Post on 02-Apr-2015
Transforming health care globally… through palliative care
Transforming health care globally… through palliative care
www.PalliativeMed.org www.IPCRC.netwww.PalliativeMed.org www.IPCRC.net
Public Health Perspective on Palliative Care: Transforming Healthcare in Sweden
Frank D. Ferris, MD, FAAHPM, FAACE
Institute for Palliative Medicineat San Diego Hospice
University of California San Diego
University of Toronto
Imagine . . .
What do YouWant Your Illness
Experience to be ?
11 22
33 44
Where would you like to receive your care?
1. Acute care
2. Long-term care
3. Home
Swedish Life Expectancy Age 0
World Bank Data
2009 = 81.4
How many are 50 - 60 ?
Likely to die 2030s – 2040s…
How will you achieve your
goals ?
Who will provide your care ?
Transforming health care…
through palliative care
Transforming health care…
through palliative care
www.PalliativeMed.org www.IPCRC.netwww.PalliativeMed.org www.IPCRC.net
Objective…
A Road Map to Build
Palliative Care ( PC )Capacity in Sweden…
Success & Challenges…
Mortality as an Indicator of Need( 2008 est., x 1,000 )
All Causes Cancer AIDS• World 55.678 7.56 2.845
Late Presentation
Low Resources
Limited or No Treatment
Palliative Care Service Development Globally(from the International Observatory on End-of-Life Care of Lancaster, UK)
No activity yet identified
Capacity building activity
Localized provision
Approaching integration
Source of Map: Wright et al., J. Pain Sym. Manag. 35:469 (2008)Bar graph created from data in this publication.
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2
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# C
ou
ntr
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99 / 144 LMICs have no services
Mortality as an Indicator of Need( 2008 est., x 1,000 )
All Causes Cancer AIDS
• Sweden 91,5 22,1 --
8 % of all dying, 30% dying of cancer receive
PC
• USA 2.540 586 14
42 % receive hospice care ( 2010 )
Many more receive non-hospice palliative
care
Sweden Vital Statistics…20122040
Population 9,3 M 10,6 M
% 65+ 18,3 % 25,8 %
% 80+ 5,5 % 9,4 %
Dependency ratio 28,1 44,6Crude death rate 10 12per 100 K
Deaths 93 K 127 K
Due to cancer 25 K > 32 K
Sweden Vital Statistics
Palliative Care in Sweden 2012
In 2012
• 93 K deaths all causes
> 60 % benefit from PC ≈ 55.800
• > 22.000 K deaths from cancer
> 80 % benefit from PC > 18.000
Causes of Death
1. Cardiovascular 39,4 %
2. Cancer 26,5 %
3. Neurological 3,4 %
4. Injuries 3,7 %
5. Respiratory 5,8 %
90 % of patients receiving PC have cancer !
Setting of DeathNorth America
• 23 % own home
• 77 % die in institutions( Teno et al, 1997 )
2 / 3 in hospitals
1 / 3 in nursinghomes
Sweden
• 5 – 10 % own home
• 40 – 50 % nursing homes
1993 2002
‘ One Voice ’
2002 National ModelCanadian Hospice
Palliative CareAssociation
• Consensus
Common language
Norms of practice
• English et Français
Palliative Care…• Prevents & relieves suffering
• Improves quality of living and dying• Any diagnosis
From: Ferris FD, Balfour HM, Bowen K, Farley J, Hardwick M, Lamontagne C,
Lundy M, Syme A, West P. A Model to Guide Hospice Palliative Care.
Ottawa, ON: Canadian Hospice Palliative Care Association, 2002.
From: Ferris FD, Balfour HM, Bowen K, Farley J, Hardwick M, Lamontagne C,
Lundy M, Syme A, West P. A Model to Guide Hospice Palliative Care.
Ottawa, ON: Canadian Hospice Palliative Care Association, 2002.
