PALLIATIVE CAREUPDATE

PALLIATIVE CAREUPDATE

BY

SALLY SAMPLE, MDBY

SALLY SAMPLE, MD

LIFE IS SHORTLIFE IS SHORT

Employment AffiliationsEmployment Affiliations

Medical Director Vitas Innovative Hospice, Sacramento Valley

Medical Director End-of-life pilot for Medi-Cal administered by

APS Healthcare starting 2010

Hospitalist Woodland Memorial Hospital

Medical Director Vitas Innovative Hospice, Sacramento Valley

Medical Director End-of-life pilot for Medi-Cal administered by

APS Healthcare starting 2010

Hospitalist Woodland Memorial Hospital

FINANCIAL DISCLOSUREFINANCIAL DISCLOSURE

• I have no financial gains or incentives for this talk

• I have no financial gains or incentives for this talk

GOALSGOALS

• To have everyone thinking of Palliative Care when dealing with their chronically ill patients

• To encourage discussions with those patients• To realize that just because we CAN do a treatment

doesn’t mean we SHOULD• To remember:

Everyone dies--it is not a failure

• To have everyone thinking of Palliative Care when dealing with their chronically ill patients

• To encourage discussions with those patients• To realize that just because we CAN do a treatment

doesn’t mean we SHOULD• To remember:

Everyone dies--it is not a failure

SUMMARYSUMMARY

• DEFINITIONS

• HISTORY stigma of death and dying

• PC Today and the HCP role– Some relevant references to the literature– Legislation– National and State Trends

• DEFINITIONS

• HISTORY stigma of death and dying

• PC Today and the HCP role– Some relevant references to the literature– Legislation– National and State Trends

PC DEFINITIONSPC DEFINITIONS

--Care of the entire person and family--physical, psychological, social and spiritual

– Care to minimize Suffering

Cassell,E.J.(1982).The nature of suffering and the goals of medicine. NEJM 306(11),639-45

--Care of the entire person and family--physical, psychological, social and spiritual

– Care to minimize Suffering

Cassell,E.J.(1982).The nature of suffering and the goals of medicine. NEJM 306(11),639-45

PC DEFINITIONS PC DEFINITIONS

GRAPHGRAPH

HISTORYHISTORY

HISTORYHISTORY

• PALLIATIVE CARE: OLDEST FORM OF MEDICINE

• NEWEST SUBSPECIALTY

• PALLIATIVE CARE: OLDEST FORM OF MEDICINE

• NEWEST SUBSPECIALTY

PALLIATIVE CAREPALLIATIVE CARE

19th century and before:

approach to illness involved family, church,

very few life prolonging treatments

family at death bed

dying was part of life

19th century and before:

approach to illness involved family, church,

very few life prolonging treatments

family at death bed

dying was part of life

PALLIATIVE CAREPALLIATIVE CARE

• 19th century and before

• Health Care Provider Role:

Diagnosis and Prognosis– Whether the patient would succumb

• 19th century and before

• Health Care Provider Role:

Diagnosis and Prognosis– Whether the patient would succumb

PALLLIATIVE CAREPALLLIATIVE CARE

• Civil War changed nature of death and dying--no longer family at death bed

This Republic of Suffering. By Drew Gilpin Faust

• Civil War changed nature of death and dying--no longer family at death bed

This Republic of Suffering. By Drew Gilpin Faust

PALLIATIVE CAREPALLIATIVE CARE

• Mid 20th Century---life prolonging Rx• Prognosis gave way to treatment

– Antibiotics in WWII– CPR– Gastrostomy tubes– ICU’s– Other life sustaining/prolonging treatments

• Mid 20th Century---life prolonging Rx• Prognosis gave way to treatment

– Antibiotics in WWII– CPR– Gastrostomy tubes– ICU’s– Other life sustaining/prolonging treatments

PALLIATIVE CAREPALLIATIVE CARE

• mid 20th century

– Prognosis took lesser role

– Emphasis on treatment

• mid 20th century

– Prognosis took lesser role

– Emphasis on treatment

PALLIATIVE CAREPALLIATIVE CARE

• mid 20th century

– Care of the terminally ill given less importance in medical training

– Talk of death and dying became socially unacceptable and seen as medical failures

• mid 20th century

– Care of the terminally ill given less importance in medical training

– Talk of death and dying became socially unacceptable and seen as medical failures

WHERE ARE WE TODAY?WHERE ARE WE TODAY?

