Vol. 39 No. 2 February 2010 Schedule with Abstracts 375

Improvement Model approach to describe aninnovative methodology to manage COPD pa-tient enrolled in hospice to ensure optimaloutcomes for patient, family, and the health-care system.

3. Identify a framework for similar innovativeapproaches that are applicable to othernoncancer hospice diagnosis based on chro-nicity and acuity of disease process.

Respiratory disease is the fourth leading cause ofdeath in the United States. The most commonreason for emergency department (ED) visitsfrom 1990 to 2000 in adults was disabling short-ness of breath, with more than 1 million EDvisits every year for COPD, which is incurableand progressive. Hospice benefit is underutil-ized by individuals dying of chronic lung diseaseand both genders’ death rates from lung diseaseare increasing. COPD expenditures of $37.2 bil-lion were realized in 2004.CareBeyond is a specialized hospice program de-signed specifically for COPD patients and theirfamilies. The goal of care beyond is to aggres-sively manage symptoms of COPD patients in or-der to improve their quality of life by reducingrespiratory crisis, ED visits, and hospitalizations.The program is available to all patients withCOPD with life expectancies of 6 month orless. Both psychosocial and physical needsunique to COPD patient and their loved onesare addressed. Specialized training in the formof a 1-month-long in-service training for partici-pating facilities includes a centralized trainingmodule and increased frequency of visits (dailyby a social worker and nurse in the first ‘‘powerweek’’), which enables the staff members to an-ticipate exacerbations, respond immediately,and address needs.The patients enrolled in this program were com-pared to previous unenrolled patients and weretracked for 16 weeks to assess the followingparameters:1. use of medications2. 911 calls for Shortness of breath3. hospitalizations for COPD related events4. COPD exacerbations.The patients enrolled in the CareBeyond Pro-gram clearly showed a decrease in the aboveparameters.The program shows promise for a chronic diseasemanagement approach for many noncancer hos-pice diagnoses (eg, dementia, renal failure) to op-timize outcomes and cost in the hospice setting,

while keeping the patients and their disease pro-cesses at the center of the program.

DomainStructure and Processes of Care

Good to Great: Taking a Palliative CareProgram to the Next Level ina Comprehensive, Systematic, SustainableWay (408)Mary Hicks, MSN RN APN-BC ACHPN, St. JohnHospital and Medical Center, Detroit, MI.Merry Davis, BA, Davis Strategies LLC, Durham,NC. Elizabeth DiStefano, BSN RN, St. John Health,Macomb Township, MI. Richard Payne, MD, DukeUniversity, Durham, NC. Betty Granger, SSJ, St.John Health System, Warren, MI.(All speakers have disclosed no relevant finan-cial relationships.)

Objectives1. List two successful strategies for expanding ac-

cess to palliative care services.2. Describe strategies for integration of spiritual

care and palliative care.3. Define two goals for culture change related to

PC.

St. John Health, Southeast Michigan’s largestacute care health system recently completeda comprehensive 3-year project to change theculture toward palliative care. In collaborationwith the Duke Institute for Care at the End-of-life, the health system implemented a multi-strategy palliative care (PC) initiative designedto: increase the number of patients receivingpalliative care, raise PC awareness and skills ofstaff, improve integration of spiritual care andPC, and engage local faith communities to sup-port patients and families facing chronic/serious illness. Workgroups of staff and manage-ment from different disciplines and settings ofcare implemented strategies including develop-ment and pilot testing of a tool to screen forPC needs, train-the-trainer educational pro-gram, revision of procedures for spiritual caredelivery to all patients receiving PC consultation,staff education on basic palliative care and spiri-tuality, policy and procedure revision, regularcommunication via recognized internal publica-tions, and PC conferences and written resourcesfor local clergy and lay leaders. The project wassuccessful in establishing ‘‘triggers’’ for PC con-sultation that will be applied to all patients,

376 Schedule with Abstracts Vol. 39 No. 2 February 2010

increasing the number of PC consultations 2.5-fold while decreasing the mean time from ad-mission to consultation, raising to 100% the per-centage of planned family meetings for PCpatients attended by a spiritual care provider,training 35 PC champions who educated an ad-ditional 250 staff in basic PC, engaging and mo-bilizing over 500 faith community leaders,creating new policies related to PC delivery,and documenting a positive cash flow by PC ser-vices. Culture change was evidenced by attitudesof both leaders and staff (revealed, in part, viafocus groups) regarding the value of PC, formaland informal policy change, and institution ofa system-wide PC coordinator position and of-fice. This session will provide effective toolsand strategies to improve and sustain compre-hensive program operations.

DomainStructure and Processes of Care

Case Conference II (409)

Decision-Making and Care Provision forthe Terminally Ill Patient with MentalIllnessKerry Case, MD, Medical College of Wisconsin,Waukesha, WI.(Case has disclosed no relevant financialrelationships.)

Objectives1. Describe an ethical approach to balancing an

incompetent patient’s medical needs with thepreservation of dignity and maximization ofautonomy.

2. Identify three unique vulnerabilities mentallyill patients face as they approach the end of life.

3. Recognize the role of the palliative care teamin addressing ethical distress in colleagues.

IntroductionActive mental illness can significantly complicateend of life decision making and care delivery.Skillful provision of palliative care to the men-tally ill patient is a unique challenge which takesparticular advantage of the shared strengths ofa multidisciplinary team.

CaseND, a 46-year-old woman with end-stage renal dis-ease, was unable to receive dialysis due to behav-ioral issues secondary to treatment refractoryschizophrenia. Psychosis and paranoia persisteddespite maximal doses of multiple antipsychotics.

Barriers to dialysis included refusal of vascular ac-cess procedures, fear of laboratory monitoring,and non-cooperation with the actual perfor-mance of dialysis. Repetitive restraint for treat-ment and trial of electroshock therapy weredeemed unacceptable. Comfort care was electedby the patient’s court-appointed legal guardian.Placement options for ND were limited. The pa-tient’s group home declined her return on a hos-pice plan of care due to concern for the impacther death might have on the home’s other resi-dents. Nursing homes and residential hospiceswere unable to safely manage the patient’s behav-ioral issues. The county psychiatric facility declinedadmission given non-psychiatric treatment goals.Adult foster care placement also failed.A lengthy hospitalization while awaiting place-ment contributed to psychiatric decompensa-tion, and members of the medical teamstruggled with the pursuit of comfort care foran incompetent mentally ill patient with a medi-cal illness for which life-prolonging treatmentexists. Ultimately hospice placement wasachieved in a psychiatric unit, and ND was reho-spitalized for symptom management as she died.

Discussion PointsND’s case highlights the application of ethicalprinciples in the care of a particularly vulnerablepopulation, identifies the need for enhanced ac-commodation for the mentally ill patient withinpalliative care environments, and illustrates theimportance of palliative teams addressing otherclinicians’ ethical concerns.

DomainAll domains

Mindfulness and the Difficult PatientSeth Roberts, MD, PhD, Virginia Common-wealth University, Richmond, VA.(Roberts has disclosed no relevant financialrelationships.)

Objectives1. Define mindfulness.2. List five specific mindfulness-based practices.3. Describe how to apply mindfulness-based

practices to the care of the difficult patient.The practice of hospice and palliative medicineinvolves frequent exposure to suffering, death,and difficult patient and family circumstances.Because of this, provider burnout and strategiesfor self care are recognized as critically