Integrated regional Integrated regional Palliative Care Services – Palliative Care Services – supporting end of life care supporting end of life care

OptionsOptions

Dr Robin FainsingerDr Robin FainsingerProfessor & Director Professor & Director

Division of Palliative Care Medicine Division of Palliative Care Medicine University of AlbertaUniversity of AlbertaEdmonton, AlbertaEdmonton, Alberta

CanadaCanada

ObjectivesObjectives

• Describe integrated palliative care service options

• Discuss results demonstrating end of life care outside of hospitals

65 year man with Ca Lung65 year man with Ca Lung

• Admitted to hospital with confusion• Given IM morphine for pain• Found to have Brain mets• Transferred for radiotherapy• Given IV morphine & IV hydration• Family want to take him home• Discharged without any discussion of

home care plan or end of life care options

Integrated PC ServicesIntegrated PC ServicesExist across CanadaExist across Canada

65 year man with Ca Lung65 year man with Ca Lung

• Admitted to hospital with confusion

• Assessed by Palliative Care team & started on Sc morphine & hypodermoclysis for hydration

• Found to have Brain mets

• Transferred for radiotherapy

• Assessed by PC team, Sc morphine & hypodermoclysis continued

• Family want to take him home• PC team contacts family physician & Palliative

home care• Ongoing maintenance of Sc opioids &

hydration by hypodermoclysis on return home• 3 weeks later admitted to Hospice PCU• Sc opioids & hypodermoclysis continued• Same clinical & psychosocial assessments at

all points of care• Goals of care communicated across points of

care

Bruera et al Edmonton RPCP impact on patternsBruera et al Edmonton RPCP impact on patternsof terminal cancer care. CMAJ 1999;161:290of terminal cancer care. CMAJ 1999;161:290

• Retrospective study comparing the patterns of care and sites of death before the RPCP (1992/1993) and 2nd year of operation (1996/1997)

• Cancer related deaths in acute care facilities decreased from 86% in 1992/1993 to 49% in 1996/1997

• Inpatient days in acute care hospitals decreased from 24,566 to 6,960 over the same period

Palliative Care Programs in AlbertaPalliative Care Programs in Alberta

Calgary

(October 1996)

Edmonton

(July 1995)

Interdisciplinary

Coordinated

Comprehensive

Integrated

Utilization & costs of the Utilization & costs of the introduction of system-wide introduction of system-wide

palliative care in Alberta, 1993-palliative care in Alberta, 1993-20002000

• Fassbender K, Fainsinger RL, Brenneis et al Palliative Medicine 2005;19:513-520

0

10

20

30

40

50

60

70

80

90

1993/94 1994/95 1995/96 1996/97 1997/98 1998/99 1999/00

Year

Perc

en

tFigure 4: Probability of Referral to Palliative Care by Type of Service at Any Time in Last Year of Life, 1993/94 to 1999/00, n= 16,282.

Referral to any palliativecare service

Location for the last 365 days before deathLocation for the last 365 days before death(1999/00)(1999/00) n = 2549n = 2549

0

10

20

30

40

50

60

70

80

90

100

013

26

39

52

65

78

91

10

4

11

7

13

0

14

3

15

6

16

9

18

2

19

5

20

8

22

1

23

4

24

7

26

0

27

3

28

6

29

9

31

2

32

5

33

8

35

1

36

4

TPCU Acute Hospice LTC Palliative Home Care Home

Days before death

Perc

ent

2549-

2294-

2039-

1529-

1020-

765-

510-

1784-

1275-

255-

0-

Num

ber

of

People

Fainsinger R, Brenneis C, Fassbender KFainsinger R, Brenneis C, Fassbender KEdmonton, Canada: A Regional ModelEdmonton, Canada: A Regional Model

of Palliative Care Developmentof Palliative Care DevelopmentJPSM 2007;33:634JPSM 2007;33:634

• 27.8% of cancer patients die at home Location of death

• 3.4% die in nursing homes

• 28.9% of patients die in hospice

• 40.0% die in acute care

• 8.4% in the tertiary palliative care unit

• Patients spend 87.1% of their time at home in the last year of life - Location of Care

• 3.5% of time is spent in nursing homes,

• 2.4% of time is spent in hospice PCU

• 8.1% is spent in acute care

• Includes 0.6% in the tertiary palliative care unit

P & EOL Care AchievementsP & EOL Care Achievements

• Access & availability increased

• Continuity of care/family physician involvement

• Cost Neutral

• Decreased hospital care days