STRATEGIES THAT WORK IN EARLY PALLIATION OF CHRONIC DISEASE
■ Tara Lohmann MD FRCPC, Respirologist ■ Jessica Simon MB ChB FRCPC, Palliative Care ■ Michael Slawnych MD FRCPC, Cardiologist ■ Chandra Thomas MSc MD FRCPC, Nephrologist
Faculty/Presenter Disclosure ■ Faculty: Dr. Michael Slawnych ■ Relatio ionship ips w with f finan ancial ial s sponsors: Grants/ s/Research S Support: None – Speakers B Bureau/Ho Honoraria: Novartis: speaker fees for talk on palliative – cardiology Consu sulting F Fees: s: None – Patents : None – Ot Other: Work for University of Calgary and Alberta Health Services –
Faculty/Presenter Disclosure Facult lty: : Tara L a Lohman ann • Relatio ionship ips w with f finan ancial ial s sponsors: • Grants/ s/Research S Support: No None – Speakers B Bureau/Ho Honoraria: N None – Consu sulting F Fees: s: None – Patents : None – Ot Other: Work for University of Calgary and Alberta Health Services –
Faculty/Presenter Disclosure Facult lty: : Jessic ica S a Simon • Relatio ionship ips w with f finan ancial ial s sponsors: • Gran ants/Resear arch S Support: C CIHR, A Alberta I a Innovat ates, C Can anad adian an F Frai ailty N Network – Speakers B Bureau/Ho Honoraria: None – Consu sulting F Fees: s: None – Patents : None – Other: A Alberta Health S Services ( (physi sician c consu sultant A ACP, GCD, A AHS Calgary – Zone
Faculty/Presenter Disclosure Fac aculty: Ch Chan andra T Thomas • Grants/ s/Research S Support: None – Speakers B Bureau/Ho Honoraria: None – Consu sulting F Fees: s: None – Patents : None – Ot Other: Work f for University of Calgary and AHS –
Disclosure of Financial Support This pr program h has N NOT r received f financial s suppo pport • This p program h has N NOT r receive ved i in-kind s suppo pport f from • Pot otential f l for c r confli lict(s) o of intere rest: • NONE –
Mitigating Potential Bias - This talk will not include any discussion of drugs/therapies related Novartis.
Workshop Objectives ■ Employ strategies to overcome barriers in providing a palliative care approach. ■ Recognize the impact of prognostic uncertainty in delaying the provision of palliative care. ■ Apply a rational approach to deprescribing medications and advanced interventions in persons with chronic disease in the last years of life.
What is the palliative care that you do in your practice? What are hoping to take away from today?
I consult the palliative care service: Never Rarely Sometimes Often Always
Why would/wouldn’t you consult the palliative care service?
- Palliative care Some definitions - Palliative approach to care - Hospice care
151 Patients with newly diagnosed with metastatic NSCL cancer randomized to early integrated palliative care (PC) vs standard oncologic treatment PC group had better quality of life (FACT-L, HADS), fewer patients had depressive symptoms (16% vs 38%) Fewer patients in the PC group had aggressive end-of-life care, yet median survival was longer (11.6 vs 8.9 months) Temel JS et al. NEJM 2010; 363: 733-42
What is a palliative approach to care? Advance Care Planning and Coordination of shared decision care making Symptoms and functional status Illness comprehension and coping Adapted from Temel et al., 2010; Boucher et al., 2018
Patient/ Carer factors Barriers to palliative Physician & System care in non- HCP factors factors cancer disease Illness factors
Based on the definition of a palliative care approach, does this reframe your role in the palliative care of your patients?
What is the evidence for a palliative approach to care in non- cancer?
■ Improved breathlessness mastery (CRQ) in the intervention group vs. control ■ Pre-post analysis: intervention group had improved quality of life, dyspnea, mastery, POS at 6 weeks. ■ Survival benefit in the intervention group Higginson et al. Lancet Respir Med 2014 (2): 979-987.
INSPIRED COPD Outreach Program TM ■ Home-based COPD program designed to ease transitions from hospital to community Rocker, G.M. & Verma, J. ‘INSPIRED’ COPD Outreach Program™: Doing the right things right. Clinical & Investigative Medicine 2014; 38 (1): E311-E319.
