Is Palliative Carejust another name for Rationing?

Suzana Makowski, MD MMM FACPDirector of Palliative Care in the Cancer Center of

ExcellenceUMass Memorial Healthcare & UMass Medical

School

Overview

• What is palliative care?• Stirs conflict

– Patients & families– Clinicians– Hospital administrators– Payors

• Why Cape Cod Hospital?

What is Palliative Care?

• CMO?• Continuous morphine only?

What is Palliative Care?

What is Palliative Care?• Medicare Definition:

– Palliative care means patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and to facilitate patient autonomy, access to information, and choice.

• WHO Definition:

– Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.

Palliative Care Paradigm

NEJM article: if a pill could do what palliative care can do…

Patients were evaluated for • quality of life, symptoms and functional status, • healthcare utilization throughout, and • documentation of code status.

The early palliative care intervention was performed in a structured, standardized manner and included:

1- initial outpatient assessment within 3 weeks of study enrollment by attending palliative care physician/NP evaluating:– understanding of illness/treatment goals;– presence of uncontrolled symptoms;– patient's mode of decision-making;– patient and family's ability to cope with life-limiting illness;– referral and prescription plans.

2- the palliative care team (PCT) that provided care for patients in this study included:– physicians, nurse practitioners, social workers, chaplains,

bereavement specialists, volunteers.

3- The PCT attempted to meet with patients during each oncologic clinic visit, and at least every 6 weeks.

4- Every patient in the integrated palliative care/oncology program was reviewed during the weekly Thoracic Tumor Board.

NEJM article: if a pill could do what palliative care can do…

• On healthcare utilization throughout care included:– anti-tumor regimen, – hospitalization, – aggressive end-of-life care, – hospice care  

"Aggressive end-of-life care" was defined as including one of the following: • chemotherapy within the last 14 days of life, • no hospice care, or • admission to hospice during the last 3 days of life.

Palliative Care Extends Life, Study Finds

• By DONALD G. McNEIL Jr.

In a study that sheds new light on the effects of end-of-life care, doctors have found that patients with terminal lung cancer who began receiving palliative care immediately upon diagnosis not only were happier, more mobile and in less pain as the end neared — but they also lived nearly three months longer.

[...]“It shows that palliative care is the opposite of all that

rhetoric about ‘death panels,’ ” said Dr. Diane Meier, director of the Center to Advance Palliative Care at Mount Sinai School of Medicine and co-author of an editorial in the journal accompanying the study.

“It’s not about killing Granny; it’s about keeping Granny alive as long as possible — with the best quality of life.”- Diane Meier, NYTimes

Early End-Of-Life Care Helps Lung Cancer Patients Live Longerby SCOTT HENSLEY

Guess what happens when you give people with a deadly form of lung cancer early access to palliative care?

They live about two months longer. They also feel better throughout the course of

treatment. And the people who get palliative care starting

within three weeks of diagnosis are more likely to have recorded their end-of-life wishes and, ultimately, to have less aggressive and expensive care just before dying.

Do we want to supersize healthcare?

More medical care ≠ better medical care

Family members of decedents in high-intensity hospital service areas report lower quality of:– Emotional support– Shared decision-making– Information about what to expect– Respectful treatment

Teno et al. JAGS 2005;53:1905-11.

Physicians practicing in high health care-intensity regions report more difficulty:

– Arranging elective admissions– Obtaining specialty referrals– Maintaining good doctor-patient relations– Delivering high quality care

Sirovich et al. Annals Intern Med 2006; 144:641-649

Relationship between cost of care and quality of death in the final week of life

(adjusted P= 0.006)

Zhang, B. et al. Arch Intern Med 2009;169:480-488.

Associations Between Caregiver’s Outcomes and Patients’ End-of-Life Care and Quality of Life (N=202)

Copyright restrictions may apply.

Wright, A. A. et al. JAMA 2008;300:1665-1673.

Relationship Between Quality of Life and End-of-Life Care

Copyright restrictions may apply.

Wright, A. A. et al. JAMA 2008;300:1665-1673.

So is Palliative Care then about rationing?

• Institute of Healthcare ImprovementRight Care at the Right Time in the

Right Place

Better does not necessarily require more…

Dissonance

So what could palliative care do for you?

Resolve conflict: clinician-patient• 42 year old Syrian immigrant with

metastatic non-small cell lung cancer, intubated for post-obstructive pneumonia. Septic shock on maximal pressor support. Now with multiorgan failure.

• Family present: wife, brother, parents.

• “Do everything.”

Clinician-patient/family conflict

Life Death

Everything Nothing

Care Abandonment

Cure Comfort

Hope Despair

Futility • Autonomy • Non-maleficenceWithholding • Withdrawing

IHI: Underuse • Misuse • Overuse

Clinician

Patient

Clinician-patient/family conflict

“Let him linger for our son”

So what could palliative care do for you?

Resolve conflict: clinician-clinician• Camille: 52 year old cyclist

• Bike-car accident Sunday morning resulted in massive thoracic injuries, facial injuries, bilateral intracerebral contusions/bleeding.

• Renal failure, hypotensive on multiple pressors, intubated

Trauma intensivist: “he is stabilizing and getting better”Neurosurgeon: “he shows no signs of neurologic improvement.”

