Post on 13-Apr-2017
COIN-PC: COnsolidating,
Improving, and Novel Palliative Care
Order Sets
What We’re Doing1. Improving the quality of palliative care delivered across the system
by consolidating current order sets (and perhaps creating new ones) which should:
• Increase productivity• Improve care• Decrease cost• Decrease length of stay• Decrease readmissions• Decrease adverse drug reactions and overdoses
2. Overall increase referrals to palliative care
Victoria Classification of Palliative Care
12/9/14 8
Type Goal Investigations Treatments Setting
Active (Blue) To improve quality of life with possible prolongation of life by modification of underlying disease(s). Ex: Pt. who has potentially resectable pancreatic carcinoma. May require immediate symptom control or need guidance in setting future goals.
Active (eg, biopsy, invasive imaging, screenings)
Surgery, chemotherapy, radiation therapy, aggressive antibiotic use,Active treatment of complications (intubation, surgery)
In-patient facilities, including critical care units; Active office follow-up
Comfort (Green)
Symptom relief without modification of disease, usually indicated in terminally ill patients. Ex. Pt. who has unresectable pancreatic carcinoma, no longer a candidate for or no longer desires chemo or radiation therapy.
Minimal (eg, chest radiograph to rule out symptomatic effusion, serum calcium level to determine response to bisphosphonate therapy)
Opioids, major tranquilizers, anxiolytics, steroids, short- term cognitive and behavioral therapies, spiritual support, grief counseling, noninvasive treatment for complications
Home or homelike environmentBrief in-patient or respite care admissions for symptom relief and respite for family
Urgent (Yellow)
Rapid relief of overwhelming symptoms, mandatory if death is imminent. Shortened life may occur, but is not the intention of treatment (this must be clearly understood by patient or proxy). Ex. Patient who has advanced pancreatic carcinoma reporting uncontrolled pain (8 on a scale of 10), despite opioid therapy.
Only if absolutely necessary to guide immediate symptom control
Pharmacotherapy for pain, delirium, anxiety. Usually given intravenously or subcutaneously and in doses much higher than most physicians are accustomed to using.Deliberate sedation may need to be used and may need to be continued until time of death.
In-patient or home with continuous professional support and supervision
J Palliat Care. 1993 Winter;9(4):26-32.
• 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 suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.
• Hospice care is end-of-life care. A team of health care professionals and volunteers provides it. They give medical, psychological, and spiritual support. The goal of the care is to help people who are dying have peace, comfort, and dignity. The caregivers try to control pain and other symptoms so a person can remain as alert and comfortable as possible. Hospice programs also provide services to support a patient's family.
Usually, a hospice patient is expected to live 6 months or less. Hospice care can take place
- At home- At a hospice center- In a hospital- In a skilled nursing facility
• Hospice Respite Care is short-term inpatient care provided to the individual only when necessary to relieve the family members or other persons caring for the individual at home.
• Comfort Care is an essential part of medical care at the end of life. It is care that helps or soothes a person who is dying. The goal is to prevent or relieve suffering as much as possible while respecting the dying person’s wishes.
Definitions
http://www.who.int/cancer/palliative/definition/en/http://www.nlm.nih.gov/medlineplus/hospicecare.htmlhttp://www.nhpco.org/sites/default/files/public/regulatory/Respite_Tip_sheet.pdfhttp://www.nia.nih.gov/health/publication/end-life-helping-comfort-and-care/providing-comfort-end-life
Hospice
Comfort Care
Palliative Care
Hospice Respite Care
Palliative Care PowerPlan and Phase Proposal
• Symptom Management Phases: Useful for isolated symptom management at any care classification, input from acute and chronic pain services, psychiatry, others?
• Delirium Management Phase: Diagnostic testing and acute management, developed in conjunction with neurology and psychiatry.
• Acute In-Patient Palliative Care PowerPlan: Commonly used nursing interventions, diagnostics, symptom management phases.
