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- 1. Palliative Care & AdvanceCare Planning Physician Education
- 2. • Palliative careis a medical specialty backed by an interdisciplinary team that supports the attending physician’s care of patients with serious and life-threatening illnesses. • Palliative care supports the attending physician’s plan of care by making the patient as comfortable as possible at all stages of illness, simultaneously with curative care or any other medical treatment. • Palliative care is evidence-based medical treatment that has been shown to significantly lower pain and discomfort, improve patient outcomes and boost patient and family satisfaction, while freeing the attending physician from time-consuming coordination and support. • Palliative care may also complement care provided to patients receiving disease-modifying treatment. This team assists the physician in clarifying the patient/family’s goals of treatment and designing an individualized plan of care that addresses the patient’s physical, psycho-social, spiritual and cultural needs. What is Palliative Care?What is Palliative Care?
- 3. • Palliative careis NOT in place of curative care. • Patients benefit from palliative care before, during and after beneficial, curative or life-prolonging care. • Palliative care is NOT the same as hospice. Palliative care is offered at any stage of any illness, while hospice care is appropriate for people with terminal illnesses, at the last stages of life and a prognosis of six months or less and for whom curative or life-prolonging therapies are not effective. What is it not?What is it not?
- 4. Physician Role inAddressing Advance Care Planning • Patient options for treatment • Chances of survival or prognosis • Options for pain/other symptoms of disease • Patient/family’s decision about treatment • Spiritual needs assessment How does CHW define Advance Care Planning? How does CHW define Advance Care Planning?
- 5. Physician Role inAddressing Advance Care Planning DISCUSSION & DOCUMENTATION OF THE FOLLOWING: • Patient options for treatment • Chances of survival or prognosis • Options for pain/other symptoms of disease • Patient/family’s decision about treatment Physician Role in Advance Care Planning Physician Role in Advance Care Planning
- 6. 1/30/2009 6 Advance CarePlanning is ALL about TIME •TIME intensive patient family centered communication around goals of care. •INTEGRATE pain and symptom management with all other appropriate treatment to achieve the highest quality of patient care. IMPROVE patient satisfaction with the hospital, overall medical treatment, physicians and health care team. •MEET decision making needs of patients ensuring fully informed consent based on burdens of the treatments and wishes of the family. •EASE case management burdens on physicians and support for the plan of care by helping to coordinate the treating physician’s orders; including safe and effective discharge planning. Benefits of Advance Care PlanningBenefits of Advance Care Planning
- 7. • Traditional Medicine –Cure illness • Prolong life Palliative Care Improve quality of life Pain management Symptom management Emotional support Advance Care Planning Does not exclude traditional therapy Medical Therapy ChoicesMedical Therapy Choices
- 8. • Reduce thesuffering and increase the comfort of our patients through symptom control and restoration of functional capacity. • Participate in the CHW palliative care initiative. • Plan for future medical care in the event a patient is unable to make their own decisions. • Remain sensitive to personal, cultural and religious values and beliefs. CHMC’s - Palliative Care Service GoalsCHMC’s - Palliative Care Service Goals
- 9. • Pain Management •Symptom Management • Emotional Support • Advance Care Planning • Provide assistance with: – In-hospital support – Transitions to Home, SNF or Hospice, Home Health Palliative Care Service Key Components Palliative Care Service Key Components
- 10. • Cancer • HIV/AIDS •ESRD, on dialysis with diabetes • End stage lung disease/COPD • Acute or chronic respiratory failure • Cardiac condition • CAD with bypass and CHF • ICB • Cirrhosis • Dementia with PEG/NG aspiration Appropriate Palliative Care Referral Diagnoses Appropriate Palliative Care Referral Diagnoses
- 11. Appropriate Palliative Care ReferralDiagnoses Appropriate Palliative Care Referral Diagnoses
- 12. MD order foractual team intervention • Comfort Measures (Supportive Care) *** • End-of-life Care • Hospice Care End of Life Patients ONLY • Terminal Care How is a Palliative Care Physician Order Written? How is a Palliative Care Physician Order Written?
- 13. • Palliative CareService helps the patient/family make choices regarding goals of care and may include disease modifying treatment as well as comfort measures. • Hospice Services are for patients that have a life expectancy of 6 months or less. Hospice focuses on comfort care at the end of life. What is the difference between Palliative Care Services and Hospice? What is the difference between Palliative Care Services and Hospice?
- 14. • Prognosis ispoor, less than 6 months • A referral must first be made to CHMC Palliative Care Services • Primary Physician agrees that hospice services are appropriate and thus orders hospice care • Patient/family agree to hospice care • Patient meets admitting criteria. What is required to make a Hospice Referral? What is required to make a Hospice Referral?
