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BRANDY MILLWARD, LCSW PALLIATIVE CARE: HOW CAN IT HELP WITH YOUR PATIENTS’ TRANSITIONS?
BRANDY MILLWARD, LCSW
PALLIATIVE CARE: HOW CAN IT HELP
WITH YOUR PATIENTS’ TRANSITIONS?
Objectives
1) What is Palliative Care?
2) What are Goals of Care?
3) When is the right time to get Palliative Care involved?
4) How can Palliative Care help with transitions?
5) What is the role for Social Work in Palliative Care?
Objective 1
What is Palliative Care?
What is Palliative Care?
World Health Organization Definition
Palliative Care is an approach that improves quality of life of patient’s and their families facing the
problems associated with life-threatening illness, through the prevention and relief of suffering by
means of early identification and impeccable assessment and treatment of pain and other
problems, physical, psychosocial and spiritual.
What is Palliative Care?
Center for Medicare and Medicaid
Palliative care means patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care
throughout the continuum of illness involves addressing physical, intellectual, emotional, social,
and spiritual needs and facilitating patient autonomy, access to information, and choice
Federal Register 2008 - 73 FR 32204, June 5, 2008
Evidenced Based Outcomes
• Improve symptoms • Improved quality of life• Avoid hospitalization and to remain safely and adequately cared for at
home• Improve patient and family satisfaction• Reduce grief and acute/posttraumatic stress disorder among
bereaved family members • Lowers healthcare costs• Decreased emergency department utilization • Among patients hospitalized in intensive care units (ICUs), benefits of
early proactive palliative care involvement include more and earlier ICU family meetings and shorter length of stay
• Improves survival with certain cancer diagnoses• Increase utilization of hospice
-references at end of slide deck
But wait I already do palliative care!
Secondary and tertiary palliative care in US hospitals. Von Gunten. JAMA. 2002 Feb 20;287(7):875-81
Primary Level
Secondary Level
Tertiary Level
Palliative Care is a response to the success of turning once acutely terminal diagnoses into chronic illness with improved survival:
World Health Organization Position Statement:
“this change in thinking emerged from a new understanding that problems at the end of life have
their origins at an earlier time in the trajectory of disease”
Palliative Care: the World Health Organization's global perspective. Sepúlveda C, Marlin A, Yoshida T, Ullrich A. J Pain Symptom Manage. 2002 Aug;24(2):91-6
Palliative Care Consult: Three Parts
Symptom ManagementPain
Shortness of BreathNauseaAnxiety
DepressionConstipation
Weakness
Goals of CareDecision Making Capacity
Quality of LifeInformed Decision Making
Family/Social DynamicsMedical Ethics Issues
DispositionAdvanced Directives(POLST, POA)
Interdisciplinary Team
BiopsychosocialspiritualAssessmentSocial Support
Home Setting/FunctionalCommunity Resources
Psychological-BehavioralSpiritual-Cultural
Objective 2
What are Goals of Care?
What are Goals of Care?
Hopes
Expectations
Outside
Influence
Quality of
Life
Goals of Care
Patient Family Medical Team
Goals of Care
Patient Family Team
How do you figure out a person’s medical goals?
• Takes time and conversations
• Develop relationships
• Explore beliefs and values
• Explore how one defines Quality of Life
• What gives your life meaning?
• Informed decision making
• Call out conflicts
• Must be readdressed if medical picture evolves
Needs to be well documented in your medical record, can’t be locked in a safe at home
Objective 3
When is the right time to get Palliative Care involved?
Difference:
Patient goals
Prognosis
Similarities:
Quality of Life
Symptom Management
Team Approach
Diagnosis
Palliative Care
Hospice
When is the right time for Palliative Care?
Murray SA, Kendall M, Boyd K, Sheikh A.
Illness trajectories and palliative
care. BMJ : British Medical Journal.
2005;330(7498):1007-1011.
Illness Trajectory: Terminal Diagnosis
Illness Trajectory: Organ Failure
Illness Trajectory: Frailty or Neurologic Decline
Out with the old, in with the new…
National Consensus Project for Quality Palliative Care (2004). Clinical practice guidelines for quality palliative care.
http://www.nationalconsensusproject.org.
Be very aware of our use of language and how this
can set up complicated grief later.
• Be aware of words like “a battle”, “she’s a fighter”, “you can beat this”
• Where does this kind of language leave someone who’s body is not responding to treatments, interventions, or therapies?
• How does this kind of language affect someone who is “tired”, “worn out”, saying “I can’t do this anymore”?
• How does this kind of language affect ACP discussions?
• How can we rephrase these social mantras and leave everyone feeling empowered and heard?
Objective 4
How can Palliative Care help with transitions?
How can Palliative Care help with transitions?
• You can begin with primary Palliative Care
• Palliative Care can be part of an inpatient and/or ED referral source
• Continuity of care within the EMR
• Palliative care can be part of discharge planning– Pt’s can self-refer and usually does not need a referral or pre-auth
– Check your region for availability of outpatient services
– A few HH agencies in your area may have enhanced PC HH programs
Objective 5
What is the role of Social Work and Care Management in Palliative Care?