So what could palliative care do for you?

Resolve conflict: clinician-clinician• Defining goals of care

• Coordinating care• Providing support for family and

clinicians• Addressing PTSD & depression

among survivorsTrauma intensivist: We can stabilize him to leave ICU, the hospital. He can live.Neurosurgeon: May be stabilized hemodynamically, but without meaningful neurologic improvement.Family: We know he won’t walk or bike again, but will he be able to make jewelry again?

So what could palliative care do for you?Resolve conflict: clinician-clinician

• Early family/interdisciplinary and multidisciplinary team meetings.

• Goals of care defined by family, and then interpreted to clinical decisions.

What is meaningful life for this person?What legacy does he want to leave? (organ donation, long-term NH placement)Role of healthcare proxy: to define goal of care, not to make specific clinical decisions.

Palliative care can help address psychological distress among

surviving family• PTSD and depression high among surviving

family of patients who die with ICU stay.• Risk factors in patients:

– Ventilator maintained at EOL– Young age

• Risk factors in family:– Female– Prior/current psychiatric history

• Interventions that may help:– Bereavement support– Ongoing discussion– Decision to withdraw life support

•Lautrette A, Darmon M, Megarbane B, et al N Engl J Med. Feb 1 2007;356(5):469-478. •Kross EK, Engelberg RA, Gries CJ, Nielsen EL, Zatzick D, Curtis JR. Chest. Sep 9 2010.

What could palliative care do for you?

Assist with coordination of care across care-settings

• 76 yo grandmother with advanced heart failure, 5 hospitalizations in the last 4 months. Readmitted for exacerbation of HF.– Readmissions is a major concern for

hospital administrators and payers.– Increases distress among caregivers,

family, patients.Discussion held with patient & family: discharge home with hospice. No hospitalizations over the following 6 months. Patient remains alive and still meets hospice criteria.

Art Buchwald quoted by Richard Severo, NYTimes – Jan 19, 2007

• As he continued to write his column, he found material in his own survival. “So far things are going my way,” he wrote in March. “I am known in the hospice as The Man Who Wouldn’t Die. How long they allow me to stay here is another problem. …But in case you’re wondering, I’m having a swell time — the best time of my life.”

What could palliative care do for you?Assist with coordination of care across care-settings

• Emergency use high among patients at end-of-life– Patients with lung cancer in Canada –

84% visited ER in last 6 months of life, 34% visited in 2 weeks of life.

– Why? Uncontrolled symptoms, caregiver fatigue, infection

Emergency room at Cape Cod HospitalGreat opportunity for innovation in palliative careSocial worker, nurse practitioner and processes

Barbera, L., Taylor, C., & Dudgeon, D. (2010). Canadian Medical Association Journal DOI: 10.1503/cmaj.091187

What could palliative care do for you?Assist with complex symptom management

• 36 yo with metastatic uterine cancer admitted to Cape Cod Hospital with severe intractable pain.

• Morphine switched to hydromorphone (Dilaudid) PCA. Titrated – but patient remains in severe pain, now agitated and with increased nausea/constipation.– Palliative care consultation called – medication

adjustment lead to alleviation of pain, normal cognition, resolved N/V and constipation within 24 hours.

– Patient discharged to home.

Optimal care for patients

Dr. Robert Martensen:“But when you look at Medicare overall half the

money that we spend in this country on Medicare is spent on patients in the last six months of their lives.

And if we were providing some kind of wonderful existence, then one could make the case but as I have written about and as I certainly experienced, and I gathered you’ve experience and many others, these last six months are not, they’re often agonizing and very unsatisfying for all concerned.”

WE WILL DO EVERYTHING. THE QUESTION IS, WHAT KIND OF EVERYTHING?

Palliative Care at Cape Cod HospitalWhy?

• Patient and family satisfaction– Improves quality of life, and at times, longevity– Provides support in complex decisions, symptom

management, coordination of care, bereavement

• Clinician satisfaction– Quality of care– Time– Coordination of care

• Hospital leadership satisfaction– Quality– Cost savings

• Payer satisfaction– Joint Commission, leapfrog and other quality standards– National quality standards will require 24/7 access to

palliative care

UMass: Recognizes that growing palliative care is imperative for improvement of quality care in current economic condition

Palliative Care at Cape Cod HospitalHow?

• Target key areas:– Emergency Room– Centers of Excellence: Cardiology, Cancer– Areas of need: Critical Care

• Team approach – balance FTE mix based on need and location:– Physician and nurse practitioner– Social worker– Chaplain– Counselor with bereavement and expressive

arts background– Clinical Pharmacist– Administrator/Coordinator

Palliative Care at Cape Cod HospitalHow?

• Models: - CAPC as resource: business & strategic plans key

– Consultative only– Consultative + float beds/unit

• Benefit: Unit with protocols, expertise• Challenges: Clinician coverage – medical

director oversight, 24/7 staffing

– Consultative + emergency room model– Outpatient clinic – coordinate with home

health and hospice servicesRegular interdisciplinary/transdisciplinary team meetingsCollaboration with ethics, case management

Thank you

“You matter because you are you, and you matter to the end of your life. We will do all we can not only to help you die peacefully, but also to live until you die.”- Dame Cicely Saunders