Consolidating, Improving, and Novel Palliative Care: Order Sets

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

http://www.nlm.nih.gov/medlineplus/endoflifeissues.html

http://www.who.int/cancer/palliative/definition/en/

http://www.nlm.nih.gov/medlineplus/hospicecare.html

http://www.nhpco.org/sites/default/files/public/regulatory/Respite_Tip_sheet.pdf

http://www.nia.nih.gov/health/publication/end-life-helping-comfort-and-care/providing-comfort-end-life

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




Consolidation and Standardization

Activemonths•years

Comfortdays•weeks

Urgenthours•days

Patients

Providers

Places

InternExperienced




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.

https://www.capc.org/fast-facts/overview/

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




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


…

Basic ManagementSymptom #1Symptom #2

Advanced ManagementSymptom #1Symptom #2…



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

+


PC Consult

Comfort Care Admissions

Patient Dying Within Hours

to Days



AdmittedPalliative Sedation

Subphase+/-Comfort Care Measures



+/-

PC Consult

Oh Yeah!?! What About?

Patient Presents with

ComplaintHome Meds

Admitted


During Hospitalization Patient Decompensates,

Transferred to ICU

Patient Dying


Patient Dying

Goals-of-Care Shifted to Comfort

Measures



+/- Comfort Care Measures

Terminal Wean Subphase

Patient Remains Alive 24 Hours After

Terminal Wean

Patient Dying

PC Consult

PC Consult


Patient Dying



Palliative Sedation Subphase+/-Comfort Care

MeasuresPalliative Care Primary and


+/-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



Home Meds

Admitted





AdmittedPalliative Sedation

Subphase+/-Comfort Care Measures

+/-



+/-

Streamlined Modular Concept


or +/- +/-


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


Management

Terminal WeanOrder Set

1) Orders for getting any patient, regardless

of goals-of-care, admitted to the

hospital


or+/- +/-


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


Management


1) Orders for getting any patient, regardless

of goals-of-care, admitted to the

hospital


Management


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


ManagementHospice

Admission Order Set


Management


Order Set

“Palliative Care”“Symptom”

“End-of-Life”“Comfort Care”

“Hospice”“Admission”

+


Management

HospiceAdmission Order Set


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


Management


Hospice TeamAdmission Order Set


Order Set

Consolidating, Improving, and Novel Palliative Care: Order Sets

Healthcare

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