CARTOONCARTOON

PALLIATIVE CARE TODAYPALLIATIVE CARE TODAY

• Cost Reduction

1. 27-30% Medicare dollars spent last year of life

2. Palliative care services in hospitals save money*

3. Hospice referrals save money

*Center for Advancement of Palliative Care

Website:CAPC.org

• Cost Reduction

1. 27-30% Medicare dollars spent last year of life

2. Palliative care services in hospitals save money*

3. Hospice referrals save money

*Center for Advancement of Palliative Care

Website:CAPC.org

PALLIATIVE CARE TODAYPALLIATIVE CARE TODAY

ALLEVIATE SUFFERING ALLEVIATE SUFFERING

PALLIATIVE CARE TODAYPALLIATIVE CARE TODAY

• HCP’s Role • Prognosis

• Giving patients choices

• Talk of death and dying when appropriate

• Referral to palliative care and hospice when appropriate

• HCP’s Role • Prognosis

• Giving patients choices

• Talk of death and dying when appropriate

• Referral to palliative care and hospice when appropriate

PALLIATIVE CARE TODAYPALLIATIVE CARE TODAY

• HCP’s Role– Prognosis

• HCP’s Role– Prognosis

DEATH TRAJECTORY and PROGNOSISDEATH TRAJECTORY and PROGNOSIS

DEATH TRAJECTORY and PROGNOSISDEATH TRAJECTORY and PROGNOSIS

DEATH TRAJECTORY and PROGNOSISDEATH TRAJECTORY and PROGNOSIS

DEATH TRAJECTORYDEATH TRAJECTORY

• Prognosis dwindling patient• Prognosis dwindling patient

DWINDLING PATIENTDWINDLING PATIENT

DWINDLING PATIENTDWINDLING PATIENT

HCP’S ROLEHCP’S ROLE

• Prognostication– Difficult at best--little or no training– Foreseeing and Foretelling– Doctors are overly optimistic

Christakis, N.A. and Lamont, E.B. (2000).Extent and

determinants of error in doctor’s prognoses in terminally ill patients: prospective cohort study; BMJ 320, 469-72.

• Prognostication– Difficult at best--little or no training– Foreseeing and Foretelling– Doctors are overly optimistic

Christakis, N.A. and Lamont, E.B. (2000).Extent and

determinants of error in doctor’s prognoses in terminally ill patients: prospective cohort study; BMJ 320, 469-72.

PALLIATIVE CARE TODAYPALLIATIVE CARE TODAY

• HCP’s Role– Giving patients choices

• HCP’s Role– Giving patients choices

PALLIATIVE CARE TODAYPALLIATIVE CARE TODAY

• Giving patients choices:

• POLST--Cal Legislation AB 3000

effective January 1, 2009

• Giving patients choices:

• POLST--Cal Legislation AB 3000

effective January 1, 2009

HEALTH CARE PROVIDER’S ROLEHEALTH CARE PROVIDER’S ROLE

HEALTH CARE PROVIDER’S ROLEHEALTH CARE PROVIDER’S ROLE

• TALK OF DEATH AND DYING

– Legislation “Patient Self Determination Act” of 1991• Requires inpatients be asked about advance care

directives

• TALK OF DEATH AND DYING

– Legislation “Patient Self Determination Act” of 1991• Requires inpatients be asked about advance care

directives

HEALTH CARE PROVIDER’S ROLEHEALTH CARE PROVIDER’S ROLE• TALK OF DEATH AND DYING

– California law “Right to Know End-of-Life Options” Act AB 2747

– Enacted 5/2008– Patients that have a terminal illness have to be given

accurate info about treatment options and pain management

• TALK OF DEATH AND DYING

– California law “Right to Know End-of-Life Options” Act AB 2747

– Enacted 5/2008– Patients that have a terminal illness have to be given

accurate info about treatment options and pain management

HEALTH CARE PROVIDER’S ROLEHEALTH CARE PROVIDER’S ROLE

• NEXT YEAR in Contra Costa County:

– A Pilot program for Medi-Cal and End-of-Life

administered by APS Healthcare--more next year

• NEXT YEAR in Contra Costa County:

– A Pilot program for Medi-Cal and End-of-Life

administered by APS Healthcare--more next year

HEALTH CARE PROVIDER’S ROLEHEALTH CARE PROVIDER’S ROLE

• Talk of Death and Dying– Why is it so hard for us

• Talk of Death and Dying– Why is it so hard for us

HEALTH CARE PROVIDER’S ROLEHEALTH CARE PROVIDER’S ROLE

• Talk of Death and Dying--Myths– The hard conversation will depress patients– Patients will lose hope– Saying it will make it happen

• Talk of Death and Dying--Myths– The hard conversation will depress patients– Patients will lose hope– Saying it will make it happen

HEALTH CARE PROVIDER’S ROLEHEALTH CARE PROVIDER’S ROLE

HEALTH CARE PROVIDER’S ROLEHEALTH CARE PROVIDER’S ROLE

HEALTH CARE PROVIDER’S ROLEHEALTH CARE PROVIDER’S ROLE

HEALTH CARE PROVIDER’S ROLEHEALTH CARE PROVIDER’S ROLE

SUMMARYSUMMARY

• Dying and death are inevitable

• Palliative care or hospice--can alleviate suffering

• Choices--we have them--think about them; discuss them – With life-limiting illnesses

• Aggressive disease modifying treatment• Palliative care• Hospice

• Dying and death are inevitable

• Palliative care or hospice--can alleviate suffering

• Choices--we have them--think about them; discuss them – With life-limiting illnesses

• Aggressive disease modifying treatment• Palliative care• Hospice

THANK YOUTHANK YOU

• Sally Sample, MD

• Email sasample@comcast.net

• Sally Sample, MD

• Email sasample@comcast.net