Palliative Care Consultation TeamAn IntroductionBasics of Pain Management11.30.09

What is Palliative Care?

What is Palliative Care?

• One definition:• “comprehensive, interdisciplinary care,

focusing primarily on promoting quality of life for patients living with a serious, chronic, or terminal illness and for their families…assuring physical comfort and psychosocial support. It is provided simultaneously with all other appropriate medical treatments.”

• Billings, J Palliative Medicine, 1999

• California HealthCare Foundation

• Spreading Palliative Care in Public Hospitals Initiative

• Focus on providing culturally sensitive care

• We have one of six implementation grants statewide

California public hospitals lag private hospitals in palliative care

Palliative Care Programs 2007, by Hospital Ownership

0%

10%

20%

30%

40%

50%

60%

70%

Non-profit District City/County For-profit

Percentage of hospitals with programs

CCRMC data

• Review of data from patient deaths, January - June 2009

• How many patient deaths after > 30 days in the hospital?

• In which unit do most patient deaths occur?

• What are the major causes of death among our patients?

Length of stay for patients who ultimately died

Length of Stay Prior to Death

0

10

20

30

40

50

60

1 5 9 13 17 21 25 29 33 37 41 45 49 53 57 61

Patients

Nu

mb

er

of

Days

Location at time of death

Patient Location at Time of Death

FLOOR33%

IMCU15%

CCU52%

Causes of death at CCRMC, January-June

2009Reported Cause of Death

29%

15%

13%

10%

7%

7%

19%

Septicemia

Acute RespiratoryFailure

Liver or Renalfailure

Malignancy

COPD

Acute MI

Other

The CCRMC Palliative Care Consultation Service

• A multidisciplinary team which will collaborate with CCRMC staff in providing palliative care to our patients

• An integrative service• Available for inpatients in our first

year• Expanding to the ED in our second

year

Multidisciplinary

• Clinicians (Hellman-Wylie, Steinhart, Freedman, Akin, Tzvieli, Kuruvilla, McCormick…and you?)

• Social work (Linda Russell)

• Pharmacists (Katherine Dial, Sharon Sihota)

• Interpreters• Psychiatry consult-liaison staff (Liat Porat, John

Echols)• Nursing education (Marianne Bunce)

• Residents (Matt Foster, Sergio Urcuyo)

• Any resident on elective block who wants to join us for consultations is welcome

When do I consult?

• Terminal illness with distressing symptoms

• Chronic illness with distressing symptoms

• Patient/family prefer to be at home rather than hospital

• Prolonged critical care course with poor prognosis

• Lack of clarity in goals of care

When do I consult?

• Chronic illness with frequent hospitalizations

• Patient/family lack understanding of diagnosis and prognosis

• Advance care planning - choosing a DPOA, completing an advance directive

• You just don’t have time to find out what is going on….

What will we do?

Review referred cases and arrange family meetings

Support relationship of primary team with patient and family

Explore social historyReview current medications and other ordersEstablish advance directivesArrange home or hospice servicesCo-follow patients with you

Our Challenges

• Palliative care for an ethnically diverse population

• Integrative care - effective collaboration between two teams

• Education throughout the institution - nursing staff, residents, and others

Attitudes toward care at the end of life vary by race and ethnicity

• CHCF sponsored survey of 1,800 California adults in 2006

• Which comes closer to your view?– “Doctors and nurses should always

do everything possible to save a life.”– “Sometimes there are circumstances

where a patient should be allowed to die.”

Attitudes toward care at the end of life vary by race and ethnicity

0

10

20

30

40

50

60

70

White Latino AA Asian

Allow deathIt dependsDo everything

Culturally appropriate palliative care

• Interpretation - Interpreters trained to act as cultural brokers, not simply translators

• Cultural humility• Strength of provider-patient

therapeutic relationship key to navigating gaps in understanding

Our Challenges

• Integrative care - effective collaboration between two teams– Primary team included in meetings whenever

possible– Encourage residents to lead meetings

• Education throughout the institution - nursing staff and other disciplines– Inclusion of the bedside nurse in meetings with

patients and families.– Continuing education sessions for nursing staff– Educational programs with other disciplines?

(RTs, etc.)

• Palliative care team is available Monday - Friday, 8 am - 5 pm

• Call schedule available on amion.com with password “ccrmc”

• Think of palliative care broadly, not just in terminal illness

• We will learn as we go - please give us feedback so that we can do just that