Hospice and Palliative Care: An Overview Patrick J. Macmillan, MD, FACP Division of Palliative...
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Transcript of Hospice and Palliative Care: An Overview Patrick J. Macmillan, MD, FACP Division of Palliative...
Hospice and Palliative Care:
An OverviewPatrick J. Macmillan, MD, FACPDivision of Palliative Medicine
Department of Internal MedicineEast Tennessee State University
James H. Quillen College of Medicine
Introduction
What is Palliative and Hospice Medicine?
Disease that are most frequently seen
Hospice guidelines
Evidence for Palliative and Hospice Care
Resources
Philosophy
Emphasize advanced planning and ongoing care and support rather than crisis intervention
Promotion of psychosocial and spiritual growth and development
No specific therapy is excluded—treatment is based, however, on meeting treatment goals rather than effect on underlying disease
Radiation, chemotherapy, surgery are NOT excluded in palliative or hospice care
History: Western Civilization
Earliest recorded hospice 475 in Rome
Middle Ages: Christian religious orders in Europe
Modern hospice movement: Irish sisters of charity 1879
St. Christopher’s Hospice 1967 in London remains one of the preeminent hospice programs in the world
First hospice program in US opened in 1974 in New Haven, CT
1996 450,000 patients were served by 2,700 hospice programs
Alternatives
Quality of Life
Medical Ethics
Palliative Care
Medical Care for people with serious illnesses—focuses on relief from symptoms and suffering
Palliative medicine is the study and management of patients with active, progressive, far advanced disease for whom the prognosis is limited and the focus of care is quality of life.
WHO: “active total care of patients whose disease are NOT responsive to curative treatments.”
Is Palliative Care the same as Hospice?
Palliative Care
NO—Hospice is a “focus” of Palliative Care targeted at the terminally ill
Goals: Improve quality of life for family and patient
Give patient a voice in Tx Plan
Appropriate at any stage of serious illness
Palliative Care
“Patient and Family centered care that optimizes quality of life by anticipating, preventing and treating suffering.
A continuum of treatment that focuses on all aspects of a person
NQF National Framework and Preferred Practices for Palliative and Hospice Care
Palliative Care
Referral: complications, uncontrolled symptoms, multiple comorbidities, and patient or family distress
Assistance needed for complicated decision-making
Palliative Medicine
Lancet September 2010; Double-blind, randomized controlled trial
Study comparing Palliative O2 vs. Intranasal room air
239 patients, life-limiting illness, refractory dyspnea and PaO2>55
Each group received either O2 or room air at 2L/min NC
Conclusion: No significant difference in rating of dyspnea; air movement across the face (hand held fan) helps relieve dyspnea
Oxygen is costly and risky for some patients
Simple interventions can be used in case where there is NOT true hypoxia
Hospice Care
Hospice Care: 6 months or less to live IF disease runs its natural course. (Also need family consent)
Hospice Care
Cancer, COPD, Heart disease, ESRD, ESLD, Dementia, CVA, AFTT, Debility, AIDS
NHO (National Hospice Organization) medical guidelines
Cancer: Cancer plus metastasis (clinical findings) with widespread aggressive and progressive disease
PPS score of < 70%
Patient refusing further Tx
Hospice Care
COPD: Severe and progressive lung disease
FEV1<30% predicted
ER visits or hospitalization for lung infections
Hypoxemia at rest (o2 sat<88%)
Hypercapnea (Pco2 >50 mm Hg)
Best indicator is FEV1
Hospice Care
Heart Failure
New York Heart Association Class IV (Sxs at rest)
Optimal Tx
Other: refractory arrhythmias, hx of cardiac arrest, syncope
Can be on transplant list
Hospice Care
Dementia
Severe Dementia and 1st occurrence of medical complications
Severity: unable to ambulate independently, no meaningful conversation, urinary/fecal incontinence, unable to dress/bathe independently. “total care”
Medical complications: UTI’s, aspiration PNA, wt loss, etc.
Documentation of rapid decline
Hospice Care
HIV Disease
CD4 count<25
Viral Load >100K copies/mL
Decreased functional status
Other: CNS Lymphoma, PML, wasting, MAC bacteremia, refractory Toxoplasmosis
Note: 80% HIV patients alive 10 years after seroconversion
Hospice Care
End-stage liver disease
INR>1.5 and Albumin <2.5 gm/dl
Clinical syndromes: Ascites in spite of diuretics, SBP, Hepatorenal syndrome, Hepatoencephalopathy despite lactulose
Recurrent variceal bleed
Other: active etoh abuse, Hep B, CA, malnutrition
Note: Patients can be on hospice pending liver transplants
Hospice Care
End-stage renal disease
No dialysis
Lab criteria: creatinine >8.0 and clearance <10
Others: CVA, coma, ALS, MS, Parkinson’s disease, AFTT, debility
Hospice/Palliative Care
90% of Americans die after living with a chronic, progressive incurable illness
1/3 of healthcare costs occur in last year of life
Duke University Study (2007): hospice saves Medicare an average of more than $2,300 for each hospice beneficiary
Reduction in Medicare costs if hospice recipients been on for a longer period
Hospice patients lived an average of 29 days longer than those not referred to hospice
Hospice/Palliative Care
Study: 228 ambulatory patients with newly diagnosed non-small cell lung cancer
Standard oncologic care vs. palliative care
Palliative care group survived longer (11.6 months vs. 8.9 months)
Analysis (included age and performance status) showed early palliative care was an independent predictor of survival
Subgroup (107 patients in both groups) survived to 12 weeks—PC group reported better quality of life
Hospice/Palliative Care
Palliative care group received less chemo
Made fewer ER visits
More likely to die at home
Resource Use in the Last 6 Months of Life Among Medicare Beneficiaries With Heart
Failure, 2000-2007
Archives of Internal Medicine: Retrospective cohort study: February 14, 2011
US patients, 200,000 Medicare beneficiaries who died in 2000-2007
Use of hospice increased from 19% to 40% over the course of the study
Average number of days in ICU increased
80% of patients were hospitalized in last 6 months of life
Hospice/Palliative Care
Assessed length of patients stay in hospice
19% stayed < 3 days, 37% < 1 week
Hospice Use and High-Intensity Care in Men Dying of Prostate Cancer
Archives of Internal Medicine: Retrospective cohort study 2011
Hospice use among men dying of Prostate CA between 1992-2005
53% used hospice—22% of this group enrolled in hospice < 1 week
Conclusion: “short stays [in hospice] don’t allow patients to receive full benefits of enrollment in hospice.”
Hospice/Palliative Care
Study did find an increase in use of hospice care over time
Hospice patients less likely to receive high-intensity care
Conclusion: “Increasing the appropriate use of hospice care for patients at end of life could both improve quality of death and reduce ineffective health care expenditures.”
Hospice/Palliative Care
Late referrals are due partly to physicians attitudes about death
May view patients death as a medical or personal failure
May feel they have nothing else to offer when curative goals are exhausted
Distance themselves from patients and families because uncomfortable talking about death
Hospice/Palliative Care
Prognosis-related issues also problematic
Accurately predicting prognosis is difficult (particularly non-cancer diagnosis)
Best Prognosticators: length of practice, subspecialists
If you have known the patient a long time---less accurate
Hospice/Palliative Care
The Good News
Changes in attitudes regarding advanced diseases and improving quality of life
More acceptance of Palliative care concept
Access to palliative care improving
Curriculum changes in medical school