• Palliative Sedation Phase: Palliative sedation orders, developed in conjunction with ethics.
• End-of-Life PowerPlan and Terminal Wean Phase: Updating existing end-of-life orders.
Medical and Surgical PowerPlans Activemonths•years
Acute In-Patient Palliative Care PowerPlan
Comfortdays•weeks
Palliative Sedation PhaseTerminal Wean Phase
Urgenthours•days
/\Delirium Management PowerPlan
Symptom Management Phase\/
/\Delirium Management and
Symptom Management Phases\/
/\End-of-Life PowerPlan
\/
/\End-of-Life PowerPlan
\/
• PainSubdivided by organ
system• Dyspnea• Nausea• Diarrhea• Constipation• Anorexia• Depression• Anxiety• Insomnia
Terminal Ventilator Wean
• Palliative care is involved in < 100% of terminal ventilator weans.
• Medical and surgical critical care is involved in 100% of terminal ventilator weans.
FF #33-35
Patients, Providers, and Places
Activemonths•years
Comfortdays•weeks
Urgenthours•days
Patients
Providers
Places
InternExperienced
Palliative Care Specialist
No or nascent palliative care service
Mature, fully staffed, palliative care service
Current SituationActive
months•years
Comfortdays•weeks
Urgenthours•days
Patients
Providers
Places
InternExperienced
Palliative Care Specialist
No or nascent palliative care service
Mature, fully staffed, palliative care service
Consolidation and Standardization
Activemonths•years
Comfortdays•weeks
Urgenthours•days
Patients
Providers
Places
InternExperienced
Palliative Care Specialist
No or nascent palliative care service
Mature, fully staffed, palliative care service
e
HierarchyGoals-of-Care
Symptom Management
Separate Palliative Care PowerPlans Proposal
Advantages
• Provider can search for exactly what patient needs.
• Modular Phase design can be integrated easily into other PowerPlans.
Disadvantages
• Increased confusion due to seemingly more choices.
• Increased risk of less appropriate order selection.
• Risk of multiple orders for the same medication due to using different phases.
• Symptom Management Phases• Delirium Management Phase
Medical and Surgical PowerPlans Activemonths•years
• Goal-of-Care PowerPlan Comfortdays•weeks
• End-of-Life PowerPlan• Palliative Sedation Phase• Terminal Wean Phase
Urgenthours•days
FF #3, 106, 107
Single Palliative Care PowerPlan Proposal
Advantages
• All-inclusive, everything contained in one place.
• Stratifying medication orders by classification might increase safety.
Disadvantages
• Necessitates large size may complicate usability.
• Separating orders by classification may complicate management when orders needed are in different part of the PowerPlan.
• Dose Limited Symptom Management Phases
• Delirium Management PhaseActive
months•years
• Goal-of-Care Phase• Dose Liberalized Symptom
Management PhasesComfortdays•weeks
• End-of-Life Phase• Continuous Infusion Symptom
Management Phases• Palliative Sedation Phase• Terminal Wean Phase
Urgenthours•days
FF #3, 106, 107
Wheel of ConsolidationConsolidation
• Institutional Goal• Existing PowerPlans• Different Points-of-view
• Internal data• Literature• https://www.capc.org/fast-facts/overview/
• Repetition, e.g. “Favorites”• Education
• Software Limits• IUH Policy• Site Differences
• Beginning a process, not racing for a goal
• Primum non nocere
AMIA Annu Symp Proc. 2007 Oct 11:568-72.
Query #1• If we don’t admit patients, why do we have
admission order sets?
• Primary services admitting for “palliative care” or end-of-life care.
• Would an adjunctive palliative care or end-of-life care orders used in conjunction with a generic admission order set be more universally usable?
Query #2• In general as a consulting service, are we
recommending orders or placing them?
