Palliative Care

Cardinale B. Smith, MD, MSCRAssistant Professor

Division of Hematology/ Medical Oncology Tisch Cancer Institute

Brookdale Department of Geriatrics & Palliative Medicine

Hertzberg Palliative Care Institute Icahn School of Medicine at Mount Sinai

Palliative Care• Specialized medical care for people with serious

illnesses. • 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.

• 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.

• Appropriate at any age and at any stage of a serious illness, and can be provided together with curative or disease directed treatments.

Palliative Care in Practice

• Expert control of pain and symptoms• Uses the crisis of the hospitalization to

facilitate communication and decisions about goals of care with patient and family

• Coordinates care and transitions across fragmented medical system

• Provides practical support for family and other caregivers (+ clinicians)

Palliative /Hospice CarePalliative /Hospice Care Disease-focused Care(“Aggressive Care”)

Disease-focused Care(“Aggressive Care”)

Old Model: Two types of care

The Cure - Care Model: The Old System

Life Prolonging Care

Palliative/

Hospice

Care

DEA TH

Disease Progression

Death &Bereavement

Disease Modifying Therapycurative or restorative intent

LifeClosure

Diagnosis

A New Vision of Care

Palliative Care Hospice

Palliative Care

Palliative Care Is

Excellent, evidence-based medical treatment

Vigorous care of pain and symptoms throughout illness

Care that patientswant at the same time as efforts to cure or prolong life

Palliative Care Is NOT

Not “giving up” on a patient

Not in place of curative or life-prolonging care

Not the same as hospice or end-of-life care

Consumer Knowledge of Palliative Care 95% of respondents agree

that it is important that patients with serious illness and their families be educated about palliative care.

92% of respondents say they would be likely to consider palliative care for a loved one if they had a serious illness.

92% of respondents say it is important that palliative care services be made available at all hospitals for patients with serious illness and their families.

CAPC/ACS Public Opinion Survey, 2011

Significance of Palliative Care

• More patients with serious illness not imminently dying, but living with chronic and debilitating conditions

• Surveys of patients and families have identified top needs:• Relief of suffering• Practical support needs• Open communication• Opportunities to relieve burdens and strengthen

relationships with families

Lifetime Risk of:

Palliative Care – Relevance In Context

Heart disease: 1:2 men; 1:3 women (age 40+)

Cancer: > 1:3

Alzheimer's: 1:2.5 – 1:5 by age 85

Diabetes: 1:5

Parkinson’s: 1:40

The Reality of the Last Years of Life: Death Is Not Predictable

Series1

0

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CancerEnd-Stage Organ FailureDementia (years)

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(slide adapted from Joanne Lynn, MD, Rand Health/CMS)

Time

Hospital Palliative Care:The 5 Main Principles

1. Clinical Quality

2. Patient and Family Preferences

3. Demographics

4. Education

5. Finances

Why palliative care?

1. The Clinical Imperative

The need for better quality of care for people with serious and complex illnesses.

Everybody with serious illness spends at least some time in a hospital...

• 98% of Medicare decedents spent at least some time in a hospital in the year before death.

• 15-55% of decedents had at least one stay in an ICU in the 6 months before death. Average length of stay in the ICU is 2-11 days.

Dartmouth Atlas of Health Care 1999 & 2006

Symptom Burden of Patients Hospitalized With Serious Illness at 5

U.S. Academic Medical Centers

% of 5176 patients reporting moderate to severe pain between days 8-12 of admission

Colon Cancer 60%Liver Failure 60%Lung Cancer 57%COPD 44%CHF 43%

Desbiens & Wu. JAGS 2000;48:S183-186.

Why palliative care?

2. Concordance with patient andfamily wishes

What is the impact of serious illness on patients’ families?

What do persons with serious illness say they want from our healthcare system?

What Do Patients with Serious Illness Want?

• Pain and symptom control• Avoid inappropriate prolongation of

the dying process• Achieve a sense of control• Relieve burdens on family• Strengthen relationships with

loved ones

Singer et al. JAMA 1999;281(2):163-168.

“Difficult” Conversations Improve Outcomes

• Multisite, longitudinal study of 332 patient-family dyads

• 37% of patients reported having prognosis discussion at baseline

• These patients had lower use of aggressive treatments, better quality of life, and longer hospice stays

• Family after-death interviews showed better psychological coping for those with conversations as compared to those without

Wright et al. JAMA 2008 300(14):1665-1673

What Do Family Caregivers Want?Study of 475 family members 1-2 years after bereavement• Loved one’s wishes honored• Inclusion in decision processes• Support/assistance at home• Practical help (transportation, medicines, equipment)• Personal care needs (bathing, feeding, toileting)• Honest information• 24/7 access• To be listened to• Privacy• To be remembered and contacted after the death

Tolle et al. Oregon report card.1999 www.ohsu.edu/ethics

Families Want to Talk About Prognosis

• Qualitative interviews with 179 surrogate decision makers of ICU patients

• 93% of surrogates felt that avoiding discussions about prognosis is an unacceptable way to maintain hope

• Information is essential to allow family members to prepare emotionally and logistically for the possibility of a patient's death

• Other themes:• moral aversion to the idea of false hope• physicians have an obligation to discuss prognosis• surrogates look to physicians primarily for truth and

seek hope elsewhere

Apatira et al. Ann Intern Med. 2008;149(12):861-8

Why palliative care?

3. The demographic imperative

Hospitals need palliative care to effectively treat the growing number of persons with serious, advanced and complex illnesses.

