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DISCLAIMER
PHI includes, but is not limited to:- Patient name- Date of birth- Address- Occupation- Name of patient’s friends/family- Other identifiable features, i.e.
scars, tattoos, hair/eye color
Please DO NOT disclose any Protected Health Information (PHI)
Palliative Care ECHO ClinicWe are Nevada's Leading Forum for
Interdisciplinary Palliative CareWe aim to:
Collaborate with an interdisciplinary team of palliative care providers in Nevada
Assemble a forum of health care practitioners throughout the state of Nevada whom Project ECHO
supports and prepares to deliver basic palliative care
Raise the quality of life for Nevadans living with serious illness
Establish a resource of expertise and education for a diverse health care audience on practices,
resources and policy in palliative care
Palliative Care ECHO – Year in Review, and Something New!
Kim Anderson, BBAVice President of Business DevelopmentVice Chair of Palliative Care and Quality of Life Advisory Council for NevadaHarmony Hospice
Jessica Cate, PharmD, BCPS, BCGPClinical Pharmacy SpecialistGeriatrics and Home Based Primary CareVA Sierra Nevada Health Care System
Kelly Conright, MD, CMDInternal Medicine, Geriatric Medicine, HPMHPM Fellowship Director, UNRSOMAttending Physician, GECVA Sierra NV Health Care System
Jonathan McCaleb, MD, CMD, HMDCUNRSOM Associate Professor, Family Medicine,Geriatrics, Hospice and Palliative Medicine CLC Medical Director, GEC Attending PhysicianVA Sierra NV Health Care System
Conflicts of Interest
None
Learning Objectives
• Review differences between palliative care (PC) and hospice care
• Discuss which patients are appropriate for palliative care consult
• Describe an approach to determine a person’s goals and values• Review hospital based PC, home based PC, outpatient based
PC, and PC in the nursing home • Discuss national PC report card and Palliative Care & Hospice
Education & Training Act (PECHTA)
The Differences Between Hospice and Palliative Care
Palliative Care• Any time during Illness• May be combined with curative care• Community resources support• Coordination of care transitions &
education for patient / family during the course of the illness (from hospitals, clinic, community agencies, and spiritual programs)
Hospice Care• Prognosis of 6 months or less• Focus of comfort care when
decisions are made not to seek curative care
• Coordinates caregiving support & bereavement counseling after the death of a loved one
Who Gets it??
• Palliative care is appropriate at ANY stage in a serious and/or chronic illness
• Including when cure may be unlikely, but not impossible• Patients can receive palliative care while still pursuing curative
intent treatment such as • Chemotherapy• Radiation therapy• Percutaneous coronary interventions• Surgery• Hemodialysis
Would you be surprised?
Consider Palliative Care for patients with:• Cancer • New diagnosis of chronic and/or life limiting disease• Advanced or multiple organ failure• Progressive neurological disease• Multiple recent hospitalizations for any of the above• Complex family dynamics• Prior to initiating a life sustaining treatment such as a feeding
tube or dialysis• “Would I be surprised if this patient died in the next year?”
The Bow Tie Model
How?
Serious Illness
Conversation Guide
Hospital based PC
Benefits of Hospital Palliative Care
• Lower cost • Improved Quality of life for patients• Decreased caregiver stress• Provider well-being
Barriers to Palliative Care in the Hospital
• Resource Availability• Lack of awareness of Resources• Referrer Reluctance• Patient and Family Reluctance
Home based PC
Benefits of Home based Palliative Care:
• Guide patients into right care at right time• Reduce overall health costs• Reduce hospitalization/re-hospitalization rates, ER visits and costs
associated with end of life • Decrease caregiver burden while retaining their involvement• Improve quality of life and satisfaction
Outpatient based PC
Criteria for Outpatient Palliative Care Referrals
1- Severe physical symptoms.2- Severe emotional symptoms.3- Request for hastened death.4- Spiritual or existential crisis.5- Assistance with decision making or care planning, 6- Patient request for referral7- Delirium 8- Spinal cord compression, 9- Brain or leptomeningeal metastases, within 3 months of advanced cancer
diagnosis for patients with median survival of 1 year or less10- Progressive disease despite second-line therapy
Hui, D., Mori, M., Watanabe, S. M., Caraceni, A., Strasser, F., Saarto, T., … Bruera, E. (2016). Referral criteria for outpatient specialty palliative cancer care: an international consensus. The Lancet Oncology, 17(12), e552–e559. https://doi.org/10.1016/S1470-2045(16)30577-0 [5]
Barriers to the Use of Outpatient Palliative Care
• Lack of performance measures for patient-centered care and outcomes.
• Cost of providing the service
• Limited practice capacity, which includes the availability of personnel, time, and other resources necessary for the delivery of the intervention
• Geographic and socioeconomic access disparities
• Limited knowledge about palliative care services among patients and families
Bekelman, D. B., Rabin, B. A., Nowels, C. T., Sahay, A., Heidenreich, P. A., Fischer, S. M., & Main, D. S. (2016). Barriers and Facilitators to Scaling Up Outpatient Palliative Care. Journal of Palliative Medicine, 19(4), 456–459. https://doi.org/10.1089/jpm.2015.0280 [1]
PC in the Nursing Home
Rehabbed to Death
Deprescribing
• Part of good prescribing, backing off when doses are to high or stopping medication that are no longer needed or may be causing harm
• When to consider• Goals of care• No longer effective• Completed• Unsafe
Benefit• Evidence for
ongoing indication
• Evidence for effectiveness
Risk• Known adverse
effects• Age-related
changes• Increased
comorbidities and medications
National Palliative Care Report Card, CAPC, 2019
National Palliative Care Report Card, CAPC, 2019
National Palliative Care Report Card, CAPC, 2019
Palliative Care & Hospice Education & Training Act
Palliative Care & Hospice Education & Training Act
Questions?
Survey
Please complete this brief survey. Your feedback is vital to our continued improvement of Project ECHO Nevada programming!
Thank you!
Thank you!
• Thank relevant partners• Next session date/topic• Advertise relevant resources/ECHOs
References• Rehabbed to Death: Breaking the Cycle JAGS 2019 Flint, et al• Palliative care: Nursing home Up to Date, Oct 2019• Reeve E, Gnjidic D, Long, Hilmer S. A systematic review of the emerging definition of
'deprescribing' with network analysis: implications for future research and clinical practice. Br J Clin Pharmacol 2015;80(6):1254-68.
• Reeve E, Shakib S, Hendrix I, Roberts MS, Wiese MD. Review of deprescribing processes and development of an evidence-based patient-centered deprescribing process. Br J Clin Pharmcol 2014;78(4):738-747.
• American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2019 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2019;00:1-21, 2019.
• National Palliative Care Report Card, CAPC, 2019• White, N., Kupeli, N., Vickerstaff, V. et al. How accurate is the ‘Surprise Question’ at
identifying patients at the end of life? A systematic review and meta-analysis. BMC Med15, 139 (2017)