• Using our own PowerPlans should be easy
• Recommending from our own power plans is more challenging
• Pre-generated phrases that reference palliative care Phases and PowerPlans
Query #3• Can pain management be better organized?
• By type?
• Nociceptive
• Neuropathic
• Psychogenic
• By location?
• Headache
• Gastrointestinal
• Genitourinary
• Boney Metastasis
PhysicalCause?
Assoc. SxDebility and Fatigue
SocialRole
RelationshipOccupation
Financial Cost
SpiritualExistential copingReligious beliefs
Meaning of life/illnessPersonal value
PsychologicalEmotional Response
Comorbid mood disorder ± anxiety
Adjustment to new baseline
Symptom
ChaplaincyArt & Music Therapy
Social WorkFinancial Navigator
Occupational Therapy
Social WorkPsychologyPsychiatry
Acute Pain ServiceChronic Pain Service
Palliative CareOther SpecialitiesPhysical Therapy
Total Symptoms
Symptom Management
Diagnosis?
Desired and Feasible?Yes No
No YesDisease Modifiable?
No Yes
Desired and Feasible? Work-up Beyond Scope of
Palliative Care Order Sets
No Yes
Treatment Resolves/Improves Sx?Yes No
Palliative Care SymptomManagement Orders
Palliative Care SymptomManagement Orders
Palliative Care SymptomManagement Orders
Palliative Care SymptomManagement Orders
Discharge
Model Intern
Experienced Palliative Care
Specialist
End-of-Life
PainManagement
DyspneaManagement
End-of-Life
PainManagement
DyspneaManagement
PalliativeSedation
PainManagement
DyspneaManagement
Primary Palliative Care Tools
(Phases) and Toolboxes
(PowerPlans)
Specialist Palliative Care Tools
(Phases) and Toolboxes
(PowerPlans)
People deliver high-quality palliative care.Orders that compose Phases that make-up PowerPlans are the
tools and organization of those tools to
effectively deliver that care.
Tiered Symptom Management
Symptom #1Management
Symptom #2Management
…
SubphasesPowerPlans
By S
ympt
omBy
Use
r Exp
ertis
e
Currently
Symptom #1Basic ManagementAdvanced Management
Symptom #2Basic ManagementAdvanced Management
…
Basic ManagementSymptom #1Symptom #2
Advanced ManagementSymptom #1Symptom #2…
Symptom #1Basic ManagementAdvanced Management
Symptom #2Basic ManagementAdvanced Management
Basic ManagementSymptom #1Symptom #2…
Advanced ManagementSymptom #1Symptom #2…
**
*
* Example: Palliative Care Primary and Speciality Symptom Management** Example: Palliative Care Admission / Hospice Admission & Palliative Care Specialty SUBPHASE
Modular Concept
Medical & Surgical Admission Orders
Palliative Care Primary and
Specialty Symptom Management PowerPlan Terminal Wean
SubphasePalliative Sedation
Subphase
or
and/or
+/-
+/- +/-
Complication or decline leading to comfort goal-of-
care
+/- Comfort Care Measures
End-Of-Life / Comfort Care /
Hospice Respite Admission Orders
Bowel Elimination-Constipation
Nursing Protocol
and/or
Palliative Care Symptom
Management Subphases
Nausea and VomitingPain Management
Bowel Management
Patient With Suffering
Patient With Suffering
Home Meds
Admitted Palliative Care Primary and
Specialty Symptom Management PowerPlan
+
Medical & Surgical Admission Orders
PC Consult
Comfort Care Admissions
Patient Dying Within Hours
to Days
End-Of-Life / Comfort Care /
Hospice Respite Admission Orders
AdmittedPalliative Sedation
Subphase+/-Comfort Care Measures
Palliative Care Primary and
Specialty Symptom Management PowerPlan
+/-
PC Consult
Oh Yeah!?! What About?
Patient Presents with
ComplaintHome Meds
Admitted
Medical & Surgical Admission Orders
During Hospitalization Patient Decompensates,
Transferred to ICU
Patient Dying
Oh Yeah!?! What About?
