CHAMPCHAMPHow to Approach Palliative CareHow to Approach Palliative Carein the Older Patientin the Older Patient

Déon Cox Hayley, DODéon Cox Hayley, DO

University of ChicagoUniversity of Chicago

Objectives of session

1. To understand and be able to apply the concept of gradual implementation of palliative care.

2. Teach others

Curative care

Death

Traditional approach to end of life care

Continuum of Care ModelContinuum of Care Model

Disease Progression

DEATH

Curative Intent

Palliative Care

CurativeCare

Death

Gradual implementation of Gradual implementation of end of life careend of life care

• Curative measuresCurative measures: : – go all out toward prolonging lifego all out toward prolonging life

• Hospice and palliative careHospice and palliative care: : – go all out toward symptom relief go all out toward symptom relief

• ChallengeChallenge to sensitively negotiate to sensitively negotiate between those extremes with patients between those extremes with patients & families& families

OutlineOutline

• Who?Who?• What?What?• Where?Where?• When?When?

– PrognosticationPrognostication• How?How?

Who?Who?

• For For patients who have serious or life-patients who have serious or life-threatening disease(s). threatening disease(s). – Many appropriate conditionsMany appropriate conditions

• Not just cancerNot just cancer• Don’t even have to have a traditional Don’t even have to have a traditional

“diagnosis”“diagnosis”

What is palliative care?What is palliative care?

• Care with focus on quality of life. Care with focus on quality of life. – Symptom managementSymptom management– Decision-making Decision-making

Weighing benefits and burdens

All decisions should go through the lens of how they will impact the patient

Decisions in palliative careDecisions in palliative care

• Will it help the patient?Will it help the patient?– In their remaining life?In their remaining life?– Within their goals of care?Within their goals of care?

• If it will help, what are the burdens?If it will help, what are the burdens?– Pain or other symptomsPain or other symptoms– Physical limitationsPhysical limitations– Risk of adverse eventsRisk of adverse events– CostCost

Is it worth it?Is it worth it?

Holmes, H. M. et al. Arch Intern Med 2006;166:605-609.

The model shows that the 4 steps in medication decision making form a pyramid, visually representing the

appropriate medications at any level

Holmes, H. M. et al. Arch Intern Med 2006;166:605-609.

Use of the model in 3 distinct cases illustrates how it is used depending on the 4 components

Holmes, H. M. et al. Arch Intern Med 2006;166:605-609.

An example of a distorted model shows that all 4 components may not readily agree

Palliative Care/HospicePalliative Care/Hospice

Hospice

Palliative Care

Where?Where?

• HospitalHospital• HomeHome• OutpatientOutpatient• Nursing homeNursing home

When?When?

• PrognosticationPrognostication– Would you be surprised if this Would you be surprised if this

person died within the next year?person died within the next year?– Other prognostic markersOther prognostic markers

•AgeAge•Co-morbiditiesCo-morbidities•FunctionFunction

Many elderly are near the end Many elderly are near the end of their lives as indicated by of their lives as indicated by the following markers:the following markers:

– Limited life expectancy Limited life expectancy – Decreased reserveDecreased reserve– Co-morbidities and geriatrics Co-morbidities and geriatrics

syndromessyndromes– Functional impairmentsFunctional impairments

Quartile: Age: 70 75 80 85 90 95

Top 25 % 21.3 17.0 13.0 9.6 6.8 4.8

50th percentile 15.7 11.9 8.6 5.9 3.9 2.7

Lowest 25% 9.5 6.8 4.6 2.9 1.8 1.1

(NCHS. Life Tables of the United States, 1997. Adapted from Walter & Covinsky. JAMA 2001;285(21):2750-6.)

Upper, Middle and Lower Quartiles of Life Expectancy: U.S. WOMEN, 1997

Quartile: Age: 70 75 80 85 90 95

Top 25 % 18.0 14.2 10.8 7.9 5.8 4.3

50th percentile 12.4 9.3 6.7 4.7 3.2 2.3

Lowest 25% 6.7 4.9 3.3 2.2 1.5 1.0

(NCHS. Life Tables of the United States, 1997. Adapted from Walter LC and Covinsky KE. JAMA 2001;285(21):2750-6.)