Role of Social Work and/or Care Management in Palliative
Care
• Comprehensive/holistic bio-psycho-social-spiritual assessments
• Community resource brokering
• Symptom management
• Assessment—Diagnosis—Treatment—Maintenance—Refer
• ACP (Advanced Care Planning) Conversations
Comprehensive/ Holistic Bio-Psycho-Social-Spiritual
Assessments
Community Resource Brokering
(Insurance and Private Pay)
• Transition planning throughout the spectrum of care
• Authorizations when needed for equipment, referrals, placement, medications
• Primary goal is for safety
• Help with patient and family independence and empowerment
• Help with patient resiliency
• Help with support system burnout
• Aftercare resources and relationships
Symptom Management
• Pain (education, existential suffering, coping, relaxation, mindfulness)
• SOB (SOB anxiety cycle much like in COPD)
• Appetite (depressive features? changes in appetite?)
• Memory (stress related or induced? illness trajectory?)
• Weakness and Fatigue (depressive features? Grieving the gap?)
• Emotions (grief/loss, fear, sadness/depression, anxiety, anger, worthlessness, etc.)
How can SW/CM impact symptom management?
Social Work Psychosocial Assessment, Diagnosis,
Treatment, Maintenance, Refer
• Assessments – Chart review
– 1:1 interview
– Collateral Info
Psychosocial Assessment, Diagnosis, Treatment,
Maintenance, Refer
• Diagnosis (Not place for SMI)– Neurodevelopmental disorders (F03.90 dementia)
– Depressive disorders (depression FCodes, F32.9 hopelessness, F06.31 mood disorder due to know physiological condition with depressive features)
– Anxiety disorders (anxiety FCodes, F41.1 anticipatory anxiety, F06.4 due to medical condition, F06.8 due to mult medical problems, F41.0 due to disorder due to general medical condition with panic attack
– Trauma and Stressor related disorders (F43.21, grief, unresolved grief reaction, prolonged grief reaction, F43.2 adjustment reaction to medical therapy, F43.21 anticipatory grief, F43.29 stress and adjustment reaction, Z60.0 problems of adjustment to life-cycle transitions
– Disruptive, impulse-control, and conduct disorders (F54 other psychological factors affecting medical condition)
– Subsyndromal… anxiety, depression
Handbook of Psychiatry in Palliative Medicine. Chochinov, Harvey Max, & Breitbart, William. (2009).
Psychosocial Assessment, Diagnosis, Treatment,
Maintenance, Refer (continued)• Treatment
– IDT approach (MD, RN CM, SW)– Individual mental health therapy in clinic
• ACT• Behavioral• CBT• CPT• Dialectical• EFT• Family Systems• Guided Imagery• Interpersonal Psychotherapy• Life Sketch• Mindfulness• Narrative• Progressive Relaxation• Role Play• Self-Compassion• Solution Focused
Psychosocial Assessment, Diagnosis, Treatment,
Maintenance, Refer (continued)
• Maintenance– F/u apts
– Calls to check on progress/needs
– Self-care and Self-compassion
– Weekly Palliative Care Support Group
– Medication (as needed by physician)
Psychosocial Assessment, Diagnosis, Treatment,
Maintenance, Refer (continued)
• Refer– Community Therapist
– Psychiatry
– Chaplaincy
SW/ CM Role as Facilitator of ACP discussions
• POA– Watch for vulnerable populations and circumstances– Capacity– Family dynamics– Emotionally preparing POA for possible difficult decisions
• POLST– Emotional blocks, spiritual beliefs, medical literacy, allowing discussions to be
a bonding event with team– Skill in navigating dynamics– Personalizing paperwork (“it’s not about how you want to die”)– Defining quality of life and the ‘why’ behind medical treatments– Ensuring communication with IDT, other acute settings and clinics/facilities– Empowering family to respect wishes and address their own emotional
reactions to pt’s wishes
SW/CM Role as Facilitator of ACP discussions
• Documentation and billing for outpatient ACP discussions. Problem list must include ZCode (Z78.9).
• The types of medical care preferred• The comfort level that is preferred• How the pt prefers to be treated by others• What the pt wishes other to know• Must have notation of capacity (MSE)• Document minutes spent face-to-face with pt separately in ACP
discussions• Must be signed by physician with notation you were asked by the
physician, advanced care provider (NP, PA) to complete ACP documentation
• 30 minute billing codes (99497 & 99498)
CASE STUDY
66 y/o female, married but in an insecurely bonded relationship. Hx of chronic pain in her back, Chron’s disease, and arthritis. Now coming into the palliative care clinic, by referral of PCP, for breast cancer diagnosis. Independent prior with use of cane. Now feeling increased pain that is closely intertwined with existential fear and suffering. Also experiencing chemo related N/V, weakness, hair loss, sores in mouth, changes in eye sight, and some mild confusion and cognitive changes she calls ‘chemo brain’. Three supportive children, retired decorator that loves to make holidays special events for her grandchildren. Hx of childhood sexual abuse, hx of long-standing addiction issues with previous suicidal ideation but is now sober and helps with recovery counseling. Hx of being estranged from her LDS faith. Tells of an experience where she “crossed over and spoke with her mom and grandma” that had passed. She told them she wanted to “come with them” but they told her “she wasn’t done yet.”
