Perspectives on Palliative Care
Timothy G. Ihrig, MD, MA
Medical Director, Palliative Medicine
Trinity Regional Health System
ihrigtg@ihs.org
Objectives
• Define the scope and role of palliative care as
specialized medical care for people with
serious illnesses
• Coordinate palliative care between
professionals and across institutional settings
Definition
Palliative care is specialized medical care
for people with serious illnesses. It is
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.
Palliative Care: Defined
Palliative care is provided by a team of
doctors, nurses, and other specialists who
work together with a patient's other doctors
to provide an extra layer of support. It is
appropriate at any age and at any stage in a
serious illness and can be provided along with
curative treatment.
Palliative Care: Defined
- Cancer
- Cardiac disease (Congestive Heart Failure)
- Chronic Obstructive Pulmonary Disease
- Kidney failure
- Dementia
- HIV/AIDS
- Amyotrophic Lateral Sclerosis (ALS)
Palliative Care: Defined
What is it?
1. Pain & Symptom Management
2. Communication/Counseling
3. Care Planning
Palliative Care: Pain & Symptoms
Pain & Symptom Management
–Sx’s: Nausea, Anorexia, Anxiety, Delirium, Diarrhea,
Dyspnea
–Education:
• O2 and the Management of Dyspnea
–Systems:
• Advocacy for opioid availability, including proper
dosing forms
Palliative Care: Communication
Communication
– Determining the Decision Maker or Process
–
–
–
–
–
Facilitating decision making
Determining Goals of Care
Preferred Intensity of Care
Delivering Bad News
Prognostication: Average MD overestimates by average of 5 fold
Counseling
–
–
–
–
–
Grief Counseling
Anticipatory Guidance
Parenting
Depression
Spirituality
Communication: Goals First!
Goals
Treatments
•
•
•
•
•
•
•
•
•
•
•
•
Cure
Restore Function
Maintain Function
Live Longer
Be at Home
Avoid Bankruptcy
See the birth of a
grandchild
Mechanical Vent
CPR
Electrical Cardioversion
Artificial Nutrition
Rehospitalization
Palliative Care: Care planning
Personalized Care:
1. Recommend treatment plans to match goals
– Don’t recommend treatments that won’t accomplish stated goals.
2. Facilitate Continuity of Care Plan Across Settings
–
–
–
–
Discharge Planning / Case Management
Clear documentation
Rational DNR/LLST Orders
POLST (Physician Orders for Life Sustaining Treatment)
Palliative Care: Myth of “giving up”
Harvard Oncology Group Study N Engl J Med 2010;363:733-42.
Patients who received Palliative Care:






Less Depression
Less Chemotherapy
Less Hospitalization
More Likely to Die at Home on Hospice
More likely to be DNR
Higher Quality of Life
 *Life Expectancy: 2.7 months longer!!!
Palliative Care: Expertise
• Physician: Board Certified Specialty (same as
Cardiology, etc)
• Nurse: HPNA, Hospice & PC Certification. ELNEC
Training
• Chaplain: Clinical Pastoral Education, Board
Certification
• Social work: Palliative Care Certification
• Administrator: Certification (NHPCO)
Palliative care: The Team
Interdisciplinary
Team
Unique model in health care:
• One Care Plan organized
by patient issue.
• Shared accountability for
all issues.
• Flat
• MD, RN, LVN, NP, LCSW,
Chaplain, Admin.,
Volunteer, Pharmacist
Multidisciplinary
Group
• Parallel Play
• Individual care plans
organized by specialty
• Hierarchical, with a
physician “In charge”.
• Minimal shared
accountability amongst
group members for
individual patient
outcomes
Palliative Care: Defined
Life Prolonging Care
Medicare
Hospice
Benefit
Life Prolonging
Hospice Care
Care
Palliative Care
Dx
Death
Old
New
Objective Two
Coordinate palliative care between
professionals and across institutional settings
A Year in the Life of a Patient
5
6
13
Social
Workers
Meds
Hospital
Admissions
Physical
Therapists
Nurses
Weeks SNF
Care
2
22
5
37
6
Nursing
Homes
19
5
Clinic Visits
Months of
Home Care
6
Community
Referrals
Source Johns Hopkins, RWJ 2010 (G Anderson)
2
Home Care
Agencies
4
Occupational
Therapists
16
Physicians
Coordinate
Why: Transitions in Care Concerns
• “Coordinating Care – A Perilous Journey through the Health Care
System” (T. Bodenheimer, MD NEJM 358 March 2008)
– 1/3 of patients with chronic illness and hospitalization had no
post discharge follow-up arrangements
– Less than ½ of PCPs were provided discharge information /
medications
– 3% of PCPs are involved in discussions with hospitalists
regarding patients’ discharge plans
– PCPs are infrequently notified that patient discharged
Why: Readmissions
- 1 in 5 Medicare patients re-hospitalized within
30 days of discharge
- Half of these occurred before seeing outpt MD
- Estimated cost 17.4 billion
Jencks, Williams, and Coleman
NEJM 2009, Vol 360, 1418-1428
Palliative Care Patients
Inpatient
Care
Services / Design Options for Palliative Care
Coordinate: Difficulties
Generalist Palliative Care: all clinicians
– “Routine” communication/symptom control
*** Specialty Pall Care ***
– Family meetings—esp. “difficult cases”
– Complex symptom management
– Time management
– Support for difficult decisions
Coordinate: Opportunities
What would the ideal look like?
- Efforts to broaden the spread of palliative care
principles through
1. early patient identification (triggers)
2. systems change to guide right care at right
time - routine family meetings
3. emphasis on more generalist palliative care
4. specialists for truly complex problems
5. quality improvement-data driven change
Coordinate: Opportunities
What would this look like to a patient?
- I am screened on admission for unmet pall care needs;
if present …
1. My primary providers have policy-defined roles in
the assessment of my pall care needs
2. My providers have the training to complete routine,
“generalist level” pall care interventions
3. My family is informed and engaged in the process of
care
4. Specialist Pall Care services are involved by hospital
standards, based on my condition/problems