.C.C. 2009;54:386-396
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Palliative Approach:
Care through all the transitions
Early
Chronic Disease
Management
Hope for cure
survivor
Decompensation
Disease advancement
experiencing life limiting illness
Complication indicators
Seniors at risk
Dependency and symptoms
increase
PPS
ESAS
Home care
BC Palliative benefits
Transition 1
Transition 2
Transition 3
Decline and last days
Transition 4
Death and
bereavement
Transition 5
Time of
Diagnosis
Time
McGregor and Porterfield 2009
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Best practice: Integrating the palliative approach
• Concurrent palliative and
disease modifying care.
• Elimination of the “terrible
choice”.
• Advance Care Planning and
patient centered decision
making.
• “Sick enough to die” rather
than “certain to die”.
Melanie Merriman PH.D. MBA
NHPCO Conference Fall 2003
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Best practice: Collaborative and interdisciplinary
Palliative Care Australia
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Outcomes: Palliative approach to care
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Improved quality of life
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Improved survival
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Outcomes
• “Good death” in the most appropriate location.
• Better pain and symptom management.
• Better long term outcomes for bereaved
relatives.
• Improved experience of care.
• Better quality of care.
• Lower health care costs.
Zhang et al. Arch Intern Med Vol 169(5) Mar 9 2009:480-488
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BC Guidelines.ca
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Table discussion (15 minutes)
• Introduce yourself and how you are involved with
patients with chronic and life threatening illness.
• Identify what you hope to get out of the session
today to improve the care of patients in relation to
considering palliative/supportive care needs.
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Table discussion (continued)
Think about your self-audit OR a recent death
of a non-cancer patient you were involved with`
• Were you satisfied with the experience?
 If so, what made it work?
 If NOT satisfied, why not?
• What were some of the gaps in clinical care?
• What could have been done differently?
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