Patient Dying
Goals-of-Care Shifted to Comfort
Measures
End-Of-Life / Comfort Care /
Hospice Respite Admission Orders
+/- Comfort Care Measures
Terminal Wean Subphase
Patient Remains Alive 24 Hours After
Terminal Wean
Patient Dying
PC Consult
PC Consult
Oh Yeah!?! What About?
Patient Dying
End-Of-Life / Comfort Care /
Hospice Respite Admission Orders
Palliative Sedation Subphase+/-Comfort Care
MeasuresPalliative Care Primary and
Specialty Symptom Management PowerPlan
+/-Discharged and Readmitted to
In-Patient Hospice
Palliative Care and Hospice
• We are not hospice. But, we see a lot of patients who need hospice.
• Hospice uses palliative care order sets to admit patients.
Hospice AdmissionsHome Hospice
Patient Needing Respite
Home Hospice Patient
Needing Acute Symptom
Management
End-Of-Life / Comfort Care /
Hospice Respite Admission Orders
Home Meds
Admitted
End-Of-Life / Comfort Care /
Hospice Respite Admission Orders
Palliative Care Primary and
Specialty Symptom Management PowerPlan
AdmittedPalliative Sedation
Subphase+/-Comfort Care Measures
+/-
Palliative Care Primary and
Specialty Symptom Management PowerPlan
+/-
Streamlined Modular Concept
Medical & Surgical Admission Orders
or +/- +/-
Bowel Elimination-Constipation
Nursing Protocol
andHospital Admit /
To The Floor Orders
End-Of-Life / Comfort Care
Order Set
and/or
2) Non-pharmacological and pharmacological options for the non-
specialist for symptom management
regardless of goals-of-care
3) Non-pharmacological and pharmacological
orders to promote dignity, comfort, and ease suffering at the
end-of-life
Palliative Care Symptom
Management
Terminal WeanOrder Set
1) Orders for getting any patient, regardless
of goals-of-care, admitted to the
hospital
Medical & Surgical Admission Orders
or+/- +/-
Bowel Elimination-Constipation
Nursing Protocol
and
Hospital Admit /To The Floor Orders
and/or
2) Non-pharmacological and pharmacological options for the non-
specialist for symptom management
regardless of goals-of-care
Palliative Care Symptom
Management
Terminal WeanOrder Set
1) Orders for getting any patient, regardless
of goals-of-care, admitted to the
hospital
Palliative Care Symptom
Management
End-Of-Life / Comfort Care
Order Set
HospiceAdmission Order Set
Hospice Status
All Other Statuses - Curative Goal
Comfort Goal
3) Non-pharmacological and pharmacological
orders to promote dignity, comfort, and ease suffering at the
end-of-life
4) Orders for getting any patient admitted to in-patient hospice after
hospice consultation and discharge from
previous hospital stay
Palliative Care, Hospice, End-of-Life, Comfort Care, and Terminal
Wean Modular Design
Synonyms
Palliative Care Symptom
ManagementHospice
Admission Order Set
Palliative Care Symptom
Management
End-Of-Life / Comfort Care
Order Set
“Palliative Care”“Symptom”
“End-of-Life”“Comfort Care”
“Hospice”“Admission”
+
Palliative Care Symptom
Management
HospiceAdmission Order Set
End-Of-Life / Comfort Care
Order Set
“Comfort Care” “Palliative Care”
+
Help, my patient is suffering!
Is goal-of-care natural death with dignity and
comfort?
Yes No
Has hospice been consulted and the patient been
discharged with intent to readmit on in-patient hospice?
Yes No
Is the patient on mechanical ventilation?
Yes No
Palliative Care Symptom
Management
Terminal WeanOrder Set
Hospice TeamAdmission Order Set
End-Of-Life / Comfort Care
Order Set