Disclosures We have no significant financial relationships Advances - PowerPoint PPT Presentation

3/12/2016 Disclosures We have no significant financial relationships Advances in Palliative Care in to disclose • Anne Kinderman, MD Underserved Settings – Director, Supportive & Palliative Care Service, ZSFG – Associate Clinical Professor of Medicine, UCSF Care of Vulnerable and Underserved Populations • Heather A. Harris, MD – Associate Medical Director, Supportive & Palliative March 12, 2016 Care Service, ZSFG – Associate Clinical Professor of Medicine, UCSF Outline Outline • Define palliative care • Recognize when to start palliative care • Challenges • Review advance care planning with • Evidence vulnerable patients • Tools • Review updates in documenting • Recommendations patients’ wishes 1

3/12/2016 Traditional model for serious illness Clinical scenario “Nothing More Can Be Done” You are a hospitalist caring for a Mr. Chavez, 100 a 45 year-old Spanish-speaking man with stage IV NSCLC, admitted with dyspnea Palliative Care and fatigue. While working up the cause of his symptoms, you suggest to the % Curative care patient’s oncologist that you think that a Hospice Care focus palliative care consult would be appropriate. He says that Mr. Chavez is “not ready for palliative care” because he is young, and still wants to pursue 0 Time chemotherapy. Death Terminal phase Adapted from S Pantilat, PCLC 2005 Palliative What is palliative care? Care “Palliative care is specialized medical care for people with Hospice Care serious illnesses. This type of care is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness - whatever the diagnosis. Life-prolonging therapy Pain The goal is to improve quality of life for both the patient and Management the family. Palliative care is 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. Palliative care is appropriate at any age and at any stage in a serious illness, and Relationship Between Hospice, Palliative Care, Pain can be provided together with curative treatment.” Management, and Life-Prolonging Therapy • Hospice Care is a specialized form of Palliative Care • Hospice Care and Life-prolonging therapy usually do not overlap Center to Advance Palliative Care, 2011 • Palliative care includes specialized training in pain management, but typically does not manage chronic pain 2

3/12/2016 Integrated model for serious illness Benefits of early palliative care “Best care possible” • Stage IV NSCLC 100 – Automatic outpatient palliative care referral Bereavement – Standard care Curative care % • Results focus – Improved QOL Hospice Care – Less intensive end-of-life care – Less depression Palliative Care – Increased survival (~3mo) 0 Time Terminal phase Death Temel et. al., 2010 NEJM Adapted from S Pantilat, PCLC 2005 Do patients know Best practice: concurrent care what palliative care is? Very Don't Know, 8% Knowledgeable, 5% Knowledgeable, 3% Somewhat Knowledgeable, 14% Not At All Knowledgeable, 70% Center to Advance Palliative Care, 2011 3

3/12/2016 Are vulnerable patients afraid of Clinical bottom line palliative care? • Integrating palliative care earlier and providing it cuidados paliativos concurrently with disease-directed therapy leads to: 姑息治療 Gūxí zhìliáo – improved clinical outcomes ch ă m sóc gi ả m nh ẹ – greater patient and caregiver satisfaction паллиативный уход – lower costs of care – (prolonged survival) (palliativnyy ukhod) pampakalma pag-aalaga ةيفيطلتلا ةياعرلا (alrrieayat alttaltifia) How might you change your practice? Clinical scenario, cont. • Integrate palliative earlier – “Extra layer of support” After introducing Mr. Chavez to the concept of – Focus on the reason for palliative care, and reassuring the oncologist referral (e.g. symptom that receiving chemotherapy and palliative care management) • Resources are not mutually exclusive, there is agreement – Chinese American Coalition that he could benefit from palliative care. for Compassionate Care However, he’s about to be discharged from the – CSU Course focusing on hospital and you’re unsure of what resources cultural competence in caring for Latinos are available in the community. – Interpreters curriculum in http://www.caccc-usa.org/ palliative care https://csupalliativecare.org/programs/latinos/ http://www.chcf.org/publications/2011/11/interpreting-palliative-care-curriculum 4

