Palliative Care: Year in Review 2013 Lynn A. Flint Eric Widera UCSF, - - PDF document

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Palliative Care: Year in Review 2013 Lynn A. Flint Eric Widera UCSF, - - PDF document

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5/28/2013 Palliative Care: Year in Review 2013 Lynn A. Flint Eric Widera UCSF, Division of Geriatrics No disclosures 1 5/28/2013 Objectives 1. Define palliative care 2. Discuss recent findings in palliative care research focus on health

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Palliative Care: Year in Review 2013

Lynn A. Flint Eric Widera UCSF, Division of Geriatrics

No disclosures

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Objectives

  • 1. Define palliative care
  • 2. Discuss recent findings in palliative care

research – focus on health services and communication

  • 3. Determine whether these studies are

relevant to general internal medicine

  • 4. Review news from the past year

Definition

From the Center to Advance Palliative Care: “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.”

www.capc.org/building‐a‐hospital‐based‐palliative‐care‐program/case/definingpc, accessed 4/8/2013

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Definition

“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.”

Image: Am J Prev Med 2011;40(5S2);S217‐S224

Definition

“It is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment.”

Image: Journal of Supportive Oncology 2012;10:180‐187.

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“Matching treatments to patient goals.”

Medicine

Palliative Medicine Hospice Disease directed care

…Internal Medicine Family Medicine Physical Medicine Emergency Medicine Surgery Psychiatry Ob‐Gyn…

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What is your preferred place of death?

1) Emergency room 2) Home 3) Hospital 4) Nursing home 5) No preference

What about your preferred place to be two weeks before your death?

1) Emergency room 2) Home 3) Hospital 4) Nursing home 5) No preference

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Source: California Healthcare Foundation, 2011 JAMA 2013;309(5):470‐477.

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Site of death: not the whole story

10 20 30 40 50

2000 2009 Acute Care Hospice

JAMA 2013;309(5):470‐477.

Site of death: not the whole story

5 10 15 20 25 30 35 2000 2009 Hospital ICU Use Transitions JAMA 2013;309(5):470‐477.

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Bottom line

From 2000 to 2009, despite a decline in hospital deaths and an increase in hospice use, end of life ICU use and health care transitions increased among Medicare decedents.

How does this apply to general practice?

  • Place of death is important to many
  • “Place of decline” is discussed less often
  • ICU, multiple transitions not ideal in last days

and weeks of life

  • Important to discuss with patients and

document their preferences

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When would you refer patients with advanced cancer to palliative care?

1) At diagnosis 2) If active symptoms 3) When no disease‐directed treatments are available 4) If functional decline 5) All of the above

Early Palliative Care

Temel JS et al. N Engl J Med 2010;363:733‐742.

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JAMA Intern Med 2013;173(4):283‐290.

Key elements of PC visits

Relationship and rapport building Relationship and rapport building Addressing symptoms Addressing symptoms Addressing coping Addressing coping Establishing illness understanding Establishing illness understanding Discussing cancer treatments Discussing cancer treatments Engaging family members Engaging family members End of life planning End of life planning

JAMA Intern Med 2013;173(4):283‐290.

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Illness understanding‐info preference: “she likes the ‘straight story’…” Illness understanding‐prognostic awareness: “understands that her prognosis is 6‐12 weeks.” Addressing coping: “copes by trying not to think about his diagnosis and focusing on the present.”

JAMA Intern Med 2013;173(4):283‐290.

Key elements over time

5 10 15 20 25 30 35 Initial Middle Late

  • No. of coded text

EOL Planning Discussing cancer tx Illness understanding: Px awareness Illness understanding: info preference JAMA Intern Med 2013;173(4):283‐290.

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JAMA Intern Med 2013;173(4):283‐290.

Bottom line

  • “Focus of PC is not browbeating patients into

accepting hospice and avoiding resuscitation

  • r hospitalization…”
  • PC complemented oncologists’ work

– Little overlap – Different focus

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How does this apply to general practice?