…Palliative Care…
PresentationPresentation DeathDeath
Therapies tomodify disease
Therapies tomodify disease
BereavementCare
BereavementCare
6m6m
End-of-life /Hospice CareEnd-of-life /
Hospice Care
Therapies to relieve suffering and / or
improve quality of life
Therapies to relieve suffering and / or
improve quality of life
Palliative Care
...Palliative Care
Help to
• Eat well
• Sleep well
• Maintain function
• Minimize stress
Live better Live longer
Needsof Patients / Families
Processof ProvidingCare
“ The Model… …is the most importantdocument in the history
of hospice palliative care in Canada ”
“ The Model is implicit in all hospice palliative care in Canada –
it’s like the hard drive in every computer, invisible but supporting everything. ”
CHPCA Model Impact
• Patient / family care
National Health Accord
Access to medications for home PC
• Education
Pallium
EFPPEC
• Research
Canadian Institutes for Health Research
2012
‘ One Voice ’
2012 National Guidelines
The Challenge… 2012 - 2040,
how will Sweden applythe Guidelines
to PC funding, skills & services…
Human Rights Watch“ Pain & PC are Human Rights ”
India Kenya Ukraine
Unrelieved Pain is Medical Torture
Call to Action…
How will Sweden
• Ensure PC human right
• Include in health policy with funding
- cancer, elders, all diagnoses
WHO proposed:Opioid use
is an indicator of PC capacity…
Global Morphine-Equivalent Opioid Consumption,
Pain Policy Studies Group, Madison, WI
Swedenhas many
medications & opioids for palliative care…
and all medical uses…
> 80 % of global morphine consumed by 7 countries with < 10 % of world’s population. Developing countries
( > 80% of world’s population ), consume < 10 % of global morphine
2. Canada 76.7
1. Austria 177Substitution Therapy
23 Countries > Global Mean
131 Countries < Global Mean
3. USA 74.4
14. Sweden 20
10. Sweden 20
2. Canada 142
1. USA 198
8. Sweden 31.5
5. Sweden 31.5
Call to Action…
How will Sweden increase
per capita opioid use ?
Call to Action…
How will Sweden avoid
medication stock-outs ?
Call to Action…
Train ALL healthcare professionals
to provide palliative care…
For Palliative Medicine ( PM ),Sweden Needs…
Assumption• Each Palliative Medicine specialist
60 % clinical & 40 % teaching
300 new patients / year
30 year career cycle
Palliative Care
PresentationPresentation DeathDeath
Therapies tomodify disease
Therapies tomodify disease
BereavementCare
BereavementCare
6m6m
End-of-life /Hospice CareEnd-of-life /
Hospice Care
Therapies to relieve suffering and / or
improve quality of life
Therapies to relieve suffering and / or
improve quality of life
Palliative Care
…For only End of Life Care, Sweden Needs
2012
• 93 K deaths
60 % benefit from PC
• 55.800
PM Specialists
• Have 68
• Need 186
2040
• 127 K deaths
• 76.000
• Need 254 new !
PC Skills...
1° Basic Skills
All HealthcareProfessionals
1° Basic Skills
All HealthcareProfessionals
1°Advanced Skills
Cariology,Geriatrics,Oncology,
Etc.
1°Advanced Skills
Cariology,Geriatrics,Oncology,
Etc.
2°Expert skills
Palliative CareConsultants /
Teams
2°Expert skills
Palliative CareConsultants /
Teams
3°Academic
Palliative Care
3°Academic
Palliative Care
Educational Interventions…
A stepwise process…
as a Model…
Time ( yr ) 3 5 7 9 11
Sensitization
Courses ( Basic & Advanced )
Visiting Scholars ( Expert Identification )
Fellowships ( Experts )
Leadership ( Leaders )
Scholars in Residence ( Education & Research )
IPM Education
More tomorrow…
Research
Call to Action…
Develop newpalliative care knowledge & translate it into practice…
Swedish Registry
• Online access
• All deaths in Sweden
• Quality improvement
Methylnaltrexone Time to Laxation
p < 0.0001
J.Thomas et al. J Clin Oncol 2005; 23: 16S ( Abstract )
New Engl J Med 358 ( 22 ); 2332 May 29, 2008
Innovative Research
• Rapid management of depression
Methylphenidate
Ketamine
• New class of antinausea medication
• Effectiveness of educational strategies
In-country
Fellowship
Leadership
IPM Research
0
5
10
15
20
25
30
35
# o
f S
tud
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19
90
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91
19
92
19
93
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94
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99
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20
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IPM - Open Research Studies by Year1990 - 2008
Complementary
Staff Development
Medical Records
Psychosocial
Medical Intervention
Bereavement
Education
Palliative Care Service Development Globally(from the International Observatory on End-of-Life Care of Lancaster, UK)
No activity yet identified
Capacity building activity
Localized provision
Approaching integration
Source of Map: Wright et al., J. Pain Sym. Manag. 35:469 (2008)Bar graph created from data in this publication.