SW/CM INTERVENTIONS IN CASE STUDY
• Comprehensive assessment (biological, psychological, social, spiritual)
• IDT interventions for symptom management including medication management with awareness of emotional perpetuation/triggers
• Individual SW mental health visits (coping, adjustment, addiction, bonding issues with support system, self-perception…)
• ACP discussion, being mindful of her spiritual experience, teasing out depression
What is happening with Palliative Care at
McKay-Dee Hospital?
• Pilot Program for Intermountain System
• Rapid growth
• Multiple Projects:
Palliative Care Algorithm (soon to be published in Journal of Pain and Symptom Management)
Continuous improvement: Regional IDT with HH/Hospice and Community CM
Program Development: Acute Inpatient program
Community Grants
System Organization
Questions?View from McKay Dee Clinic Palliative Care Clinic in Ogden
Special thanks to Dr. April Krutka
References for Palliative Care Outcomes
• Palliative Care Inpatient Service in a Comprehensive Cancer Center: Clinical and Financial Outcomes
Ahmed Elsayem, Kay Swint, Michael J. Fisch, J. Lynn Palmer, Suresh Reddy, Paul Walker, Donna Zhukovsky, Patti Knight, and Eduardo Bruera; Journal of Clinical Oncology 2004 22:10, 2008-2014
• Thomas J. Smith, Patrick Coyne, Brian Cassel, Lynne Penberthy, Alison Hopson, and Mary Ann Hager. Journal of Palliative Medicine. July 2004, 6(5): 699-705.
• Irene J Higginson, Ilora Finlay, Danielle M Goodwin, Alison M Cook, Kerry Hood, Adrian G.K Edwards, Hannah-Rose Douglas, Charles E Norman, Do Hospital-Based Palliative Teams Improve Care for Patients or Families at the End of Life?, Journal of Pain and Symptom Management, Volume 23, Issue 2, 2002, Pages 96-106, ISSN 0885-3924
• Paolo L Manfredi, R.Sean Morrison, Jane Morris, Suzanne L Goldhirsch, John M Carter, Diane E Meier, Palliative Care Consultations, Journal of Pain and Symptom Management, Volume 20, Issue 3, 2000, Pages 166-173, ISSN 0885-3924
• Casarett D, Johnson M, Smith D, Richardson D. The Optimal Delivery of Palliative CareA National Comparison of the Outcomes of Consultation Teams vs Inpatient Units. Arch Intern Med. 2011;171(7):649-655. doi:10.1001/archinternmed.2011.87
• Wachterman MW, Pilver C, Smith D, Ersek M, Lipsitz SR, Keating NL. Quality of End-of-Life Care Provided to Patients With Different Serious Illnesses. JAMA Intern Med. 2016;176(8):1095-1102. doi:10.1001/jamainternmed.2016.1200
• Brumley, R., Enguidanos, S., Jamison, P., Seitz, R., Morgenstern, N., Saito, S., McIlwane, J., Hillary, K. and Gonzalez, J. (2007), Increased Satisfaction with Care and Lower Costs: Results of a Randomized Trial of In-Home Palliative Care. Journal of the American Geriatrics Society, 55: 993–1000. doi:10.1111/j.1532-5415.2007.01234.x
• Morrison RS, Penrod JD, Cassel JB, Caust-Ellenbogen M, Litke A, Spragens L, Meier DE, Palliative Care Leadership Centers' Outcomes Group. Cost Savings Associated With US Hospital Palliative Care Consultation Programs. Arch Intern Med. 2008;168(16):1783-1790. doi:10.1001/archinte.168.16.1783
References for Palliative Care Outcomes
• Wright AA, Zhang B, Ray A, Mack JW, Trice E, Balboni T, Mitchell SL, Jackson VA, Block SD, Maciejewski PK, PrigersonHG. Associations Between End-of-Life Discussions, Patient Mental Health, Medical Care Near Death, and Caregiver Bereavement Adjustment. JAMA. 2008;300(14):1665-1673.
• Jennifer S. Temel, M.D., Joseph A. Greer, Ph.D., Alona Muzikansky, M.A., Emily R. Gallagher, R.N., Sonal Admane, M.B., B.S., M.P.H., Vicki A. Jackson, M.D., M.P.H., Constance M. Dahlin, A.P.N., Craig D. Blinderman, M.D., Juliet Jacobsen, M.D., William F. Pirl, M.D., M.P.H., J. Andrew Billings, M.D., and Thomas J. Lynch, M.D. Early Palliative Care for Patients with Metastatic Non–Small-Cell Lung Cancer. N Engl J Med 2010;363:733-42