3/12/2016 Growth of palliative care programs Expansion into the community • 67% of hospitals now report • Clinic-based services offering palliative care services – Co-located or embedded – 90% of hospitals with 300+ beds – Stand alone – 59% of public hospitals • Home-based services • Significant expansion in CA – Hospice & home health programs safety net hospitals – Enhanced case management – 2007: 4 hospitals (24%) • SNF-based services – 2013: 17 hospitals (100%) • Telehealth https://reportcard.capc.org/ Center to Advance Palliative Care, 2015 Tool for California Community-based palliative care • County summaries • 2011 survey of California hospitals – Inpatient and outpatient – Only 24 hospitals (7%) reported having outpatient PC programs and palliative care services sufficiency • Fewer pediatric palliative care programs (8 total) – Population and annual • Unknown death volume – Compare with existing – National or safety net prevalence programs and their – Home - or SNF-based prevalence capacity http://www.chcf.org/publications/2015/02/palliative-care-data Rabow, 2014 J Palliative Med 5

3/12/2016 Landmark legislation Meeting the need for vulnerable patients Specialty Palliative Care • Passed September 2014 • Based on success of pediatric pilot Secondary • Requires the DHCS to “establish standards and Palliative Care provide technical assistance for Medi-Cal managed care plans to ensure delivery of palliative care services.” Primary Palliative Care • Await all-plan letter to managed Medi-Cal programs – Develop alternative payment models How might you change your practice? Clinical bottom line • Continuing Education • Sub-specialty palliative care is not available equitably – CSU Institute for Palliative Care throughout the country – Center to Advance Palliative Care – current move from inpatient to outpatient settings – VitalTalk – ELNEC • The vast majority of palliative care will be provided – Harvard: Center for Palliative Care – Palliative Care Masters Degree through primary palliative care (U Colorado Denver) • System Redesign – not just individuals, but systems change http://www.chcf.org/publications/2015/08/weaving-palliative-care 6

3/12/2016 Advance Care Planning: Clinical scenario, cont. Disparities for Vulnerable Patients • Not many Americans have advance directives You are seeing Mr. Chavez in the outpatient – Only 18-30% of general population setting and want to address his end of life – Lower among non-Whites, lower SES wishes. Whenever you try to bring up the • Systems not reliable in following directives topic, his body language changes and he says that “God will decide,” then changes the – Missing/wrong 70% of the time even in Canada! subject. – Black cancer pts far less likely than whites to have advance care preferences honored Wilkinson, 2007 Rand Corp Heyland, 2013 JAMA Int Med Loggers, 2009 J Clin Onc Barriers to advance care planning Additional barriers in the safety net • Provider- and System-level barriers • Patient-level barriers – Communication about end of life – Perceive advance care planning (ACP) as irrelevant – Communication across cultures – Don’t understand or need help completing legal – Takes longer to communicate (e.g. patients with documents limited English proficiency) – Not enough time during visit – Limited access to tools – Poor relationship with family/friends, or don’t want – Limited staffing to burden them • Laws may make it harder for vulnerable pts to – Personal barriers (e.g. too sad, too nervous) complete advance directives Elliott, 2016 J Pain Sympt Mgmt Sudore R, 2008 J Am Geriatr Soc Castillo, 2011 Ann Int Med 7

3/12/2016 Common experiences with Determining patient readiness advance care planning • Prior engagement with ACP Keys for changing experience with ACP: • Redefine goals – Personal experience • Assess pt readiness – Surrogacy or vicarious experiences • Help motivate engagement in • Insight into health, function dialogue with surrogates and • Clarification of personal values, wishes provider over time • Discussions about values, wishes • Prioritize certain aspects of ACP – With family/friends • Identifying surrogate(s) – With clinicians • Clarifying broad wishes/goals Creative ways to activate patients ACP and motivational interviewing Pre- Maintenance contemplation Action ● Discuss with family Contemplation ● Discuss with clinicians ● Document www.prepareforyourcare.org – English and Spanish Sudore R, 2008 J Am Geriatr Soc 8