Docstoc

Palliative Care Competencies

Document Sample
Palliative Care Competencies Powered By Docstoc
					Palliative Care


    Stephen Bernard, MD, FACP
     Chip Baker RN, MS, NP-C
The Nature of Suffering and the Goals of
Medicine
           -- Eric J. Cassell
 The relief of suffering and the cure of disease
   must be seen as twin obligations of a medical
   profession that is truly dedicated to the care
   of the sick. Physicians‟ failure to understand
   the nature of suffering can result in medical
   intervention that, though technically
   adequate, not only fails to relieve suffering
   but becomes a source of suffering itself.
What is palliative care?
Interdisciplinary care to improve quality
  of life for patients with advanced illness
  and for their family.
  •   pain and symptom management
  •   emotional and spiritual support
  •   help with difficult treatment decisions
Palliative Care

   Pain Management
   Anorexia/Cachexia
   Nausea and vomiting
   Dyspnea
   Constipation/Bowel Obstruction
   Delirium
What patients want
 Patients with life-limiting chronic illness (n=126)
   say their primary goals are:
 • receiving adequate pain management

 • avoiding prolongation of dying

 • achieving sense of control

 • relieving burdens

 • strengthening relationships

                         Singer PA et al. JAMA 1999; 281:163-168
       Patient Concerns
   Pain (80%)
   Fatigue (90%)
   Weight Loss (80%)
   Lack of Appetite (80%)
   Nausea, Vomiting (90%)
   Anxiety (25%)
   Shortn’s of Br’th. (50%)
   Confus’n-Agitation (80%)
Honest communication

 “Being honest is a big deal. She never
   had a clue that she was that close to
   the end. I think doctors should have
   told her that death was close. She
   never had the chance to say good-bye.”
               -- recently bereaved family member
       When is palliative care given?
                               Hospice
               Rx to
           Modify disease




                            Palliative Care

Presentation                       6m Death

        Palliative Care Program      Bereavement Care
Hospice and Palliative Care

   Hospice                       Palliative Care

    < 6 months prognosis           Intervention early,
    “if the disease follows        no time frame
    its expected course”           Concurrent with active
                                   treatment
    Narrower definition of
                                   Can include interventions
    interventions                  such as radiotherapy
    Home, inpatient facility       Hospital, home, or
                                   nursing facility
UNC Palliative Care Service
 Walter (Chip)    Laura Hanson
  Baker            Renae Stafford
 Stephen          Gary
  Bernard           Winzelberg
 Tony Caprio

 June Dixon
UNC Palliative Care Consults –
New Patients Served
New Patients Served:
  2002   –   47 patients
  2003   –   110 patients
  2004   –   142 patients
  2005   –   143 patients
  2006   –   220 patients
  2007   –   192 patients (total visits = 551)
  2008   –   est. 325 patients (total visits = 870)
Pall. Care Program
Demographics
               Comparison UNC,
      Mt Sinai Palliative Care Programs--I
                     UNC                                 Mt. Sinai
                    N=304                                N=325

Period of           36 mos                                15 mos
Obs

Median Age             66                                     71



Female                58%                                   47%

African-              28%                                   26%
American
Hispanic                                                    20%

Protestnt.                                                  11%

  Manfredi, P, J Pain & Syx Mgmt, 2000; Hanson, L, J Pain & Syx Mgmt, 2008
 Comparison UNC, Mt Sinai
 Palliative Care Programs II
                     UNC                                 Mt. Sinai
                    N=304                                N=325
Period of           36 mos                                15 mos
Obs

Cancer                61%                                   57%


Cardiovasc.           13%                                    4%


Neurologic             5%                                   17%
(Dementia,
Stroke)
   Manfredi, P, J Pain & Syx Mgmt, 2000; Hanson, L, J Pain & Syx Mgmt, 2008
Distribution of Patients Seen by County
   Pain and Symptom Care Service: 2002




                              2 2 1 2
                       7 20 6     1
                              11      2
                    1   9           3
                         6 4     2
                      2
                            2           1
                          2 2          1
                                    1
                                2
   Pall. Care Program Reasons
   for Consult 2002-2005




Hanson, L, J Pain & Symptom Mgmt, 2008
Pall. Care Program Patient by
Service-2002
UNC Palliative Care Consults
by Service - 2007
UNC Palliative Care Consults
by Disease Group - 2007
Outcomes of Consultation-UNC Palliative
Care Service
          2002 and 2005 ( as %)
              2001-2002           2002-2005
                N=132               N=304
All Recs         89                  88
Implmented
Existing                             57
DNR-
New DNR          44                  26

Comfort          51                  34
Care Orders

UNC Pall Care Program, and Hanson, L, J Pain &
Syx Mgmt, 2008,
Mt. Sinai, Results of Pall Care
Consultation