Chronically Ill, Aging Population Is Growing

• The number of people over age 85 will double to 10 million by the year 2030.

• The 23% of Medicare patients with >4 chronic conditions account for 68% of all Medicare spending.

US Census Bureau, CDC, 2003 Anderson GF. NEJM 2005;353:305

CBO High Cost Medicare Beneficiaries May 2005

Hospital Based Palliative Care Programs in the United States

63% of all hospitals and 85% of mid-large size hospitals report a palliative care team

100% of cancer centers report a palliative care team

Nation moves from a “C” grade to a “B” in less than 5 years

Why palliative care?

4. The educational imperative

Every doctor and nurse-in-training learns in the hospital.

Specialty Number of Fellowship Positions

Number of Fellowship Programs

Number of Providers

Cardiology 779 175 25,901

Medical Oncology 486 130 14,000

Palliative Care and Hospice

234 85 4,400

Deficiencies in Medical Education

http://www.nrmp.org/data/resultsanddatasms2012.pdf

Improvements in Education

• 2007 Board Certification in Palliative Care

• Medical school licensing requirement:

“Clinical instruction must include important aspects of … end of life care (average 14 hours).”

Why palliative care?

4. The fiscal imperative

Hospital and insurers of the future will have to efficiently and effectively treat serious and complex illness in order to survive.

Healthcare Spending and Quality

http://ucatlas.ucsc.edu/spend.php

U.S. leads the world in per capita spending27th in life expectancy37th in overall quality of healthcare system (WHO)

I’m afraid we’ve had to move him to expensive care

National Health Expenditure Growth 1970-2003

HCFA, Office of the Actuary, National Health Statistics Group, 2003

Costs and Outcomes Associated with Hospital Palliative Care Consultation

8-hospital study Live Discharges Hospital Deaths

Costs Usual Care

Palliative Care

P Usual Care

Palliative Care

P

Total Per Day

$1,450 $1,171 <.001 $2,468 $1,918 <.001

Directs Per Admission

$11,1240 $9,445 .004 $22,674 $17,765 .003

Laboratory $1,227 $803 <.001 $2,765 $1,838 <.001

ICU $7,096 $1,917 <.001 $15,542 $7,929 <.001

Pharmacy $2,190 $2,001 .12 $5,625 $4,081 .04

Imaging $890 $949 .52 $1,673 $1,540 .21

Died in ICU X X X 18% 4% <.001

Adjusted results, n>20,000 patients

Morrison et al. Arch Internal Med. 2008. 168 (16)

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Day of Admission

Dir

ect

Co

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$)

Usual care PC consult day 4-5 PC consult day 6-7

PC consult day 8-9 PC consult day 10-11 PC consult day 12-13

8 Hospital Study:Costs/day for patients who died with palliative

care vs. matched usual care patients

Cost Savings – Medicaid in NY State

Cost savings/Day for Live DischargesMorrison et al. Health Affairs 2011 30:454-63

U. Michigan- Hospice of MichiganPalliative Care Reduces Hospital Costs

(patients with complete data as of July 1, 2002, at Medicare prices, excludes Rx)

How Palliative Care Reduces Length of Stay and Cost

Palliative care:• Clarifies goals of care with patients and

families• Helps families to select medical treatments

and care settings that meet their goals• Assists with decisions to leave the hospital, or

to withhold or withdraw treatments that don’t help to meet their goals

Aug 19 2010;363(8):733-42

What Does All this Mean from the Patient Perspective?

For patients, palliative care is a key to:• relieve symptom distress • navigate a complex medical system• understand the plan of care• help coordinate and control care options• allow simultaneous palliation of suffering along

with continued disease treatments (no requirement to give up life prolonging care)

• provide practical and emotional support for exhausted family caregivers

What Does All this Mean from the Clinician Perspective?

For clinicians, palliative care is a key tool to:

• Save timehelp to handle repeated, intensive patient-familycommunications, coordination of care acrosssettings, comprehensive discharge planning

• Provide Symptom Controlassists with controlling pain and distress for highlysymptomatic and complex patients, 24/7

-thus supporting clinician’s treatment plan

• Promote Satisfaction increases patients’ and families’ satisfaction with the quality of care provided by the clinician

What Does All this Mean from the Hospital Perspective?

For hospitals, palliative care is a key tool to:• effectively treat the growing number of people

with complex advanced illness• provide excellent patient-centered care• increase patient and family satisfaction• improve staff satisfaction and retention • meet accreditation and quality standards• rationalize the use of scarce hospital resources• increase bed/ICU capacity, reduce costs

But……….

• Disparities in access to palliative care• Lack of a solid evidence base to guide

clinical care and care delivery• Lack of research funding to support

needed research• Need for public advocacy and public and

professional education

Research Publications: Oncology and Palliative Care (2003-2005)

Gelfman LP, Morrison RS. J Palliat Med, 2008

Summary

• Palliative care improves quality of care for our sickest and most vulnerable patients and families.

• Serious illness is a universal human experience and palliation is a universal health professional obligation.

"When we honestly ask ourselves which people in our lives mean the most to us, we often find that it is those who, instead of giving advice, solutions, or cures, have chosen rather to share our pain and touch our wounds with a warm heart and tender hand. The person who can be silent with us in a moment of despair or confusion, who can stay with us in an hour of grief and bereavement, who can tolerate not knowing, not curing, and face with us the reality of our powerlessness, that is a person who cares.”

 

-Henri Nouwen