  • Not generalizable

– Single tertiary center – Intervention not easily reproduced

  • Makes the case for “primary palliative care”
  • Considering some of the key elements above

does not have to include “browbeating patients into accepting hospice”

JAMA Intern Med 2013;173:291‐292

What is the goal of palliative chemotherapy?

1) Prolong survival 2) Ease symptoms 3) Both 4) Either or both

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New Engl J Med 2012;367:1616‐1625.

“After talking with your doctors… how likely did you think it was that the chemotherapy would cure your cancer?”

Stage IV Colon Cancer

New Engl J Med 2012;367:1616‐1625. Very likely/somewhat likely

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Variables increasing likelihood of inaccurate response

  • Non‐white
  • Fee‐for service health insurance
  • Better physician communication scores

If the meteorologist says “There will definitely be rain today,” what does this mean to you?”

1) There is a 70% chance

  • f rain

2) There is a 10% chance

  • f rain

3) There is a 50% chance

  • f rain

4) There is a 100% chance

  • f rain
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Ann Intern Med. 2012;156:360‐366.

Surrogates of current ICU patients were asked about prognostic statements. For example, “If a doctor says ‘He will definitely survive,’ what does that mean to you?”

Ann Intern Med. 2012;156:360‐366. Will NOT survive (0% chance of survival) Will survive (100% chance of survival) 10% 20% 30% 40% 50% 60% 70% 80% 90%

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He will definitely not survive = 0‐50% chance of survival He has a 5% chance of surviving = 5‐40% chance of survival It is very unlikely he will survive = 15‐50% chance of survival

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“I hold onto hope strongly.” “I know my father could do better than what the doctor is saying…” “I don’t give a lot of weight to the original number.” “I don’t think [doctors] can really know.”

Bottom line

What providers say is not the only factor influencing patient and family beliefs about serious illness

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5/28/2013 19 What a patient understands What a patient understands What the doctor says What the doctor says Psychosocial Psychosocial Spiritual Spiritual Cultural Cultural Education/literacy Education/literacy Physical condition Physical condition

How does this apply to general practice?

  • Communication is the “bread and butter” of

an internist’s practice

  • A reminder that what we tell patients is not

what they take away

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Failure to engage

  • Among those with preferences, almost 30%

had no documentation AND

  • When preferences were documented, more

than 2/3 of documentation was not concordant with expressed wishes

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Bottom Line

  • Seriously ill patients are talking about their

preferences for care at the end of life

  • Document your patients preferences and the

stories of their preferences

What is the rate of survival of CPR on TV?

1) 100% 2) 70% 3) 25% 4) 10%

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New Engl J Med 1996;334:1578‐1582. New Engl J Med 2013;368:1019‐1026.

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  • 1. New Engl J Med 2013;368:1019‐1026.
  • 2. New Engl J Med 2012;367:1912‐1920.

Bottom line

  • It’s all in the framing
  • At one year, about 10% of elderly patients

who underwent in‐hospital CPR were alive; about 1/3 have clinically significant disability

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Other news

  • PCHETA introduced July 2012, re‐introduced

March 2013

  • Choosing Wisely Campaign
  • “Death panels” bill re‐introduced
  • prepareforyourcare.org

1.Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead,

  • ffer oral assisted feeding.

2.Don’t delay palliative care for a patient with serious illness of has physical, psychological, social or spiritual distress because they are pursuing disease‐directed treatment

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  • 3. Don’t leave an ICD activated when it is

inconsistent with the goals of care.

  • 4. Don’t recommend more than a single fraction
  • f palliative radiation for an uncomplicated

painful bone metastasis.

  • 5. Don’t use topical lorazepam (Ativan),

diphenhydramine (Benadryl), haloperidol (Haldol) (“ABH”) gel for nausea

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Take‐home points

  • Palliative care is for anyone facing a

serious illness

  • System changes impact the care of

seriously ill patients

  • Communication is a primary palliative

care procedure

Thank you for listening