 Manfredi, P, J Pain & Syx Mgmt, 2000
           Improvement in Symptoms for 2500 Mount
           Sinai Hospital Patients Followed by the Palliative
           Care Service (6/97-10/02)
 Severe
                                                  Pain
                                                  Nausea
Moderate
                                                   Dyspnea

   Mild



   None
UNC Pall. Care Program
Symptom Scores
UNC Palliative Care Consults –
Disposition 2002
UNC Palliative Care Consults –
Disposition 2007
 Disposition of Pts on UNC Pall
 Care Consultation Service-2002;
 2007 (as %)
             2002          2007
            N=134         N=192
  Died        41            30
 Home        30            22
  Home       19            22
  Hosp
Inpt Hosp                   7
  SNF        10            10
SNF Hosp                    6
Variable Cost/Day: PC Cases vs. NonPC Controls
Cases &     Cost/Day     Cost          % Cost    P-Value
Controls    ($)          Svng/Day      Reduc‟n
104 PC      897          107           10.7      0.03

1813        1,004
nonPC
66          850          102           10.7      0.02
PC,>25%
LOS
1127        952
nonPC
37          805          205           20.5      0.002
PC>50%
LOS
680 non     1,010
PC



  Hanson, L, J Pain & Syx Mgmt, 2008
Economic Impact of Palliative
Care-UNC, 2008




Hanson, L, J Pain & Syx Mgmt, 2008
PSCP target population
•   Patients with life-limiting incurable
    diseases
•   Patients with severe pain and other
    symptoms
•   Patients with severe psychological or
    spiritual suffering
Website for Conversion of Opioids




   http://www.hopweb.org/
Palliative Care Competencies

    Chip Baker RN, MS, NP-C
          August 2008
Palliative Care Competencies
   Palliative care is practiced with specific
    knowledge and skills including:
       Communication
       Symptom Management
       Psychosocial and spiritual support
       Medical and social service coordination

                              Morrison, RS, NEJM 2004
Case 1
   38 yo female with PMHx significant for
    myasthenia gravis dx in 2005.
    Refractory to all chemotherapy. Bed
    bound, anorexic, on trach collar with
    frequent mucous plugging. She has
    considered stopping treatment and
    states that she is „tired‟ and „wants to
    die‟.
        Case 1
   Challenges
       Moved from California to NC for treatment
        which has ultimately failed
       Husband not supportive, but wants her to
        „keep fighting‟
       2 children - aged 6 (at home) and 15 (back
        in California with her mother)
       Refusing Plex treatments at times with
        resulting symptom flares
Case 1
   Celexa 20mg PO QD
   Fentanyl 25mcg patch
   Atrovent nebs q4h
   Percocet 5/325 ii tabs PO q4h prn
   Zofran 4mg IV q8h prn
   Klonopin 0.5mg PO TID prn
   Ambien 5mg Po QHS prn
    Case 1
   ROS
        HAs with fentanyl patch but not with IV
        Anxious and Fatigued
        N&V intermittent with flares secondary to chemo
        Cough with chest tightness and pain
   PE
        RUE swollen, warm w/erythema, exquisite
         tenderness
        40% Trach collar; POX 97%; RR 26-30
        Lungs with diffuse bilateral rales and rhonchi
        Self suction x 4 during exam
Case 1
   Issues
       Symptom management
            Pain
            Dyspnea
            Anxiety
            Depression
       Goals of care
            Is Clinical Depression driving GOC?
       Discharge Disposition
    Case 1
   Plan
       Psych consult to R/O clinical depression
       Aggressive Symptom Management
            Switch to all IV fentanyl – 25mcg q3hrs prn
            Tylenol 1g PO Tid
            Scheduled Zofran
            Scheduled Klonopin 0.5mg PO q12h
       Goals of care
            Conversation with pt, mother (on phone from
             California), nurse, Neurology, and Psychiatry
Case 1
   Outcome
       Placed on comfort care
       Pt taken off trach and went home that
        night.
       Hospice services started next day.
       She died 9 days later.
Case 1
   Question to consider:
       When is it grief vs. depression?
    Grief vs. Depression
Grief:                   Depression:
 Distress related to     Generalized distress –

  loss –a normal           loss of interest,
  response                 pleasure
                          Somatic distress plus
 Some physical
                           hopelessness, guilt,
  symptoms of distress     suicidal ideation
 Still able to look      No sense of positive
  towards the future       future
      Grief vs. Depression
Grief:                      Depression:
 Associated with            Advanced disease
  disease progression         and pain