1
2
3
4
# C
ou
ntr
ies
99 / 144 LMICs have no services
Call to Action… Expand PC
services to all patients / families
in Sweden in need…and demonstrate effectiveness…
PC Specialty Services…
San Diego Hospice…• Founded 1977 - Dr. Doris Howell
Community-owned
Not-for-profit
AcademicEducationResearchAdvocacy
• Campus 1991
Gift of Joan Kroc
• SDHIPM 2009
Palliative Care in the US
PresentationPresentation DeathDeath
Therapies tomodify disease
Therapies tomodify disease
BereavementCare
BereavementCare
6m6m
End-of-lifeCare
End-of-lifeCare
Therapies to relieve suffering and / or
improve quality of life
Therapies to relieve suffering and / or
improve quality of life
Non-HospicePalliative Care
HospiceCare
…San Diego Hospice…
≈ 850 staff ≈ 750 volunteers
Budget ≈ $89 million
< 40 % cancer, > 60 % non-cancer
Hospice CarePrognosis < 6 months
Non-Hospice CareAny time
≈ 4,500 new patients per year
≈ 1,500 new consults per year
Acute CareHome
ER
DAYCARE
Elder Care,Nursing Homes
SpecializedFree-standing PC
Units
Inpatient Unit
Inpatient Unit
ICUs Outpatient Clinic / Office
Other eg, Jails
… San Diego Hospice…• Avg. Census > 1,000 patients / day
Home care 11 branches 500 – 550 / d
Long-term care 4 branches 300 – 350 / d
3 Acute inpatient units 36 beds
Pediatric team 25 – 30 / d
Ambulatory outpatient clinic
Team 7 – Px < 7 days
Triage Nurses
Extended care – nights, weekends
Outcomes… San Diego vs. Los Angeles
San Diego County
Los Angeles County
Use of Hospice Care
70 %( US ≈ 39 % )
25 %
Cost of Hospice Care
50 % higher than San Diego County
Last 2 yrs of life < $29,000 > $43,000
San Diego County
Use of Hospice Care
70 %( US ≈ 42 % )
Cost of Hospice Care
Last 2 yrs of life < $29,000
PC ‘ Inside ’…Oncology…
Cardiology…Elder care…
Etc….
Building relationships
with hospitals…
San Diego Hospice• 4 hospital-based consult services
each seeing 10 – 20 / day
UCSD Cancer Center La Jolla
UCSD Hillcrest
Scripps Mercy Hospital
Scripps Chula Vista Hospital
• Ambulatory outpatient clinics
• AIDS case management ≈ 120 / d
Building relationships with specialty
associations…
ASCO
ASCO
ASTRO
Public / MediaAwareness
Call to Action…
Increase public & media
awareness & access…
What % ofSwedish
population knows about PC…
PC = Best kept secret…
Are youprepared totalk about the death
of your loved one ?
PC Adds ‘ Days to Life& Life to Days ’
Let’s Campaign PC
Pain = entry point Increase public awareness Create demand for PC Change political will
Opportunitiesfor Sweden ?
What Experience . . .
your patients & families,
your loved ones, and ultimately yourselves
?
What Experience . . .
your patients & families,
your loved ones, and ultimately yourselves
?
“ The standards of practice we createand the people we train
will look after uswhen it’s our turn to receive care… ”
Will Sweden be ready ?
Call to Action in Sweden
Policy
Human right
National policies & funding
Education
1°, 2°, 3°
Services
All diagnoses
Whenever, wherever patient / family need care
Palliative care knowledge
Translate into practice
Public / political awareness & access
Living, not dying
Campaign to
Create demand
Political will
Pain = entry point
www.PalliativeMed.org www.IPCRC.netwww.PalliativeMed.org www.IPCRC.net
You must be the change you want to see in the worldGandhi
You must be the change you want to see in the worldGandhi