Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005...

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Ira R. Byock, Ira R. Byock, MD MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity

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Page 1: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.

Ira R. Byock, Ira R. Byock, MDMD Director of Palliative Medicine

Dartmouth-Hitchcock Medical Center

August 17, 2005

Dying in America

A Generation’s Crisis and Opportunity

Page 2: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.
Page 3: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.

Reasonable Expectations

• Routine assessment and competent treatment of pain & physical distress• Clear, complete & honest communication• Respect for people’s stated preferences• Coordination of care • Crisis prevention and management • Safe & prudent staffing ratios for nurses and CNAs • Support for family caregivers • Support for families in grief

Page 4: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.

Jan Hoffman New York Times, August 14, 2005

Awash in Information, Patients Face a Lonely, Uncertain Road

Photo: Nicole Bengiveno

Ira R. Byock
Meg Gaines traveled to Texas and California looking for ways to treat her ovarian cancer.
Page 5: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.

Institute of Medicine Institute of Medicine Dimensions and DeficienciesDimensions and Deficiencies

I. Too many people suffer needlessly at the end I. Too many people suffer needlessly at the end of life, both from errors of omission and of life, both from errors of omission and from errors in commissionfrom errors in commission

II. Legal, organizational, and economic II. Legal, organizational, and economic obstacles conspire to obstruct reliably obstacles conspire to obstruct reliably excellent care at the end of life.excellent care at the end of life.

Approaching DeathApproaching Death Nat’l Academy Press, 1997

Page 6: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.

III. The education and training of physicians III. The education and training of physicians and other health care professionals fail and other health care professionals fail to provide them the attitudes, to provide them the attitudes, knowledge, and skills required to care knowledge, and skills required to care well for the dying patient.well for the dying patient.

IV. Current knowledge and understanding are IV. Current knowledge and understanding are insufficient to guide and support the insufficient to guide and support the consistent practice of evidence-based consistent practice of evidence-based medicine at the end of life. medicine at the end of life.

Approaching DeathApproaching Death Nat’l Academy Press, 1997

Institute of Medicine Dimensions and Deficiencies

Page 7: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.

Robin Marantz Henig

New York Times Magazine, August 7, 2005

Will We Ever Arrive At the Good Death?

Photo: Nicholas Nixon

Page 8: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.

These may be the

“Good Old Days”

Page 9: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.

The Graying of America

Changing U.S. Age Distribution

SOURCE: AMARA et. al., SOURCE: AMARA et. al., Looking Ahead at American Health CareLooking Ahead at American Health Care (1988) (1988)

10 5 0 5 10 10 5 0 5 10

Millions of Persons

10

20

30

40

50

60

70

80

10

20

30

40

50

60

70

80

1980 1990 2000

Indicates the Baby-Boom Group

10 5 0 5 10

Page 10: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.

2050

4 to 1

2030

6 to 1

2010

10 to 1

1990

11 to 1

The Shrinking Pool of Caregivers

www.dyingwell.org

Page 11: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.

USA Today December 13, 2000

Page 12: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.

Where We Die

Zerzan J, Stearns S, Hanson LAccess to Palliative Care and Hospice in Nursing Homes

JAMA 2000 Nov 15, 284(19) 2489-2494

“Nearly half of Americans who live to 65 years of age will enter a nursing home

before they die.”

Page 13: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.

The Washington Post MagazineJune 9, 2002

Page 14: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.
Page 15: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.

“More than 90 percent of the nation's nursing homes have too few workers to

take proper care of patients, a new federal study has found.”

9 of 10 Nursing Homes Lack Adequate Staff, Study Findsby Robert Pear, New York Times February 18, 2002 A1 Deidre Scherer

collection

Page 16: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.

The Coming Crisis in Nursing

Source: Projections by Division of Nursing BHPr, HRSA, USDHHS, 1996

1.9

2

2.1

2.2

2.3

2.4

2.5

2.6

2.7

2000 2005 2010 2015 2020

FTE RN Requirements FTE RN Supply

Millions

Page 17: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.

USA Today

Page 18: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.

““Eighty-three percent of elderly Americans Eighty-three percent of elderly Americans

would stay in their homes until the end if they would stay in their homes until the end if they

could. Thirty percent say they’d rather die than could. Thirty percent say they’d rather die than

go into a nursing home.” go into a nursing home.”

CBS News February 27, 2001

Nursing homes and public opinion

Page 19: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.
Page 20: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.
Page 21: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.
Page 22: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.

This is one crisis we can solve!!!

Deidre Scherer collection

Page 23: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.

…and we are already spendingenough money

Robert Pope collection

Page 24: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.

Palliative Care

Hospice Care

Hospice and Palliative Care

Page 25: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.

Palliative Care

Interdisciplinary care for persons with life-threatening illness or injury which addresses physical, emotional, social and spiritual needs and seeks to improve quality of life for the ill person and his or her family.

