Palliative Care for Primary Care Providers QUYNH BUI, MD MPH DECEMBER 2015

Objectives

Define palliative care and primary palliative care

Describe the rationale for providing primary palliative care in primary care setting

Describe core domains of primary palliative care Overview tips and pearls to building a more

effective primary palliative care program

What is Palliative Care?

Patient- and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering.

What is Palliative Care? Palliative care throughout the continuum of illness

involves addressing: Physical needs Intellectual needs Emotional needs Social needs Spiritual needs Patient autonomy Access to information Choice

Palliative Care is not only hospice

Hospice care is defined as a comprehensive set of services identified and coordinated by an interdisciplinary group to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient and/or family members, as delineated in a specific patient plan of care.

What is Primary Palliative Care? Primary Palliative Care refers to the core services

and skills/competencies that are within the scope of every clinician.

Representative Primary Palliative Care skills: Basic management of pain and symptoms Basic management of depression and anxiety Basic discussions about:

Prognosis Goals of treatment Suffering Code status

Why Primary Palliative Care?

Timely palliative care Improves quality of care and quality of life Reduces overall costs while providing care that is

compatible with goals In some cases, improves survival

Why Primary Palliative Care?

Demand for palliative care will outstrip supply of palliative care providers Projected shortage of 6000 to 18,000 palliative

care specialists Outpatient palliative care clinics are rare

27/324 hospitals in California Most open part time. Capacity of 200-500

patients/year

Integrating Palliative Care at All Stages of Disease

Stage Tasks Next Steps Pre-Disease Onset/ All Adults >50

• Screen/Support AD • Discuss information sharing and

medical decision making

• Document MDPOA

Disease Onset • Confirm information sharing preferences

• Explain diagnosis and treatment options

• Discuss expectations/ goals

• Family meeting • Update AD

Disease Management • Review treatment progress • Assess for symptoms/ needs • Review goals/ AD

• Update AD • Repeat family meetings • Complete POLST/MOLST • Symptom management/

address needs • Update treatment plan

Integrating Palliative Care at All Stages of Disease

Stage Tasks Next Steps Advanced Disease

• Review and address symptoms/ needs • Assess functional status • Review and update prognosis • Review and update goals of care • Assess caregiver needs

• Connect caregiver support services

• Update POLST/MOLST, AD • Palliative care consult prn

End-Stage Disease

• Update prognosis and goals of care • Discuss referral to palliative care/ hospice • Assess patient for grief/ loss • Discuss life-completion tasks

• Family meeting • Update POLST/MOLST, AD • Comprehensive symptom

management • Assist patient with anticipatory

grief Bereavement • Normalize grief process

• Assess for depression/complicated grief • Provide follow up and

monitoring for development of depression

Clinical domains of primary palliative care Screening and Identification Prognosis/ Information sharing Assessment of needs Symptom management Goals of care/ Advance care planning

Screening and Identification WHO WOULD BENEFIT FROM PRIMARY PALLIATIVE CARE

Identifying Patients for Assessment: General Indicators

Decreasing activity/ functional performance Limited self-care Co-morbidity General physical decline Advanced disease Decreasing response to treatments Choice of no further active treatment Progressive weight loss (>10%) in past six months Repeated unplanned admissions/ ED visits Sentinel event

The Surprise Question

Would you be surprised if the patient were to die within the next 2 years? Few months, weeks?

Prognosis and Information Sharing SETTING THE STAGE FOR GOALS OF CARE

End of Life Trajectories

10 Steps to Better Prognostication

Concept 10 Steps to Better Prognostication Action Steps

Foresee

Science

Disease Start with Anchor Point Obtain details/ Speak to expert

Function Assess changes in performance status

Use functional status tool: PPS, KPS, ECOG

Tests Known physical signs/ labs related to prognosis Eg. Dyspnea, delirum

Tools Utilize palliative or end-stage prognostic toolls

PPS, PaP, PPI, SHFM, CCORT, CHESS, etc

Skill Judgement Clinician prediction of survival Adjust for prognostic factors/ bias

10 Steps to Better Prognostication

Concept 10 Steps to Better Prognostication Action Steps

Foretell Art

Center What is important to my patient/ the family?

Who/what do they want to know? How long/what will happen? Goals/hopes

Frame it Use probabilistic planning and discussion

Average survival/ time blocks, ranges

Cautions Share limitations of your prognosis Exceptions, changes

Changes Review and reassess periodically

Evaluate EOL trajectories

Follow up Stay connected Discuss ACP Symptom control Coordinate care

Assessment of Needs

Areas of Palliative Care Requiring Regular Assessment and Documentation

Area Examples Physical • Pain

• Depression/Anxiety • Dyspnea • Nausea/ Anorexia

Psychological • Caregiving burden • Stress/Grief • Coping

Social • Family structure/ Relationships • Access/ Resources • Finances • Culture

Spiritual • Spiritual beliefs/ communities • Life completion tasks

Example Questions

What do you understand about your illness? As you look ahead along the progress of your

illness: What are your expectations? Hopes?

