Adva nc e d I llne ss Co nve rsa tio ns Wha t Wo uld Be a Go o d - PowerPoint PPT Presentation

Adva nc e d I llne ss Co nve rsa tio ns Wha t Wo uld Be a Go o d Da y F o r Yo u E nd-o f-life Co nve rsa tio ns Cla re Ha wkins, MD, MSc , F CF PC, F AAF P We st Re g io n Me dic a l Offic e r, Aspire He a lth 2020 T e xa s F a mily Me dic ine Sympo sium T e xa s Ac a de my o f F a mily Physic ia ns

Disc lo sure  Dr. Ha wkins ha s disc lo se d tha t ne ithe r he no r me mb e rs o f his imme dia te fa mily ha ve a ny a c tua l o r po te ntia l c o nflic t o f inte re st.

Ob je c tive s By the e nd o f this e duc a tio na l a c tivity, the le a rne r sho uld b e b e tte r a b le to :  Re vie w princ iple s o f a dva nc e c a re pla nning  Appre c ia te the na ture o f a n e vo lving c o nve rsa tio n o ve r multiple visits  I te mize stra te g ie s tha t e nha nc e e ffe c tive ne ss o f a dva nc e dire c tive disc ussio ns

5 W’ s  Why : Be c a use o f unwa nte d c a re a t e nd o f life  Who : Pe o ple with Adva nc e d I llne sse s  “T he surprise q ue stio n” Whe n : E a rlie r tha n yo u think a nd mo re tha n o nc e  e : Yo ur o ffic e o r ho spita l  Whe r What : Se q ue ntia l, se nsitive E OL c o nve rsa tio ns   How :… E a sie r tha n yo u think!

Dispro po rtio n  90% o f pe o ple sa y tha t ta lking with the ir lo ve d o ne s a b o ut e nd- o f-life c a re is impo rta nt. 27% ha ve a c tua lly do ne so .  60% o f pe o ple sa y tha t ma king sure the ir fa mily is no t b urde ne d b y to ug h de c isio ns is e xtre me ly impo rta nt.  56% ha ve no t c o mmunic a te d the ir e nd-o f life wishe s 80% o f pe o ple sa y tha t if se rio usly ill, the y wo uld wa nt to ta lk to the ir do c to r a b o ut wishe s fo r me dic a l tre a tme nt to wa rd the e nd o f the ir life .  7% re po rt ha ving ha d this c o nve rsa tio n with the ir do c to r  82% o f pe o ple sa y it’ s impo rta nt to put the ir wishe s in writing . 23% ha ve a c tua lly do ne it.

Why  Re se a rc he rs & physic ia ns a g re e tha t to o ma ny pe o ple in the U.S. re c e ive tre a tme nts the y ne ve r wo uld ha ve wa nte d  T re a tme nts tha t do n’ t a lig n with the ir va lue s a s the y ne a r de a th  Mo st wo uld pre fe r to spe nd the ir fina l da ys a t ho me , surro unde d b y lo ve d o ne s  70% o f pe o ple die in ho spita ls, nursing ho me s a nd lo ng -te rm c a re fa c ilitie s

Whe n  Be g in we ll b e fo re a pe rso n b e c o me s ill  I t c a n b e diffic ult fo r b o th pa tie nts a nd the ir fa milie s to think c le a rly o nc e a he a lth c risis hits  “I t’ s b e tte r to wo rk thro ug h e nd-o f-life issue s while pe o ple a re still a live so tha t [fa mily me mb e rs] c a n lo o k b a c k a nd fe e l tha t the y did it rig ht,” sa ys I ra Byo c k  As pa rt o f c a ring fo r pa tie nts with a dva nc e d illne sse s (CHF , COPD, E SL D, E SRD)

“Crysta l Ba ll” T e lling the F uture  Humility, we ne ve r re a lly kno w  Quo te ra ng e s, da ys to we e ks, we e ks to mo nths, mo nths to ye a rs  But a c tua lly, we c a n b e pre tty a c c ura te with c e rta in da ta po ints  Clinic  Ho spita l

Optimism Bia s  Ove re stima te s o f L e ng th o f L ife L e ft  1:4 Prima ry Ca re  1:10 Onc o lo g y  I t is ha rd fo r Do c to rs to le t g o Christa kis NA, L a mo nt E B. E xte nt a nd de te rmina nts o f e rro r in do c to rs’ pro g no se s in te rmina lly ill pa tie nts: pro spe c tive c o ho rt study. BMJ 2000;320:469-72.

Ca se 1: T ina Ja c kso n Br Ca I V • S/ p surg e ry, ra dia tio n & two diffe re nt type s o f c he mo the ra py • Bo ne me ta sta se s • L o sing we ig ht • Una b le to g e t a ro und • T ire d o f pursuing tre a tme nt • Wa nting to fo c us o n c o mfo rt • Wha t do yo u sa y? Ado b e Sto c k L ic e nse 3344625

ra je c to ry: Ca nc e r ime T llne ss T I

Dic ho to mo us Cho ic e “DNR o r Ho spic e ” I nc re a sing Pa llia tive I nte rve ntio ns T ime

I OM Re po rt o n Ca nc e r 2013  T e a m-c a re  Prima ry Ca re  Pa llia tive Ca re  E a rly I ntro duc tio n o f Pa llia tive Ca re  Ca nc e r pa tie nts who ha ve c o nve rsa tio ns a b o ut e nd-o f-life issue s a re mo re like ly to die a t ho me o r in a c o mfo rta b le se tting , inste a d o f a ho spita l inte nsive -c a re unit

Pha sing o ut Cura tive T re a tme nt I nc re a sing Pa llia tive I nte rve ntio ns T ime

Ca se I I : Ro g e r  Ro g e r is a 65 yo with a dva nc e d COPD, who yo u ha ve se e n fo r ma ny ye a rs, a nd tre a te d with multiple inha le rs, o xyg e n a nd a fe w ho spita liza tio ns fo r e xa c e rb a tio ns  He ha s b e g un to lo se we ig ht a nd ha s se ve re e xe rc ise re stric tio n in spite o f ma xima l tre a tme nt  Ca n yo u b ring up the to pic ?  Ho w?