SocialWorkerSocialWorker

MedicalDirectorMedicalDirector

HospiceRNs

HospiceRNs

HospitalNursing

HospitalNursingResp.

TherapyResp.

Therapy

PharmacistPharmacist

ProgramCoord.

ProgramCoord.

DieticianDietician

VolunteerCoordinatorVolunteer

Coordinator

PastoralCare

PastoralCare

HospitalSW-Discharge

Planner

HospitalSW-Discharge

Planner

Patient &

Family

www.dyingwell.org

Page 26: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.

6 month prognosis

Hospice

Diagnosis

Curative &

Life-Prolonging Treatment

Sequential Model“Curative” followed by “Palliative” Care

Medicare Hospice Benefit

Page 27: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.

Diagnosis Death

Concurrent Care

“Curative” orDisease-modifying Treatment

Palliative Care

Page 28: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.

Promoting Excellencein End-of-Life Care

A national program of The Robert Wood Johnson Foundation

Page 29: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.

Bristol Bay Area

Health Corporation

Cardinal Glennon Children’s Hospital

Children’s Hospital and

Regional Medical Center

University of

Michigan Cancer Center

Promoting Excellence in End-of-Life

Care

Dartmouth-Hitchcock Norris

Cotton Cancer Center

Department of Veterans

Affairs; West Los Angeles

Medical Center

Henry Ford Health System

Hospice of the Valley

Case Western Reserve

Univ.

Louisiana State

University Medical Center

Mass. Mental Health

Medical U. of So. Carolina

Mount Sinai School of Medicine

UC Davis, Cancer Center

UC San Francisco

Univ of Chicago Medical Center

U. New Mex,

U. PA. School of Nursing

VNA. & Hospice of No. Calif

Volunteers of America

Baystate Medical Center

Cooper Green

Medical Center

Page 30: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.

An interdisciplinary team

24/7 availability

Ongoing communication

Advanced care planning

Formal symptom assessment & treatment

Crisis prevention & early crisis management

Care coordination

Spiritual care

Anticipatory guidance

Bereavement support

An interdisciplinary team

24/7 availability

Ongoing communication

Advanced care planning

Formal symptom assessment & treatment

Crisis prevention & early crisis management

Care coordination

Spiritual care

Anticipatory guidance

Bereavement support

Typical Services of Palliative Care

Page 31: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.

www.PromotingExcellence.org

It is possible to

• Expand Access• Improve Quality• Control Costs

Access Quality Costs

Promoting Excellencein End-of-Life Care

Page 32: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.

www.PromotingExcellence.org

Promoting ExcellenceMonographs

Page 33: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.

www.PromotingExcellence.org

Promoting Excellence Monographs

Page 34: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.

Alleviation of symptoms and suffering are

our first priorities…

Goals of Palliative Care

Page 35: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.

… but they are not the ultimate goals.

Goals of Palliative Care

Page 36: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.
Page 37: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.

Bill Bartholome

Page 38: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.

Bill Bartholome

Page 39: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.

• Communicating

• Completing affairs & relationships

• Resolving relationships

• Grieving

• Reviewing life, exploring meaning & purpose

• Exploring spiritual & transcendent realms

Preserving Opportunity

www.dyingwell.org

Page 40: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.

“Please forgive me”

“I forgive you”

“Thank you”

“I love you”

Completing RelationshipsSaying “The Four Things That Matter Most”

www.dyingwell.org

Page 41: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.

Ensuring the “best care possible”

Feeling that preferences were followed

Knowing the person was treated in a

dignified manner A chance to say and do the things

“that matter most”

Honoring and celebrating the person in

his/her passing

A chance to grieve together

Dying Well – Family Perspective

www.dyingwell.org

Page 42: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.

• Ensure adequate staffing and living wages for aide-level workers in long term care

• Insist on adequate training of physicians, nurses & clinicians society employs and relies on

• Encourage innovation in health service delivery promoting a continuum of care

• Decrease barriers to effective pain management

Public policies can’t do everything, but they can…

Page 43: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.

• Eliminate the arbitrary distinction between “curative” and palliative care

• Insist on accurate accounting of costs

• Empower consumer and citizen expectations

• Encourage community-based responses

• Foster cultural maturation of a healthy conclusion to life

Public policies can’t do everything, but they can…

Page 44: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.
Page 45: Ira R. Byock, MD Director of Palliative Medicine Dartmouth-Hitchcock Medical Center August 17, 2005 Dying in America A Generation’s Crisis and Opportunity.

More information available at

www.PromotingExcellence.org

www.DyingWell.org

www.ChoicesBank.org

www.Lifes-End.org


Alfred Joseph Hitchcock

Alfred Joseph Hitchcock

Ira Byock, MD · Ira Byock, MD Ira Byock, MD, FAAHPM is a leading palliative care physician, author, and public advocate for improving care through the end of life. He is Founder

Ira Byock, MD · Ira Byock, MD Ira Byock, MD, FAAHPM is a leading palliative care physician, author, and public advocate for improving care through the end of life. He is Founder

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