Palliative Care
Cardinale B. Smith, MD, MSCR
Assistant Professor
Division of Hematology/ Medical Oncology
Tisch Cancer Institute
Brookdale Department of Geriatrics & Palliative
Medicine
Hertzberg Palliative Care Institute
Icahn School of Medicine at Mount Sinai
Palliative Care
• Specialized medical care for people with serious
illnesses.
• Focused on providing patients with relief from the symptoms,
pain, and stress of a serious illness - whatever the diagnosis.
• The goal is to improve quality of life for both the patient and
the family.
• Provided by a team of doctors, nurses, and other
specialists who work with a patient's other doctors to
provide an extra layer of support.
• Appropriate at any age and at any stage of a serious
illness, and can be provided together with curative or
disease directed treatments.
Palliative Care in Practice
• Expert control of pain and symptoms
• Uses the crisis of the hospitalization to
facilitate communication and decisions
about goals of care with patient and family
• Coordinates care and transitions across
fragmented medical system
• Provides practical support for family and
other caregivers (+ clinicians)
Old Model: Two types of care
Palliative /Hospice Care
Disease-focused Care
(“Aggressive Care”)
The Cure - Care Model:
The Old System
Life
Prolonging
Care
Palliative/ D
E
Hospice
A
T
Care
H
Disease Progression
A New Vision of Care
Disease Modifying Therapy
curative or restorative intent
Life
Closure
Diagnosis
Palliative Care
Death &
Bereavement
Hospice
Palliative Care
Palliative Care Is
 Excellent, evidencebased
medical treatment
 Vigorous care of
pain and symptoms
throughout illness
 Care that patients
want at the same time
as efforts to cure or
prolong life
Palliative Care Is NOT
Not “giving up” on a
patient
Not in place of
curative or lifeprolonging care
Not the same as
hospice or end-oflife care
Consumer Knowledge of Palliative
95% of respondents agree
Care
that it is important that
patients with serious illness
and their families be
educated about palliative
care.
92% of respondents say
they would be likely to
consider palliative care for
a loved one if they had a
serious illness.
92% of respondents say it
is important that palliative
care services be made
available at all hospitals for
patients with serious illness
and their families.
CAPC/ACS Public Opinion Survey, 2011
Significance of Palliative Care
• More patients with serious illness not imminently
dying, but living with chronic and debilitating
conditions
• Surveys of patients and families have identified
top needs:
•
•
•
•
Relief of suffering
Practical support needs
Open communication
Opportunities to relieve burdens and strengthen
relationships with families
Palliative Care – Relevance In
Context
Lifetime Risk of:
Heart disease:
1:2 men; 1:3 women (age 40+)
Cancer:
> 1:3
Alzheimer's:
1:2.5 – 1:5 by age 85
Diabetes:
1:5
Parkinson’s:
1:40
The Reality of the Last Years of Life:
Death Is Not Predictable
Cancer
End-Stage Organ Failure
Dementia (years)
100
Function
90
80
70
60
50
40
30
20
10
0
Time
(slide adapted from Joanne Lynn, MD, Rand Health/CMS)
Hospital Palliative Care:
The 5 Main Principles
1.
2.
3.
4.
5.
Clinical Quality
Patient and Family Preferences
Demographics
Education
Finances
Why palliative care?
1. The Clinical Imperative
The need for better quality of care for
people with serious and complex
illnesses.
Everybody with serious illness spends at
least some time in a hospital...
• 98% of Medicare decedents spent at least
some time in a hospital in the year before death.
• 15-55% of decedents had at least one stay in an
ICU in the 6 months before death. Average
length of stay in the ICU is 2-11 days.
Dartmouth Atlas of Health Care 1999 & 2006
Symptom Burden of Patients
Hospitalized With Serious Illness at 5
U.S. Academic Medical Centers
% of 5176 patients reporting moderate to severe
pain between days 8-12 of admission
Colon Cancer
Liver Failure
Lung Cancer
COPD
CHF
60%
60%
57%
44%
43%
Desbiens & Wu. JAGS 2000;48:S183-186.
Why palliative care?
2. Concordance with patient and
family wishes
What is the impact of serious illness on patients’
families?
What do persons with serious illness say they
want from our healthcare system?
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.
“Difficult” Conversations
Improve Outcomes
• Multisite, longitudinal study of 332 patient-family
dyads
• 37% of patients reported having prognosis
discussion at baseline
• These patients had lower use of aggressive
treatments, better quality of life, and longer
hospice stays
• Family after-death interviews showed better
psychological coping for those with
conversations as compared to those without
Wright et al. JAMA 2008 300(14):1665-1673
What Do Family Caregivers Want?
Study of 475 family members 1-2 years after bereavement
•
•
•
•
•
•
•
•
•
•
Loved one’s wishes honored
Inclusion in decision processes
Support/assistance at home
Practical help (transportation, medicines, equipment)
Personal care needs (bathing, feeding, toileting)
Honest information
24/7 access
To be listened to
Privacy
To be remembered and contacted after the death
Tolle et al. Oregon report card.1999 www.ohsu.edu/ethics
Families Want to Talk About Prognosis
• Qualitative interviews with 179 surrogate
decision makers of ICU patients
• 93% of surrogates felt that avoiding discussions
about prognosis is an unacceptable way to
maintain hope
• Information is essential to allow family members
to prepare emotionally and logistically for the
possibility of a patient's death
• Other themes:
• moral aversion to the idea of false hope
• physicians have an obligation to discuss prognosis
• surrogates look to physicians primarily for truth and
seek hope elsewhere
Apatira et al. Ann Intern Med. 2008;149(12):861-8
Why palliative care?
3. The demographic imperative
Hospitals need palliative care to
effectively treat the growing number
of persons with serious, advanced
and complex illnesses.