- 15. • ALS (Lou Gehrig’s Disease) • End Stage CA ( i.e. Pancreatic Cancer) • End Stage Alzheimer’s Disease • Failure To Thrive • End Stage Renal Disease • End Stage Parkinson’s • End Stage MS • End Stage PVD • End Stage CVD/Stroke • HIV/AIDS Appropriate Hospice Referral Diagnoses Appropriate Hospice Referral Diagnoses
- 16. Write an orderin the patient’s chart for a Palliative Care Consult Central Intake Lisa McCullough 213-742-5560 Call Sheldon Lewin Director, Palliative Care Services, 213-742-5525 or hospital pager 307-2368 Contact Robert Rothbart MD, Palliative Care Medical Director Contacting the CHMC’s Palliative Care Service Contacting the CHMC’s Palliative Care Service
- 17. • Central IntakeLisa McCullough 213-742-5560 • Program Administration Sheldon Lewin 213-742-5525 / 773-968-1960 (cell) / 213-307-2368 (pager) • Educator/Clinical Specialist JO Medina 213-742-6446 • Unit Directors • Flo Guerra (Critical Care) 213-742-5624 • Rita Mae Feliciano (DOU) 213-742-5835 • Naty Armstrong (Medical Surgical, TCU, Ortho) 213-742-5423 • Chaplain: • Brother Louis, Sister Judeen` 213-742-6472 • MSW: • Herb Moorman (DOU/TCU, Orthopedics) 213-307-2326 • Robert Savedra (Critical Care) 213-307-2259 • Kristen Turski (Medical Surgical) 213-307-2288 • Lisa McCullough 213-307-1807 • RN Case Manager: • Myrna West x6486 • Alicia Pangilinan x6358 • Joyce Galantai x6484 • Sharon Tool x6347 • Patient Representative: • Ana Cacao x5858 CHMC Palliative Care Core TeamCHMC Palliative Care Core Team
- 18. CHMC “COMPASSIONATE CARE”PROGRAM Palliative Care/Advance Care Planning CASE FINDING, REFERRAL & CONSULT PROCESS CASE FINDING INTAKE SCREEN ONLY (For Internal Use/ Not Part of Medical Record) PRIMARY/ CHARGE RN ---- OBTAIN MD ORDER Comfort Measures(Supportive Care) End of Life Care Hospice Care Terminal Care TRIGGER PC CONSULT VIA AS400 TO SOCIAL SERVICES “COMPASSIONATE CARE” TEAM INTERVENTION & DOCUMENTATION CARE PLANNING ROUND(S) (Verbal and written) CARE PLAN IMPLEMENTATION Palliative Care Core Team Back –Up Clinical/ Intake Primary RN Chaplain: Brother Louis, Sister Judeen` *JO Medina MSW: Herb Moorman, Robert Savedra, Kristen Turski Lisa McCullough * Lisa McCullough RN Case Manager: Myrna West, Alicia Pangilinan, Joyce Galantai Sharon Tool Patient Representative: Ana Cacao Social Work Case Management RNSpiritual Care Ancillary Employees As Needed Rehab, Dietary, Pharmacy Patient Representative CHMC - Palliative Care ProcessCHMC - Palliative Care Process
- 19. Daily Automated Palliative CareScreening Report • California Hospital Medical Ctr • Advance Care Planning & Palliative Care Screening Report • QUERY NAME . . . . . HSQSHELADT • LIBRARY NAME . . . . HS#LIBRCMC • FILE LIBRARY MEMBER FORMAT • PHPACCT PH#FILECMC PHPACCT PHPACCTA • DATE . . . . . . . . 09/06/08 • TIME . . . . . . . . 04:30:06 • Advance Care Planning & Palliative Care Screening • California Hospital Medical Ctr • 09/06/08 04:30:06 • MR# Acct# Admit Name Aprox Disch LOS Min Serv Room Bed C/C Dr # Dr Last Name • Date Age DOB Pt Code • Dx • 6000 12345 20080905 BRO 77 19310928 0 0 I DOU 0936 01 1110 3997 KIRSONIS • ACUTE COPD • 13333 145 20080905 HO, 52 19561012 0 0 I ICU 0326 01 2102 7763 ZAHED • COPD CHF • 1111 81282525 20080705 THO72 19361210 0 0 I DOU 0950 01 1000 3983 KIM • SOB/CHFEG • 1111 16539 20080905 NI, 49 19590603 0 0 I DOU 0930 01 2503 66 AMOOIE • WEAKNESS R/O CVA • 22222 12321 20080905 TAYLOR, 54 19540222 SNF 2000 5785 PECKNER • COPD, STAPH SEPSIS, VRE URINE, DVT RT • 5678 4567 20080905 CRINER, RITA 54 19540222 SNF 0656 01 2000 5785 PECKNER • COPD, SEPSIS, VRE URINE, DVT RT THIGH • • FINAL TOTALS • COUNT 6 • * * * E N D O F R E P O R T * * * Automated Daily PC ReportAutomated Daily PC Report
- 20. CHMC - PalliativeCare Intake ScreenCHMC - Palliative Care Intake Screen I. General Information MSW/ RN COMPLETE Date_________________ Time____________________ Medical Record #_______________________________ Patient ID #____________________________________ Admit Date____________________________________ Referral Source________________________________ MD Palliative Care Order Yes No Advance Directive: Type_______________Yes No On Chart Yes No Code Status- Circle all that apply Do not resuscitate Do not Hospitalize (SNF, subacute) Comfort Measures (Supportive Care) Hospice (Referral) Full Code Limited DNR Admitting Diagnosis______________________________________ Religion/Clergy_________________Race_____________________ Next of Kin Name______________________ Relationship________________ Phone #________________ Work#____________________ II. *** Are we addressing the 5 components of Advance Care Planning? Patient Options for Treatment Chances of Survival or Prognosis Options for pain/other symptoms of disease Patient decision about treatment Spiritual care assessment