Palliative care aims to improve quality of life for patients facing serious illness through comprehensive pain and symptom management and coordination of care across settings. While some view it as a form of rationing, studies show palliative care can help patients live longer while feeling better. It works to resolve conflicts among clinicians and between clinicians and patients/families around goals of care. Implementing a palliative care program at Cape Cod Hospital could help address frequent ER visits and readmissions at end of life through improved symptom control and advance care planning.

1. Is Palliative Carejust another name for Rationing? Suzana Makowski, MD MMM FACP Director of Palliative Care in the Cancer Center of Excellence UMass Memorial Healthcare & UMass Medical School

2. Overview What is palliative care? Stirs conflict Patients & families Clinicians Hospital administrators Payors Why Cape Cod Hospital?

3. What is Palliative Care? CMO? Continuous morphine only?

4. What is Palliative Care?

5. What is Palliative Care? Medicare Definition: Palliative care means patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and to facilitate patient autonomy, access to information, and choice. WHO Definition: Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of sufferingby means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.

6. Palliative Care Paradigm

8. healthcare utilization throughout, and

11. no hospice care, or

13. “It’s not about killing Granny; it’s about keeping Granny alive as long as possible — with the best quality of life.” - Diane Meier, NYTimes

14. Early End-Of-Life Care Helps Lung Cancer Patients Live Longer by SCOTT HENSLEY Guess what happens when you give people with a deadly form of lung cancer early access to palliative care? They live about two months longer. They also feel better throughout the course of treatment. And the people who get palliative care starting within three weeks of diagnosis are more likely to have recorded their end-of-life wishes and, ultimately, to have less aggressive and expensive care just before dying.

15. Do we want to supersize healthcare?

16. More medical care ≠ better medical care Family members of decedents in high-intensity hospital service areas report lower quality of: Emotional support Shared decision-making Information about what to expect Respectful treatment Teno et al. JAGS 2005;53:1905-11. Physicians practicing in high health care-intensity regions report more difficulty: Arranging elective admissions Obtaining specialty referrals Maintaining good doctor-patient relations Delivering high quality care Sirovich et al. Annals Intern Med 2006; 144:641-649

17. Relationship between cost of care and quality of death in the final week of life (adjusted P= 0.006) Zhang, B. et al. Arch Intern Med 2009;169:480-488.

18. Associations Between Caregiver’s Outcomes and Patients’ End-of-Life Care and Quality of Life (N=202) Wright, A. A. et al. JAMA 2008;300:1665-1673. Copyright restrictions may apply.

19. Relationship Between Quality of Life and End-of-Life Care Wright, A. A. et al. JAMA 2008;300:1665-1673. Copyright restrictions may apply.

21. So is Palliative Care then about rationing? Institute of Healthcare Improvement Right Care at the Right Time in the Right Place Better does not necessarily require more…

22. Dissonance

23. So what could palliative care do for you?Resolve conflict: clinician-patient 42 year old Syrian immigrant with metastatic non-small cell lung cancer, intubated for post-obstructive pneumonia. Septic shock on maximal pressor support. Now with multiorgan failure. Family present: wife, brother, parents. “Do everything.”

24. Clinician-patient/family conflict Clinician Patient Futility • Autonomy • Non-maleficence Withholding • Withdrawing IHI: Underuse • Misuse • Overuse

25. Clinician-patient/family conflict “Let him linger for our son”

26. So what could palliative care do for you?Resolve conflict: clinician-clinician Camille: 52 year old cyclist Bike-car accident Sunday morning resulted in massive thoracic injuries, facial injuries, bilateral intracerebral contusions/bleeding. Renal failure, hypotensive on multiple pressors, intubated Trauma intensivist: “he is stabilizing and getting better” Neurosurgeon: “he shows no signs of neurologic improvement.”