Chronically Ill, Aging Population
Is Growing
• The number of people over age 85 will double to
10 million by the year 2030.
• The 23% of Medicare patients with >4 chronic
conditions account for 68% of all Medicare
spending.
US Census Bureau, CDC, 2003
Anderson GF. NEJM 2005;353:305
CBO High Cost Medicare Beneficiaries May 2005
Hospital Based Palliative Care
Programs in the United States
63% of all hospitals and
85% of mid-large size
hospitals report a
palliative care team
100% of cancer centers
report a palliative care
team
Nation moves from a “C” grade
to a “B” in less than 5 years
Why palliative care?
4. The educational imperative
Every doctor and nurse-in-training
learns in the hospital.
Deficiencies in Medical Education
Specialty
Cardiology
Medical
Oncology
Palliative
Care and
Hospice
Number of
Fellowship
Positions
Number of
Fellowship
Programs
Number
of
Providers
779
175
25,901
486
130
14,000
234
85
4,400
http://www.nrmp.org/data/resultsanddatasms2012.pdf
Improvements in Education
• 2007 Board Certification in Palliative Care
• Medical school licensing requirement:
“Clinical instruction must include important
aspects of … end of life care (average 14
hours).”
Why palliative care?
4. The fiscal imperative
Hospital and insurers of the future will
have to efficiently and effectively treat
serious and complex illness in order to
survive.
Healthcare Spending and Quality
U.S. leads the world in per capita spending
27th in life expectancy
37th in overall quality of healthcare system (WHO)
http://ucatlas.ucsc.edu/spend.php
I’m afraid we’ve had to move him to expensive care
National Health Expenditure Growth
1970-2003
HCFA, Office of the Actuary, National Health Statistics Group, 2003
Costs and Outcomes Associated with Hospital
Palliative Care Consultation
8-hospital study
Live Discharges
Costs
Total Per
Day
Usual
Care
Palliative
Care
Hospital Deaths
P
Usual
Care
Palliative
Care
P
$1,450
$1,171
<.001
$2,468
$1,918
<.001
Directs Per
Admission
$11,1240
$9,445
.004
$22,674
$17,765
.003
Laboratory
$1,227
$803
<.001
$2,765
$1,838
<.001
ICU
$7,096
$1,917
<.001
$15,542
$7,929
<.001
Pharmacy
$2,190
$2,001
.12
$5,625
$4,081
.04
Imaging
$890
$949
.52
$1,673
$1,540
.21
Died in ICU
X
X
X
18%
4% <.001
Adjusted results, n>20,000 patients
Morrison et al. Arch Internal Med. 2008. 168 (16)
8 Hospital Study:
Costs/day for patients who died with palliative
care vs. matched usual care patients
Usual care
PC consult day 8-9
PC consult day 4-5
PC consult day 10-11
PC consult day 6-7
PC consult day 12-13
2000
Direct Cost ($)
1750
1500
1250
1000
750
500
250
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21
Day of Admission
Cost Savings – Medicaid in NY State
Cost savings/Day for Live Discharges
Morrison et al. Health Affairs 2011 30:454-63
U. Michigan- Hospice of Michigan
Palliative Care Reduces Hospital Costs
(patients with complete data as of July 1, 2002, at Medicare prices, excludes Rx)
How Palliative Care Reduces
Length of Stay and Cost
Palliative care:
• Clarifies goals of care with patients and
families
• Helps families to select medical treatments
and care settings that meet their goals
• Assists with decisions to leave the hospital, or
to withhold or withdraw treatments that don’t
help to meet their goals
Aug 19 2010;363(8):733-42
What Does All this Mean from the
Patient Perspective?
For patients, palliative care is a key to:
•
•
•
•
•
relieve symptom distress
navigate a complex medical system
understand the plan of care
help coordinate and control care options
allow simultaneous palliation of suffering along
with continued disease treatments (no
requirement to give up life prolonging care)
• provide practical and emotional support for
exhausted family caregivers
What Does All this Mean from the
Clinician Perspective?
For clinicians, palliative care is a key tool to:
• Save time
help to handle repeated, intensive patient-family
communications, coordination of care across
settings, comprehensive discharge planning
• Provide Symptom Control
assists with controlling pain and distress for highly
symptomatic and complex patients, 24/7
-thus supporting clinician’s treatment plan
• Promote Satisfaction
increases patients’ and families’ satisfaction with the
quality of care provided by the clinician
What Does All this Mean from the
Hospital Perspective?
For hospitals, palliative care is a key tool to:
• effectively treat the growing number of people
with complex advanced illness
• provide excellent patient-centered care
• increase patient and family satisfaction
• improve staff satisfaction and retention
• meet accreditation and quality standards
• rationalize the use of scarce hospital resources
• increase bed/ICU capacity, reduce costs
But……….
• Disparities in access to palliative care
• Lack of a solid evidence base to guide
clinical care and care delivery
• Lack of research funding to support
needed research
• Need for public advocacy and public and
professional education
Research Publications: Oncology and
Palliative Care (2003-2005)
Gelfman LP, Morrison RS. J Palliat Med, 2008
Summary
• Palliative care improves quality of care for
our sickest and most vulnerable patients
and families.
• Serious illness is a universal human
experience and palliation is a universal
health professional obligation.
"When we honestly ask ourselves which people in our
lives mean the most to us, we often find that it is those
who, instead of giving advice, solutions, or cures, have
chosen rather to share our pain and touch our wounds
with a warm heart and tender hand. The person who
can be silent with us in a moment of despair or
confusion, who can stay with us in an hour of grief and
bereavement, who can tolerate not knowing, not curing,
and face with us the reality of our powerlessness, that is
a person who cares.”
-Henri Nouwen