Upper, Middle and Lower Quartiles of Life Expectancy: U.S. MEN, 1997

ComorbidityComorbidity and prognosisand prognosis: : Simply add up the co-existing Simply add up the co-existing conditionsconditions

020406080

100120140160180

3-year mortality /1000

0 1 2 3+

# of comorbidities

Breast cancer

Other causes

Geriatric Syndromes and Geriatric Syndromes and Remaining Life Expectancy Remaining Life Expectancy (RLE)(RLE)

• Cognitive Impairment (Dementia): Cognitive Impairment (Dementia): Acquired Acquired decline in memory and in at least one other decline in memory and in at least one other cognitive function sufficient to affect daily life.cognitive function sufficient to affect daily life.

• Disability: Disability: Dependency in carrying out Dependency in carrying out activities essential to independent living and activities essential to independent living and maintaining quality-of-life. maintaining quality-of-life.

• Frailty: Frailty: A state of high vulnerability for A state of high vulnerability for adverse health outcomes characterized by adverse health outcomes characterized by weakness, weight loss, poor endurance, low weakness, weight loss, poor endurance, low physical activity, and slow gait speed.physical activity, and slow gait speed.

RLE, 70 y.o. Men, RLE, 70 y.o. Men, with and without Alzheimer with and without Alzheimer DiseaseDisease

0

2

4

6

8

10

12

14

16

18

Overall Alzheimer's

Upper QuartileMiddle QuartileLower Quartile

Functional ImpairmentFunctional Impairment

• Percent of Persons Reporting Problems with Percent of Persons Reporting Problems with Two or More Activities of Daily Living (ADLs), Two or More Activities of Daily Living (ADLs), By AgeBy Age 1994-1995 1994-1995

Percent* Percent* • TotalTotal

65+ 65+ 6.0 6.0 • Age Group (yrs)Age Group (yrs)

65-74 65-74 3.1 3.1

75-84 75-84 7.8 7.8

85+ 85+ 18.118.1

8% 8% if fully independent, if fully independent,

14% 14% if dependent in IADL, if dependent in IADL,

27% 27% if dependent in ADL, if dependent in ADL,

40% 40% if institutionalized. if institutionalized.

Rueben Am J Med Rueben Am J Med 1992;93:6631992;93:663

2-year mortality rate 2-year mortality rate age ≥ 70 yearsage ≥ 70 years

0

20

40

60

80

100

120

Func

tion CANCER

CHF

Prognosis Can Be Difficult to Prognosis Can Be Difficult to PredictPredict

PrognosticationPrognostication

• Disease Associated Prognostic Disease Associated Prognostic FactorsFactors

• Non-disease-Associated Prognostic Non-disease-Associated Prognostic FactorsFactors– AgeAge– Functional statusFunctional status– Co-morbidityCo-morbidity

Patient

AgeComorbidityFunctional Status

Life Expectancy (LE)

LE>Cancer Survival LE<Cancer Survival

Treatment Tolerance

Adequate Inadequate

Life-prolonging Therapy Palliative Therapy

Figure 20.1 Comprehensive Geriatric Oncology

L. Balducci et al

ALGORITHM for the TREATMENT OF OLDER CANCER PATIENTS

How?How?

• Determine important factors Determine important factors influencing life expectancyinfluencing life expectancy

• Determine important factors which Determine important factors which might influence approach to caremight influence approach to care

•Physical limitationsPhysical limitations•Patient choice/goalsPatient choice/goals

• Communicate with patient Communicate with patient • Determine planDetermine plan

Potential Goals of CarePotential Goals of Care

• Avoidance of guiltAvoidance of guilt

• Staying in controlStaying in control

• Support for families and loved Support for families and loved

onesones

•A good death•Relief of suffering

•Quality of life•Maintenance or improvement in function

•Avoidance of premature death•Cure of disease

Holmes, H. M. et al. Arch Intern Med 2006;166:605-609.