Why hy? Ear arly conversat ations ab about pat atient v val alues an and go goal als li linked t to better serious i illn llness care • Increased goal-concordant care • Improved quality of life / patient well-being • Fewer hospitalizations • More and earlier palliative/hospice care • Better patient and family coping Mack JCO 2010; Wright JAMA 2008; Chiarchiaro AATS 2015; Detering BMJ 2010; Zhang Annals 2009
What matters most to seriously ill patients? Heyland 2006 CMAJ
Who has heard of the Serious Illness Conversation Care Program?
A tool you can use: The Serious Illness Care Program The Serious Illness Care Program improves the lives of people with serious illness by increasing meaningful conversations with their clinicians about their values and priorities
https://www.youtube.com/watch?v=45b2Q ZxDd_o Atul Gawande Video
Serious Illness Care Program Components Tools Serious Illness Clinician Reference Patient preparation Family Comm. Conversation Guide Guide materials Guide Train Clinicians Education 2.5-hour clinician training sessions Conversation Patient & Family Documentation Patient Screening Reminder System using the Systems template in EMR Resources Guide Change Measurement and Improvement (QI)
Why hy?
What do checklists or guides do? • Bridge gap between evidence and “real world” implementation • Assure adherence to key processes • Achieve higher level of baseline performance • Ensure completion of necessary tasks during complex, stressful situations
So w what at is is t the guid ide? Checklist + Language + Process Clinician Steps Conversation Guide • Prompts • Critical topics essential steps • Proven language • Intentional sequence … embedded in a Process that includes cuing and documenting
Out-patient Process
Staff member prepares At Bullet Rounds patient and asks who Nurse Champion Nurse champion Nurse Clinician else should be at the flags 1-2 patients per MD screens handover Yes identifies staff meeting (checks if meeting and raises decides if patient report member to set up green sleeve in hospital) these at handover is appropriate or (>5days, >65yrs) family meeting gives info letter identifies other patients No Pt agrees to MD informed meeting Yes MD Day of conversation: MD gets Staff member sets up meeting MD: has conversation 1. Charge nurse cues MD conversation (room/translator etc): 1. Documents on TR and gives handout of meeting materials and 1. Makes appt in SCM and prints materials to pt 2. Pages MD if late/no handouts from 2. Pages MD to confirm 2. Shows TR to (± residents) show designated location patient No On Discharge: 1.Bedside Nurse checks latest TR Bedside nurse Pt confirms TR Unit clerk puts TR in Yes follows up with pt and GCD in green sleeve MD hands it to unit Green sleeve about conversation 2. Instructs pt on how to use green clerk sleeve and sends it home with pt
How t w to b bridge e the e gap gap b between een wh what at pat atien ents wa want an and wh what at t they get et ? ? Ask pa k patients a about their va valu lues a s and p pri riorities an and w writ ite it it down
PAUSE
Rationalizing medications and investigations
You have had a serious illness care conversation with Dorothy Illness ss U Understanding: last year of life, deteriorating health Goals ls: Remaining in her home as long as possible Worries: Taking so many pills, not afraid to die, hopes to die in her sleep Sources o of strength: Her faith Critical a abili lities: Eating and talking Tradeoffs: Does not want “heroics” or prolonged hospital stays, would rather allow natural death at that time Fa Family: Is wondering about asking her homecare companion to be her agent
Dorothy’s meds… Tiotropium Ramipril 10 mg bid Salbutamol Nitro patch 0.6 mg/h on during the day Budesonide/Formoterol Atorvastatin 20 mg daily at bedtime Acetaminophen SR 650mg tid Amiodarone 200 mg p.o. once daily Morphine IR 10 mg qid prn Warfarin 2mg alternating with 3mg daily Gabapentin 300 mg at bedtime Vitamin D3 2000 units daily Docusate 100 mg po daily Calcium carbondate 1250mg tid Senna 8.6-17.2mg as needed Darbepoeitin 40 mcg sc every 2 weeks Omeprazole 30 mg bid Ferrous Fumuarate 300 mg bid Glargine insulin 25 units at bedtime Escitalopram 20 mg p.o. once daily Humulin R 8-12 units bid qAM & qSupper Duloxetine 60 mg p.o. once daily Levothyroxine 88 mcg daily Zopiclone 7.5 mg daily at bedtime Amlodipine 10 mg daily Trazodone 400 mg p.o. once daily Furosemide 80 mg bid Melatonin 5 mg p.o. at bedtime Carvedilol 25 mg bid
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