1 / 36

Improving Palliative Care in the U.S.: Challenges and Opportunities for a Good Death

This presentation by Dr. David J. Casarett explores the state of palliative care in the U.S., addressing critical aspects such as the meaning of a "good death," pain and symptom management, prognosis communication, and patient preferences. It highlights the challenges faced in providing optimal care, especially among older patients, and suggests potential improvements through palliative care initiatives and better communication. The session also discusses the financial implications of end-of-life care and the role of hospice and palliative care in enhancing quality of life for patients with serious illnesses.

emerald-mills
Télécharger la présentation

Improving Palliative Care in the U.S.: Challenges and Opportunities for a Good Death

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Palliative care in the US David J Casarett MD MA Division of Geriatrics University of Pennsylvania

  2. Outline • Death and dying in the US • What is a good death? • Problems/opportunities for improvement: • Pain and symptom management • Prognosis • Discussions/preferences • Solutions? • Hospice • Palliative care • Ideal palliative care in the US

  3. Death and dying in the US: Cause of death (2000) • #1: Heart disease • #2: Cancer • #3: Cerebrovascular disease • #4: Chronic lower respiratory disease • #5: Unintentional injuries • #6: Diabetes • #7: Acute respiratory infection • #8: Alzheimer’s Disease • #9: Renal Failure • #10: Sepsis

  4. Trajectories of functional decline CHF/COPD Cancer Dementia

  5. Death and dying in the US: Trajectories of illness (>65) • On average, >2 years of significant disability before death • Illness that will eventually be fatal is diagnosed about 3 years before death • 80% of patients die after a lengthy period of decline that is either: • Steady, unidirectional (Dementia) • Intermittent with exacerbations (Heart failure, Emphysema, Coronary Artery Disease, Cancer)

  6. Death and dying in the US: Costs Costs Lifespan (years)

  7. Epidemiology: General points • Most deaths in the US occur in patients > 65 year old • Deaths are usually the result of chronic, progressive illness, particularly in older patients • Costs (borne by health system, patients, families) increase gradually over the last years of life

  8. How well are we doing in ensuring a good death? • What is a good death? • How well are we doing in providing a good death? • Pain and symptom management • Discussing prognosis • Communication about goals and preferences

  9. What is “a good death”? • Unique to each individual and dependent on culture (Have to ask patient) • But several clear themes: • Physical comfort • Psychological/emotional well-being • Spiritual peace • Dignity • Control • Time with family, closure

  10. How well are we doing?Pain and symptom epidemiology • Multisite WHO collaborative study of cancer patients, Vaino et al 1996: • Moderate-severe pain:51% • Anorexia: 30% • Weakness: 25% • Constipation: 29% • Nausea: 20% • Dyspnea: 21%

  11. How well are we doing? Pain and symptom management • Multisite inpatient SUPPORT study, Lynn: • Severe pain: 40% • Severe dyspnea: 40-50% • Confusion: 18% • Fatigue: 80% • Multisite ECOG cooperative study, Cleeland: • 67% any pain • 42% of those with pain had inadequate analgesic medications prescribed • Inadequate analgesia 3x as common among minorities

  12. How well are we doing? Communication • 44% of bereaved family members of elderly deceased cited communication about prognosis as very important, Hanson 1997 • 85% of cancer patients stated that they wanted all information, good and bad, Cassileth 1980

  13. Challenges of estimating prognosis:How long will this patient live? • Patient: • 74 year old • Class IV heart failure (symptoms at rest) • Diabetes, renal failure • 1-2 months

  14. How accurate are we at prognostication?

  15. How good are we at communicating prognosis estimates? • 326 patients referred to hospice by 258 physicians, Lamont 2001 • Overestimated prognosis by factor of 1.2 • Communicated an overestimated prognosis by factor of 3.5

  16. How well are we doing? Communication about preferences • SUPPORT study, SUPPORT investigators 1995: • 47% of physicians knew when their patients wanted to avoid CPR • 40% of patient/family-physician pairs discussed CPR • Medicare resource use study, Teno 2002: • 20% of seriously ill Medicare patients said their care was too aggressive

  17. Summary of problems and opportunities • Pain and other symptoms • Common • Often poorly managed • Uneven burden (non-white patient, older patients) • Prognosis • Inaccurate • Difficult to communicate • Communication • Inadequate attention to patient preferences • Missed opportunities to initiate discussions

  18. Solutions • Palliative care • Two ways of delivering palliative care in the US: • Hospice • Palliative consults

  19. Palliative care • Palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness…(WHO): • Symptom relief • Psychological and spiritual well-being • Maintains function • Applicable throughout serious illness

  20. 2 definitions of palliative care • Narrow definition: “Comfort care”, focus only on providing comfort and relieving symptoms. Palliative care provided near the end of life when there are no further treatment options • Broad definition: WHO definition, holistic care provided throughout illness. Palliative care provided when there are no further treatment options and in parallel with active treatment.