Ca se I I Ro g e r 65 COPD “D” Can you br ing up  Multiple inhale r s, oxyge n and a the topic ? fe w hospitalizations for e xac e r bations How?  He has be gun to lose we ight and has se ve r e e xe r c ise r e str ic tion in spite of maximal tr e atme nt Ado b e Sto c k L ic e nse # 64486308

I llne ss T ra je c to ry: Chro nic I llne ss Org a n F a ilure COPD o r CHF E xa c e rb a tio n

I ntro duc ing T he T o pic  “Afte r lo o king a t wha t ha s b e e n g o ing o n in the pa st ye a r, I think we sho uld ta lk a b o ut whe re this a ppe a rs to b e g o ing ”  “Ho w do yo u fe e l a b o ut c o ntinuing to g o to the ho spita l? ”  “Whe n this ha ppe ns a g a in do yo u wa nt to g o o n a b re a thing ma c hine ? ”  “Sinc e we kno w tha t COPD will like ly ta ke yo ur life , ha ve yo u tho ug ht wha t it will b e like to die ? ”

Ca se I I I : Ja vie r 73 Hispa nic Ma n Advanc e d de me ntia and s/ p CVA with he miple gia. He r e quir e s signific ant assistanc e with daily ac tivitie s and has de c ubitus ulc e r s whic h ar e not he aling. His BMI is 17 How c an you intr oduc e the topic to his wife or his c hildr e n? Ado b e Sto c k L ic e nse # 521338815

I llne ss T ra je c to ry: Wa sting I llne sse s F ra ilty suc h a s De me ntia

Ca ta lysts  Ho spita liza tio ns a re e ve nts whic h pro vo ke a c o nve rsa tio n  De c isio n po ints  I V a lime nta tio n  NG o r PE G tub e fe e ding  Ca re g ive r b urno ut  Pre ssure wo unds whic h c a n’ t he a l

 Ho spita l  Offic e  Ho me Whe re

Ho spita l Disc ha rg e Pro g no sis Var iable Sc or e Ma le se x 1 Ne e ds a ssista nc e with 1-4 ADL s a t disc ha rg e 2 Ne e ds a ssista nc e with a ll ADL s 5 Co ng e stive He a rt F a ilure 2 Ca nc e r 3 Me ta sta tic Ca nc e r 8 Cre a tinine 3.5 g / dl 2 Se rum a lb umin > 3 g / dL 1 Se rum a lb umin < 3 g / L 2 Va lida tio n c o ho rt fro m Wa lte r & c o lle a g ue s # 16, F ro m Yo u CMAJ 2014

Ho spita l Disc ha rg e Pro g no sis T otal Sc or e 1-ye ar mor tality, % 0-1 po ints 4 2-3 po ints 19 4-6 po ints 34 >6 po ints 64 JAMA Oc to b e r 8, 20008

ACP Billing Co de s 99497 a nd 99498 F a c e -to -fa c e se rvic e b e twe e n a physic ia n o r o the r q ua lifie d  he a lthc a re pro fe ssio na l (QHP) a nd a pa tie nt, fa mily me mb e r o r surro g a te in c o unse ling a nd disc ussing a dva nc e dire c tive s, with or without c o mple ting re le va nt le g a l fo rms Re q uire s a fa c e -to -fa c e visit, ho we ve r, the pa tie nt ma y no t b e  pre se nt  He a lth Ca re Pro xy,  Dura b le po we r o f a tto rne y fo r he a lthc a re ,  L iving will  OOHDNR  30 minute s

Ho w  L iste n  Ask the ir unde rsta nding a nd b uild o n it  Sta rt with MPOA a s mo st impo rta nt / e a sie st do c ume nt  Do n’ t dwe ll o n CPR/ no CPR b ut ra the r o n the ir g o a ls o f wha t the y wo uld do in the la st we e ks o r mo nths o f life ,  “Wha t wo uld b e a g o o d da y fo r yo u? ”

SPI K E S Pro to c o l fo r De live ring Ba d Ne ws Se tting o f the inte rvie w  Arra ng e fo r so me priva c y  Ask who sho uld b e pre se nt  Co nside r inc luding a c o lle a g ue  Sit do wn a nd ma ke e ye c o nta c t Pe r c e ption o f the pa tie nt  “ Wha t do yo u kno w a b o ut yo ur illne ss”  “Wha t ha s b e e n g o ing o n with yo ur he a lth o ve r the la st ye a r”

SPI K E S Pro to c o l fo r De live ring Ba d Ne ws Invitation fro m the pa tie nt  De te rmine wha t the pa tie nt wa nts to kno w  “Do yo u wa nt me to e xpla in a ll the de ta ils o f yo ur c o nditio n? ” Knowle dge T ra nsfe r  Use simple la ng ua g e , a nd sma ll a mo unts o f info rma tio n, c he c king fo r unde rsta nding (a llo wing pa tie nts a nd fa mily to ta lk)  Ac kno wle dg e unc e rta inty in pro g no sis g iving ra ng e s no t e xa c t numb e rs