Transitioning to Palliative Care: Starting the Conversation

Dr. José PereiraHead Division of Palliative Care, University of Ottawa

Medical Chief, Palliative Care Service, Bruyère Continuing Care & The Ottawa Hospital

Provincial Medical Lead for Palliative Care, Cancer Care Ontario

Faculty/Presenter Disclosure

Faculty: Dr. José Pereira Program: 51st Annual Scientific Assembly

Relationship with commercial interests:– Grants/Research Support: Takeda (past) Education grant to

conduct review of breakthrough pain– Speakers Bureau/honoraria: Nil to report– Consulting Fees: Nil to report– Other: Nil to report

Disclosure of Commercial Support

This program has NOT received financial support This program has NOT received in-kind support

(except for myself and my organization who have allowed me to be here to present on their time)

No potential for conflict(s) of interest to declare

Mitigating potential bias

Jose Pereira– Nil to declare

QUESTIONSWhat is the annual mortality rate of patients with NYHA Class II?

What is annual mortality rate of patients with NYHA Class IV?

CHF Mortality

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QUESTIONSWhat is the annual mortality rate of patients with NYHA Class II?

What is annual mortality rate of patients with NYHA Class IV?

CHF Mortality

NYHA Class II - Annual mortality rate 5-

15%- 50-80% die suddenly

NYHA Class IV- Annual mortality rate

30-70%- 5-30% die suddenly

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Heyland DK et al. Discussing prognosis with patients and their families near the end of life: impact on satisfaction with end-of-life care. Open Medicine 2009;3(2):101-110

QUESTIONIn a study of 440 patients with end-stage disease, the % of patients who recalled prognosis discussions with their families :

1. Cancer patients?2. CHF patients?3. COPD patients?

Participants who recalled prognosis discussions

Patients (n=440) : 18% Family members (n=160): 30%

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Patients Had discussion %

Did not have discussion %

Cancer patients (n=151) 27% 73%

CHF (n=99) 14% 86%

COPD (n=115) 9% 91%

Cirrhosis (n=47) 21% 79%

Heyland DK et al. Discussing prognosis with patients and their families near the end of life: impact on satisfaction with end-of-life care. Open Medicine 2009;3(2):101-110

Participants who recalled prognosis discussions

Old model of Palliative Care

Palliative Care: Earlier in illness, not only at end-of-life

RCT of patients with newly diagnosed metastatic lung cancer

Early palliative care consultation versus standard of later referral for end of life care

Compared to late referred patients, patients with early palliative care consultation had:– Less depression & anxiety– Better quality of life– Lived longer (3 months)

Temel J, et al. Early Palliative Care for Patients with Metastatic Non–Small-Cell Lung Cancer. NEJM 2010; 363:733-42

Activating palliative care does not shorten life

Palliative and End of Life Trajectories

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Palliative Alerts

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For some patients the decline may be more gradual while for others it may be more precipitous

Death

Explore pt’s understanding of illness,

discuss prognosis & goals of care.

Explore pt’s understanding of illness,

discuss prognosis & goals of care.

Encourage patient to see family

physician regularly or find one.

Encourage patient to see family

physician regularly or find one.

Advance care planning. Discuss code status

Review treatment plan

Advance care planning. Discuss code status

Review treatment planEnsure ESAS &

PPS/ECOG done at each visit.

Ensure ESAS & PPS/ECOG done at

each visit. Initiate home care

Initiate home care

Establish plans to deal with emergencies

(e.g. pain crisis)

Establish plans to deal with emergencies

(e.g. pain crisis)

DNR & Advanced directives

DNR & Advanced directives

Discuss preferred

versus optimal place of death

based on needs &

circumstances

ILLNESS TRAJECTORY IN PROGRESSIVE CANCER

Consult Palliative Care

Team as needed

Consult Palliative Care

Team as needed

%

Palliative and End of Life Trajectories

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Palliative and End of Life Trajectories

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“Will I be surprised if this patient died in the next 6 to 12 months?”

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Ask the question

Gold Standards Framework: General and Disease-specific indicators

Gold Standards Framework: General and Disease-specific indicators

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How did you feel while viewing the video?What was done well?What can be done better?What are some useful phrases?

Goals of care 1

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How did you feel while viewing the video?What was done well?What can be done better?What are some useful phrases?

“How long do I have to live?”

“I wish things were different”

Quill T. Ann Int med 2001

www.advancecareplanning.ca

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QUESTIONWhat prevents us from having end-of-life discussions?

QUESTIONS??