How can we help address concerns and needs of those around you?

How is our treatment working for you? What abilities are most important to you to

maintain?

Symptom Management

Pain

Pain: Short acting opiates

Good for dose titration and breakthrough pain Initial Routine Dosing:

Opioid naïve: (severe pain): Oral morphine liquid 10-20 mg IR q 4 hr/ 5 mg in elderly/frail

Opioid tolerant: May need to increase dose by 50-100%

Consider opioid rotation

Pain: Breakthrough Pain

Use IR preparation of same opioid used for baseline dosing

When baseline opioid is methadone or transdermal fentanyl, use alternative IR form like morphine or hydromorphone

Each breakthrough dose is about 10% of total 24 hr dose

Pain: Opioid Titration

With short acting opioids, best pain control achieved within 24 hours

If pain is uncontrolled: Increase by amount equal to total dose of

breakthrough medication Increase by 25-50% for mild to moderate pain,

50-100% if severe pain

Pain: Convert to ER Preparation

Calculate total morphine dose required Calculate equianalgesic 24 hour dose and

correct for cross-tolerance Divide dosing according to pharmacokinetics Recalculate breakthrough dose

Pain: Opioid choice Opioids 90-95% eliminated by the kidney

Dehydration or acute renal failure will impair clearance

Increase dosing interval or decrease dose size Consider stopping scheduled dosing and go

to prn only Hydromorphone has fewer active metabolites

than morphine or oxycodone Fentanyl is metabolized only by liver Avoid meperidine, propoxyphene, agonists-

antagonists

Pain: Opioid side effects

Sedation, constipation, nausea, confusion Treat adverse effects Opioid rotation Adjuvant pain therapy

Pain: Other pain medications

Acetaminphen/ NSAIDs Gabapentin, anticonvulsants TCAs Corticosteroids Topical lidocaine

Opioids: Side effects: Nausea/ Vomiting: Dopamine- acting antiemetics

(metoclopramide, haloperidol) Ondansetron or benzodiazepines if refractory

Constipation: Stimulant laxatives (senna, bisacodyl)rather than stool softeners Osmotic agents (MOM, lactulose, sorbitol),

enemas Sedation: Dosing or opioid change,

psychostimulant Delirium: Work up, dosing or opioid change, Haldol,

donepezil

Depression SSRIs/ SNRIs

Duloxetine and venlafaxine can be used for adjuvant pain treatment

TCAs Atypical antidepressants Psychostimulants Start dosing low and titrate slowly

Depression: Psychostimulants Methylphenidate 5mg qAM and q 12 noon, max

40 mg/day Modafinil 100 mg qAM, max 200 mg/ day Dextroamphetamine 5 mg qAM and a 12 noon,

max 40 mg/ day

Dyspnea

Treat underlying cause Symptomatic management:

Oxygen Opioids Anxiolytics

Cool air across patient’s face

Dyspnea: Opioids

Hydrocodone: 5 mg q 4 hr, q 2 hr prn Morphine IR: 5-15 mg po q 4 hr Oxycodone: 5-10 mg po q 4 hr Hydromorphone: 0.5-2 mg p q 4 hr Tolerance not usually a problem Keep to low doses, dosing guidelines.

Advance Care Planning/ Goals of Care

Potential Goals of Care Cure of disease Avoidance of premature death Maintenance/ improvement of function Prolongation of life Relief of suffering Optimized quality of life Maintenance of control A good death Support for families and loved ones

BUMC PROCEEDINGS 2001;14:134–137

7 Steps in Negotiating Goals of Care

1. Create the right setting 2. Determine what the patient and family knows 3. Explore what they are expecting or hoping for

the future 4. Suggest realistic goals 5. Respond empathetically 6. Make a plan an follow through 7. Review and revise periodically as appropriate

BUMC PROCEEDINGS 2001;14:134–137

Language about palliative care that has negative connotations

Do you want us to do everything possible? Will you agree to discontinue care? It’s time we talk about pulling back. I think we should stop aggressive therapy I’m going to make it so he won’t suffer

BUMC PROCEEDINGS 2001;14:134–137

Language about palliative care with more positive connotations

We will concentrate on improving the quality of your child’s life

I’ll do everything I can to help you maintain your independence.

I want to ensure that your father receives the kind of treatment he wants.

I will focus my efforts on treating your symptoms. Let’s discuss what we can do to fulfill your wish to

stay at home. BUMC PROCEEDINGS 2001;14:134–137

Advance Medical Directives http://www.iha4health.org/our-services/advance-directive/

Medicare Billing for Advance Care Planning 99497: Initial 30 minute advance care

planning consultation (wRVU 1.5) 99498: Add-on code for additional 30

minute time blocks needed for advance care planning (wRVU 1.4)

Summary Primary palliative care is complementary of

disease-modifying care Primary care has unique capabilities and

responsibilities in providing primary palliative care

Primary palliative care should be provided throughout the continuum of serious illness

Domains of physical, psychological, social and spiritual needs should be assessed and addressed on an ongoing basis

Goals of care are dynamic