Palliative Care/Advance Care Planning “COMPASSIONATE CARE TEAM” INTAKE SCREEN ONLY (Do Not Place in Medical Record) V. Check current and or recommended services Social Services MSW COMPLETE Emotional Support Advance Care Planning Advance Directive Information & Education Family conference Case Management Hospice Facility ___________________________ ***Home Care Hospice–Palliative Care Services Name ______________Contact_____________________ Insurance______________Tele #____________________ Nursing Home SNF with Hospice Services Residential Housing with Hospice Services Long-Term Care Facilities Durable Medical Equipment Patient & Family Education Family Conference Chaplain Services Spiritual Needs Assessment & Support Grief & Bereavement Family Conference VI. Summary: (Comments) MD approved/declined PC Consult MSW/ RN COMPLETE IV. Check current and or recommended services RN COMPLETE ***Pain Management Pain Rating________ Symptom Management – Circle all that apply Respiratory Dyspnea Cough GI Anorexia Constipation Diarrhea Nausea / Vomiting Terminal Dehydration Neuro/Psych Fatigue Depression/Anxiety Delirium/Agitation/Confusion Patient & Family Education Family Conference III. Does the patient meet the following criteria? Diagnostic Criteria RN COMPLETE Patients with cancer Patients with AIDS Patients over 50 years with ESRD, on dialysis with diabetes Patients over 50 years with end stage lung disease/COPD Patients with acute or chronic respiratory failure Patients with cardiac condition Patients over 65 with CAD with bypass and CHF Patients over 65 with ICB Patients over 65 with cirrhosis Patients over 65 with dementia with PEG/NG aspiration PNA ADDRESSOGRAPH
- 21. 1/30/2009 21 CHMC- FY09PC Metrics Metric FY09 Target FY 09 Performance Advance Care Planning >70% 53.76% Number of PC Consults (YTD) 128 Palliative Care Outcome Goals Must achieve target in 2 measures % Patients discharged to Hospice (YTD) .60% 2.67% % End-of-life patients discharged to Hospice at Home (YTD) 2.20% 1.48% Avatar Improvement in Pain Management (YTD) 88.5% 86.21% CHMC – FY09 PC/ACP MetricsCHMC – FY09 PC/ACP Metrics
- 22. 1/30/2009 22 AB 3000was signed into law by the Governor on August 4. This new law ensures that when a patient has a completed Physician Orders for Life-Sustaining Treatment (POLST) form, the form must be honored by all health care providers. (POLST) is like a prescription and gives direction in very quick, concise language about the procedures medical personnel should and should not perform. The POLST form is completed by the attending physician after discussion with patient/family or surrogate decision-maker regarding patient preferences including : patient options for treatment, chances of survival or prognosis, options for pain or other symptom management and most importantly the patients decision about treatment. POLST-Physician Orders Life Sustaining Treatment • The POLST represents a very specific way of summarizing wishes of an individual regarding life- sustaining treatment. The form accomplishes two major purposes: • It is portable from one care setting to another • It translates wishes of an individual into actual physician orders. If you have any questions about POLST or AB 3000, please contact: Judy Citko , Coalition for Compassionate Care at (916) 552-7573 or [email protected] Jamie Terrence, CHMC Risk Management (213)742-5882 Sheldon Lewin, CHMC Social Services & Education at (213) 742-5525
- 23. 1/30/2009 23 What Advantagedoes a POLST form offer vs. an Advance Directive? An advance directive is recommended for ALL adults. POLST is recommended for people who are terminally ill. POLST translates the person’s broader/more general wishes (as reflected on the advance directive) and operationalizes those wishes given the person’s actual medical condition. Advance directives come in too many shapes and sizes to be useful to emergency responders. Emergency responders need to make a decision in split second whether to start life support & don’t have time to read through a multi-page document. POLST is standardized and uses clear, consistent language.
- 24. 1/30/2009 24 What isa POLST Form? The POLST form is a bright pink medical order form signed by a California State Licensed physician that indicates why types of life- sustaining treatment the patient does or does not want if they become seriously ill. Additionally, a health care professional must sign this form in order for it to be followed by other health care professionals. The form includes medical orders and patient preferences regarding; •CPR (cardiopulmonary resuscitation) •Intubation and mechanical ventilation •Artificial hydration and nutrition •Future hospitalization and transfer •Antibiotics
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