  21. 2 Definitions of palliative care: Active treatment Comfort care Throughout illness Diagnosis Death

  22. How can we improve end of life care? • Patient: 74 years old, CHF, diabetes. • Symptoms: Pain, dyspnea • Uncertainty about prognosis • Needs additional social support at home

  23. Hospice care in the US • Hospice industry: • ~5,200 organizations nationwide • >1,300,000 patients/year • Interdisciplinary team (Physician, nurse, social worker, chaplain, volunteer) • Hospice services • Care provided in home, acute care, long term care • Medications related to hospice diagnosis • Respite care (5 consecutive days) • Home health aide services (2 hours/day) • Bereavement follow up and counseling for >1 year

  24. Hospice eligibility • Prognosis of 6 months or less if the illness runs its usual course, according to 2 physicians • Referring MD • Hospice medical director • Hospice reimbursement often requires that additional criteria are met: • Developed by NHPCO • Promulgated by Fiscal Intermediaries • Complex, difficult for clinicians to remember and use effectively

  25. Hospice: an ideal solution? • “Narrow”/Comfort care • Theoretical problems: • Eligibility is difficult to determine • Prognosis is challenging • Must give up access to many life-sustaining treatments: • ICU admission • Chemotherapy (unless it’s purely palliative) • Not CPR (DNR order not required)

  26. Hospice: an ideal solution? • Uneven access (decreased hospice referrals among): • Younger patients • African Americans • Nursing home residents • Patients with non-cancer diagnoses

  27. Hospice: an ideal solution? • Practical problems: • Late referrals • Median length of stay in hospice=21 days • 1/3 referred in last week of life • 10% referred in last 24 hours • Early referrals • 6% of patients “outlive” the hospice benefit • Concerns (among physicians and hospices) of censure/non-payment for inappropriate referrals

  28. Hospice summary • Ideal source of care • Interdisciplinary team • Range of benefits and services • Extensive infrastructure • Revenue stream • But: • Requires prognostic estimates • Penalties for inappropriate referrals • Result is very short lengths of stay and inadequate utilization

  29. Alternative: Palliative consults • Consultation by a nurse or physician • Done in multiple settings: • Hospital (approximately 40% of hospitals) • Nursing home • Clinic • (Home)

  30. Palliative consults: eligibility • Broad definition of eligibility • All patients, regardless of prognosis • Can continue to receive aggressive treatment

  31. Palliative consults: Services • Services vary widely • Some combination of: • Physician • Nurse • Social worker • Chaplain

  32. Palliative consults: Problems • Unlike hospice, no dedicated source of funding • Consult services supported financially by: • Some billing of insurance companies • Donations • Volunteer effort • “cost savings” • Lack of funding has limited growth

  33. Summary of hospice and palliative care • Hospice: • Home/hospital/nursing home • Dedicated funding • Clear guidelines and requirements for services • System of quality measurement • Strict eligibility criteria • Palliative care • Mostly hospital, some nursing home • No dedicated funding • No guidelines and requirements for services • No system of quality measurement • Open eligibility criteria

  34. Ideal palliative care? • Continuous—ensuring that all patients have access when they need care • Begins at diagnosis, and continues through to include bereavement support for family • Paid for like other medical care • Clear standards for high-quality care • Ideal palliative care doesn’t exist in the US

  35. The future of palliative care in the US • Growing palliative consults: • Extension into nursing homes • Care for patients at home • Increasing access to hospice: • More patients benefiting • Patients enrolling earlier • Progress is slow but steady

  36. Outline • Death and dying in the US • What is a good death? • Problems/opportunities for improvement: • Pain and symptom management • Prognosis • Discussions/preferences • Solutions? • Hospice • Palliative care • Ideal palliative care in the US

More Related