Palliative Care: Year in Review 2013 Lynn A. Flint Eric Widera UCSF, - PDF document

5/28/2013 Palliative Care: Year in Review 2013 Lynn A. Flint Eric Widera UCSF, Division of Geriatrics No disclosures 1

5/28/2013 Objectives 1. Define palliative care 2. Discuss recent findings in palliative care research – focus on health services and communication 3. Determine whether these studies are relevant to general internal medicine 4. Review news from the past year Definition From the Center to Advance Palliative Care: “Palliative care is specialized medical care for people with serious illnesses. It is focused on providing patients with relief from the symptoms, pain and stress of a serious illness— whatever the diagnosis. The goal is to improve quality of life for both the patient and the family.” www.capc.org/building ‐ a ‐ hospital ‐ based ‐ palliative ‐ care ‐ program/case/definingpc, accessed 4/8/2013 2

5/28/2013 Definition “Palliative care is provided by a team of doctors, nurses and other specialists who work together with a patient’s other doctors to provide an extra layer of support.” Image: Am J Prev Med 2011;40(5S2);S217 ‐ S224 Definition “It is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment.” Image: Journal of Supportive Oncology 2012;10:180 ‐ 187. 3

5/28/2013 “Matching treatments to patient goals.” …Internal Medicine Family Medicine Physical Medicine Emergency Medicine Surgery Psychiatry Ob ‐ Gyn… Hospice Medicine Palliative Medicine Disease directed care 4

5/28/2013 What is your preferred place of death? 1) Emergency room 2) Home 3) Hospital 4) Nursing home 5) No preference What about your preferred place to be two weeks before your death? 1) Emergency room 2) Home 3) Hospital 4) Nursing home 5) No preference 5

5/28/2013 Source: California Healthcare Foundation, 2011 JAMA 2013;309(5):470 ‐ 477. 6

5/28/2013 Site of death: not the whole story 50 40 30 20 10 0 2000 2009 Acute Care Hospice JAMA 2013;309(5):470 ‐ 477. Site of death: not the whole story 35 30 25 20 15 10 5 0 2000 2009 Hospital ICU Use Transitions JAMA 2013;309(5):470 ‐ 477. 7

5/28/2013 Bottom line From 2000 to 2009, despite a decline in hospital deaths and an increase in hospice use, end of life ICU use and health care transitions increased among Medicare decedents. How does this apply to general practice? • Place of death is important to many • “Place of decline” is discussed less often • ICU, multiple transitions not ideal in last days and weeks of life • Important to discuss with patients and document their preferences 8

5/28/2013 When would you refer patients with advanced cancer to palliative care? 1) At diagnosis 2) If active symptoms 3) When no disease ‐ directed treatments are available 4) If functional decline 5) All of the above Early Palliative Care Temel JS et al. N Engl J Med 2010;363:733 ‐ 742. 9

5/28/2013 JAMA Intern Med 2013;173(4):283 ‐ 290. Key elements of PC visits Relationship Relationship Addressing Addressing Addressing Addressing and rapport and rapport symptoms symptoms coping coping building building Establishing Establishing Discussing Discussing Engaging Engaging illness illness cancer cancer family family understanding understanding treatments treatments members members End of life End of life planning planning JAMA Intern Med 2013;173(4):283 ‐ 290. 10

5/28/2013 Illness understanding ‐ info preference: “she likes the ‘straight story’…” Illness understanding ‐ prognostic awareness: “understands that her prognosis is 6 ‐ 12 weeks.” Addressing coping: “copes by trying not to think about his diagnosis and focusing on the present.” JAMA Intern Med 2013;173(4):283 ‐ 290. Key elements over time 35 30 EOL Planning 25 No. of coded text Discussing cancer tx 20 15 Illness understanding: Px awareness 10 Illness understanding: info preference 5 0 Initial Middle Late JAMA Intern Med 2013;173(4):283 ‐ 290. 11

5/28/2013 JAMA Intern Med 2013;173(4):283 ‐ 290. Bottom line • “Focus of PC is not browbeating patients into accepting hospice and avoiding resuscitation or hospitalization…” • PC complemented oncologists’ work – Little overlap – Different focus 12