   Retains capacity for       Change in capacity to
    pleasure                    enjoy life or former
                                pleasures
   Still able to express      Bored, lack of
    feelings and humor          interest and
                                expression
Grief vs. Depression
Grief:                   Depression:
 Comes in waves          Constant,
                           unremitting
   Passive wish for        Intense and
    death                    persistent suicidal
   Can cope with            ideation
    distress on own or      Requires
    with supportive          intervention –
    listening                medication, therapy
Case 2
   71 yo male with PMHx sig for stage IV
    NSC Lung Cancer with metastases to
    thoracic spine, cerebellum, and liver.
    Post combination radiation/chemo.
    Respiratory arrest in the field. Intubated
    and transferred to MICU. Stay c/b
    probable aspiration pneumonia and
    intractable back pain. Decision made by
    family for terminal ventilator wean.
Case 2
   Challenges
       Requiring high dose Opiates
       Large supportive family
            Decisions made as a family
       Family hanging on every movement of
        patient
            Erratic movements seen as pain
       Survival of patient beyond predicted
        prognosis
Case 2
   Morphine IV 5mg/hr in MICU titrated up
    to to 10mg/hr with 2mg boluses q
    1hour on the floor
    Case 2
   ROS
        „Jerking episodes‟ as per family not witnessed by
         staff
   PE
        Unresponsive
        Cardiac - RRR - 90
        Breathing with rattle – RR 14 even
        Skin warm and dry
        Widely scattered, brief UE and LE dyskinetic mvts
             Witnessed tonic-clonic episode
Case 2
   Issues
       Symptom management
            Is this pain?
       Family support and education
    Case 2
   Plan
       Secretions – Scopolomine 1.5mg patch
       Myoclonus – opiate induced
            Reduce Morphine IV by 25% to 7mg/hr
                 Continue titration downward or opiate rotation if
                  movements continue
            Suggest to nursing to use respiratory distress
             as trigger for Morphine boluses.
            Family education and support.
Case 2
   Outcome
       No more tonic-clonic episodes
       Minimized dyskinetic movements
       Family verbalized less anxiety
       Pt died in 3 days
            10 days after extubation
Case 2
   Question to consider:
       When is opiate rotation useful?
   OPIOID CLEARANCE AND
   ACTIVITY
  Agent        Met.        Met/Kidney   ?ON
 Morph.      3,6 gluc.         +        +
 Oxycod.    O,N demeth.        +        +
Hydromorp   3,6, and nor      +?        +
Methadone    N demeth          -         ?
 Fentanyl    N demeth.         +        +
 Codeine      O, 15%           +        +
              Morph.
Case 3
   80 yo female with nonoperable
    pancreatic mass obstructing the biliary
    tree. Past medical history
    unremarkable. Call for assist with
    symptom mgt, patient/family support
    and discharge disposition.
    Case 3
   Challenges
       Relatively clean health history
       Lives in Halifax county with husband who is 85
        and with mild dementia
            2 daughters near by to assist with care
       3 stents placed/replaced (3/06, 5/06, 5/07) with
        good results of relieving symptoms
       Does not want to transition to hospice because
        does not want to surrender possibility of future re-
        stenting
       Refusing SNF placement
       Goal to get OOB and care for household
Case 3
   ASA 325mg PO OD
   Nexium 40mg PO OD
   Pancrease I PO TID with meals
   Percocet 5/325 ii tabs PO q4h prn pain
   Morphine IVP 2mg q2h prn pain
Case 3
   ROS
       Nausea with anorexia
       Constipation
       Denies pain or pruritis
       Dizziness when OOB
   PE
       Exquisite jaundice – total bili 36.0
       Significant deconditioning
Case 3
   Issues
       Symptom Management
            Pain
            Nausea
            Anorexia
            Fatigue
       Goals of care
            Are her goals realistically unobtainable?
       Discharge Disposition
Case 3
   Plan
       Pain
            Change Percocet to Oxycodone elixir
            Bowel regimen
       Deconditioning
            PT/OT eval
       Nausea
            Reglan tid
            Pancrease tid
       D/C plans
Case 3
   Outcome
       Found a hospice agency that would
        support PT/OT and pursuit of stent
        replacements for symptom relief (would
        not pay room and board)
       D/C home with hospice
       Died 2 weeks later
Case 3
   Question to consider:
       Are all hospices created equal?
Case 3
   Hospice
       2006 49% not-for-profit; 46% for profit
       Medicare funding
            Based on area wage index
            Based on level of care
                 Home $130.79 day
                 Continuous home care $763.36 day
                 Inpatient Respite $135.30 day
                 General inpatient $581.82 day
            Medicare per patient cap
                 Based on number of patients
                     2006 mean daily census 45.6 patients

                     16.2% of providers routinely care for more than 100

                      persons