The model shows that the 4 steps in medication decision making form a pyramid, visually representing

the appropriate medications at any level

Goals may change as Goals may change as disease progressesdisease progresses

• Some goals may take priority over Some goals may take priority over othersothers

• The shift in the focus of care isThe shift in the focus of care is– gradualgradual– an expected part of the an expected part of the

continuum continuum • Review goals with any changeReview goals with any change

Mr. P—56 years oldMr. P—56 years old

• Admitted with sepsis secondary to Admitted with sepsis secondary to chronic pressure ulcerschronic pressure ulcers

• Hospitalized 2 months with multiple Hospitalized 2 months with multiple complicationscomplications

• Called to assess for palliative careCalled to assess for palliative care

PMHPMH

• IV drug abuse and alcoholismIV drug abuse and alcoholism• Epidural abcessEpidural abcessparaplegiaparaplegiahorrible stage IV horrible stage IV

pressure ulcers, non-healingpressure ulcers, non-healingchronic hardware chronic hardware infection/osteomyelitisinfection/osteomyelitis

• Re-current sepsis (Several admissions to the Re-current sepsis (Several admissions to the hospital this year)hospital this year)

• PVD s/p Rt BKAPVD s/p Rt BKA• HTNHTN• DVTDVT• Probable hepatoma dx’ed by CT + elevated AFPProbable hepatoma dx’ed by CT + elevated AFP

Hospital CourseHospital Course

• Pain Pain – Hesitant to give too many narcs b/c of abuse historyHesitant to give too many narcs b/c of abuse history

• Been in the hospital 2 months, tired Been in the hospital 2 months, tired – PICC line w/IV abxPICC line w/IV abx– Frequent lab drawsFrequent lab draws– DVTDVT

• Refusing therapies Refusing therapies (completely (completely competent)competent)– Diverting colostomy to prevent wound re-Diverting colostomy to prevent wound re-

infectioninfection– Liver bxLiver bx– Frequent lab drawsFrequent lab draws– More imagingMore imaging

ExamExam

• BP= 110/70BP= 110/70• Alert, oriented, slightly uncomfortable appearingAlert, oriented, slightly uncomfortable appearing• Poor dentitionPoor dentition• Chest-Chest-

– HRRR, soft sys murmurHRRR, soft sys murmur– Lungs clr Lungs clr

• Abd-tight distensionAbd-tight distension• Sacral ulcer-down to bone (metal)Sacral ulcer-down to bone (metal)• Rt BKA—stump clear, Lt foot dry, sl cool but skin Rt BKA—stump clear, Lt foot dry, sl cool but skin

intactintact

PrognosisPrognosis

• HepatomaHepatoma– 20% survival at one year, 6% 5-year 20% survival at one year, 6% 5-year

survival survival

• InfectionsInfections– Re-occuringRe-occuring

• FunctionFunction

Communication Communication

• Attending told him he had 100% Attending told him he had 100% mortality at one year. mortality at one year.

• “ “I was told I would live at least one I was told I would live at least one year.” year.”

Goals of careGoals of care

• In light of limited life expectancy, he In light of limited life expectancy, he wanted to spend his time with his wanted to spend his time with his mother and granddaughter at home.mother and granddaughter at home.

• Pain controlPain control

• Therefore, appropriate for Therefore, appropriate for palliative carepalliative care

How to implement palliative How to implement palliative carecare

• Look at every order, Look at every order, • Evaluate benefits to him vs. burdensEvaluate benefits to him vs. burdens

– MedicationMedication– TherapiesTherapies– DiagnosticsDiagnostics

Holmes, H. M. et al. Arch Intern Med 2006;166:605-609.

The Medication Appropriateness Index

What orders?What orders?

• Wound careWound care• TelemetryTelemetry• DietDiet• EchoEcho• Labs—Labs—

– Frequent blood culturesFrequent blood cultures• MedicationsMedications

– PainPain– IV AbxIV Abx– AntihypertensiveAntihypertensive

Improving Care for Patients Improving Care for Patients with Advanced Diseasewith Advanced Disease

• Challenge in those with long Challenge in those with long term progressive disability term progressive disability and eventual death:and eventual death:– No point marks a dramatic No point marks a dramatic

transition from ‘cure’ to ‘care’transition from ‘cure’ to ‘care’– Disease-modifying treatments Disease-modifying treatments

mixed with symptom mixed with symptom prevention and reliefprevention and relief

– Comprehensive advance care Comprehensive advance care planningplanning

SummarySummary

• Identify those with limited life Identify those with limited life expectancy for starting palliative expectancy for starting palliative care care – Focus on symptom managementFocus on symptom management– Put all your orders through the lens of Put all your orders through the lens of

how it will help the patient how it will help the patient