27. So what could palliative care do for you?Resolve conflict: clinician-clinician Defining goals of care Coordinating care Providing support for family and clinicians Addressing PTSD & depression among survivors Trauma intensivist: We can stabilize him to leave ICU, the hospital. He can live. Neurosurgeon: May be stabilized hemodynamically, but without meaningful neurologic improvement. Family: We know he won’t walk or bike again, but will he be able to make jewelry again?

28. So what could palliative care do for you?Resolve conflict: clinician-clinician Early family/interdisciplinary and multidisciplinary team meetings. Goals of care defined by family, and then interpreted to clinical decisions. What is meaningful life for this person? What legacy does he want to leave? (organ donation, long-term NH placement) Role of healthcare proxy: to define goal of care, not to make specific clinical decisions.

31. Art Buchwald quoted by Richard Severo, NYTimes – Jan 19, 2007 As he continued to write his column, he found material in his own survival. “So far things are going my way,” he wrote in March. “I am known in the hospice as The Man Who Wouldn’t Die. How long they allow me to stay here is another problem. …But in case you’re wondering, I’m having a swell time — the best time of my life.”

32. What could palliative care do for you?Assist with coordination of care across care-settings Emergency use high among patients at end-of-life Patients with lung cancer in Canada – 84% visited ER in last 6 months of life, 34% visited in 2 weeks of life. Why? Uncontrolled symptoms, caregiver fatigue, infection Barbera, L., Taylor, C., & Dudgeon, D. (2010).Canadian Medical Association Journal DOI: 10.1503/cmaj.091187 Emergency room at Cape Cod Hospital Great opportunity for innovation in palliative care Social worker, nurse practitioner and processes

33. What could palliative care do for you?Assist with complex symptom management 36 yo with metastatic uterine cancer admitted to Cape Cod Hospital with severe intractable pain. Morphine switched to hydromorphone (Dilaudid) PCA. Titrated – but patient remains in severe pain, now agitated and with increased nausea/constipation. Palliative care consultation called – medication adjustment lead to alleviation of pain, normal cognition, resolved N/V and constipation within 24 hours. Patient discharged to home.

34. Optimal care for patients Dr. Robert Martensen: “But when you look at Medicare overall half the money that we spend in this country on Medicare is spent on patients in the last six months of their lives. And if we were providing some kind of wonderful existence, then one could make the case but as I have written about and as I certainly experienced, and I gathered you’ve experience and many others, these last six months are not, they’re often agonizing and very unsatisfying for all concerned.”

35. We will do everything. The question is, what kind of everything?

36. Palliative Care at Cape Cod HospitalWhy? Patient and family satisfaction Improves quality of life, and at times, longevity Provides support in complex decisions, symptom management, coordination of care, bereavement Clinician satisfaction Quality of care Time Coordination of care Hospital leadership satisfaction Quality Cost savings Payer satisfaction Joint Commission, leapfrog and other quality standards National quality standards will require 24/7 access to palliative care UMass: Recognizes that growing palliative care is imperative for improvement of quality care in current economic condition

37. Palliative Care at Cape Cod HospitalHow? Target key areas: Emergency Room Centers of Excellence: Cardiology, Cancer Areas of need: Critical Care Team approach – balance FTE mix based on need and location: Physician and nurse practitioner Social worker Chaplain Counselor with bereavement and expressive arts background Clinical Pharmacist Administrator/Coordinator

38. Palliative Care at Cape Cod HospitalHow? Models: - CAPC as resource: business & strategic plans key Consultative only Consultative + float beds/unit Benefit: Unit with protocols, expertise Challenges: Clinician coverage – medical director oversight, 24/7 staffing Consultative + emergency room model Outpatient clinic – coordinate with home health and hospice services Regular interdisciplinary/transdisciplinary team meetings Collaboration with ethics, case management

39. Thank you “You matter because you are you, and you matter to the end of your life. We will do all we can not only to help you die peacefully, but also to live until you die.” - Dame Cicely Saunders