5/28/2013 How does this apply to general practice? • Not generalizable – Single tertiary center – Intervention not easily reproduced • Makes the case for “primary palliative care” • Considering some of the key elements above does not have to include “browbeating patients into accepting hospice” JAMA Intern Med 2013;173:291 ‐ 292 What is the goal of palliative chemotherapy? 1) Prolong survival 2) Ease symptoms 3) Both 4) Either or both 13

5/28/2013 New Engl J Med 2012;367:1616 ‐ 1625. “After talking with your doctors… how likely did you think it was that the Stage IV Colon Cancer chemotherapy would cure your cancer?” Very likely/somewhat likely New Engl J Med 2012;367:1616 ‐ 1625. 14

5/28/2013 Variables increasing likelihood of inaccurate response • Non ‐ white • Fee ‐ for service health insurance • Better physician communication scores If the meteorologist says “There will definitely be rain today,” what does this mean to you?” 1) There is a 70% chance of rain 2) There is a 10% chance of rain 3) There is a 50% chance of rain 4) There is a 100% chance of rain 15

5/28/2013 Ann Intern Med. 2012;156:360 ‐ 366. Surrogates of current ICU patients were asked about prognostic statements. For example, “If a doctor says ‘He will definitely survive,’ what does that mean to you?” 10% 20% 30% 40% 50% 60% 70% 80% 90% Will NOT survive Will survive (0% chance of survival) (100% chance of survival) Ann Intern Med. 2012;156:360 ‐ 366. 16

5/28/2013 He will definitely not survive = 0 ‐ 50% chance of survival He has a 5% chance of surviving = 5 ‐ 40% chance of survival It is very unlikely he will survive = 15 ‐ 50% chance of survival 17

5/28/2013 “I hold onto hope strongly.” “I know my father could do better than what the doctor is saying…” “I don’t give a lot of weight to the original number.” “I don’t think [doctors] can really know.” Bottom line What providers say is not the only factor influencing patient and family beliefs about serious illness 18

5/28/2013 What the doctor says What the doctor says What a patient What a patient Physical condition Physical condition Cultural Cultural understands understands Psychosocial Psychosocial Education/literacy Education/literacy Spiritual Spiritual How does this apply to general practice? • Communication is the “bread and butter” of an internist’s practice • A reminder that what we tell patients is not what they take away 19

5/28/2013 Failure to engage • Among those with preferences, almost 30% had no documentation AND • When preferences were documented, more than 2/3 of documentation was not concordant with expressed wishes 20

5/28/2013 Bottom Line • Seriously ill patients are talking about their preferences for care at the end of life • Document your patients preferences and the stories of their preferences What is the rate of survival of CPR on TV? 1) 100% 2) 70% 3) 25% 4) 10% 21

5/28/2013 New Engl J Med 1996;334:1578 ‐ 1582. New Engl J Med 2013;368:1019 ‐ 1026. 22

5/28/2013 1. New Engl J Med 2013;368:1019 ‐ 1026. 2. New Engl J Med 2012;367:1912 ‐ 1920. Bottom line • It’s all in the framing • At one year, about 10% of elderly patients who underwent in ‐ hospital CPR were alive; about 1/3 have clinically significant disability 23

5/28/2013 Other news • PCHETA introduced July 2012, re ‐ introduced March 2013 • Choosing Wisely Campaign • “Death panels” bill re ‐ introduced • prepareforyourcare.org 1.Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead, offer oral assisted feeding. 2.Don’t delay palliative care for a patient with serious illness of has physical, psychological, social or spiritual distress because they are pursuing disease ‐ directed treatment 24

5/28/2013 3. Don’t leave an ICD activated when it is inconsistent with the goals of care. 4. Don’t recommend more than a single fraction of palliative radiation for an uncomplicated painful bone metastasis. 5. Don’t use topical lorazepam (Ativan), diphenhydramine (Benadryl), haloperidol (Haldol) (“ABH”) gel for nausea 25

5/28/2013 Take ‐ home points • Palliative care is for anyone facing a serious illness • System changes impact the care of seriously ill patients • Communication is a primary palliative care procedure Thank you for listening 26