Palliative Care for Primary Care Providers · Palliative Care for Primary Care Providers QUYNH BUI,...
Transcript of Palliative Care for Primary Care Providers · Palliative Care for Primary Care Providers QUYNH BUI,...
Palliative Care for Primary Care Providers QUYNH BUI, MD MPH DECEMBER 2015
Objectives
Define palliative care and primary palliative care
Describe the rationale for providing primary palliative care in primary care setting
Describe core domains of primary palliative care Overview tips and pearls to building a more
effective primary palliative care program
What is Palliative Care?
Patient- and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering.
What is Palliative Care? Palliative care throughout the continuum of illness
involves addressing: Physical needs Intellectual needs Emotional needs Social needs Spiritual needs Patient autonomy Access to information Choice
Palliative Care is not only hospice
Hospice care is defined as a comprehensive set of services identified and coordinated by an interdisciplinary group to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient and/or family members, as delineated in a specific patient plan of care.
What is Primary Palliative Care? Primary Palliative Care refers to the core services
and skills/competencies that are within the scope of every clinician.
Representative Primary Palliative Care skills: Basic management of pain and symptoms Basic management of depression and anxiety Basic discussions about:
Prognosis Goals of treatment Suffering Code status
Why Primary Palliative Care?
Timely palliative care Improves quality of care and quality of life Reduces overall costs while providing care that is
compatible with goals In some cases, improves survival
Why Primary Palliative Care?
Demand for palliative care will outstrip supply of palliative care providers Projected shortage of 6000 to 18,000 palliative
care specialists Outpatient palliative care clinics are rare
27/324 hospitals in California Most open part time. Capacity of 200-500
patients/year
Integrating Palliative Care at All Stages of Disease
Stage Tasks Next Steps Pre-Disease Onset/ All Adults >50
• Screen/Support AD • Discuss information sharing and
medical decision making
• Document MDPOA
Disease Onset • Confirm information sharing preferences
• Explain diagnosis and treatment options
• Discuss expectations/ goals
• Family meeting • Update AD
Disease Management • Review treatment progress • Assess for symptoms/ needs • Review goals/ AD
• Update AD • Repeat family meetings • Complete POLST/MOLST • Symptom management/
address needs • Update treatment plan
Integrating Palliative Care at All Stages of Disease
Stage Tasks Next Steps Advanced Disease
• Review and address symptoms/ needs • Assess functional status • Review and update prognosis • Review and update goals of care • Assess caregiver needs
• Connect caregiver support services
• Update POLST/MOLST, AD • Palliative care consult prn
End-Stage Disease
• Update prognosis and goals of care • Discuss referral to palliative care/ hospice • Assess patient for grief/ loss • Discuss life-completion tasks
• Family meeting • Update POLST/MOLST, AD • Comprehensive symptom
management • Assist patient with anticipatory
grief Bereavement • Normalize grief process
• Assess for depression/complicated grief • Provide follow up and
monitoring for development of depression
Clinical domains of primary palliative care Screening and Identification Prognosis/ Information sharing Assessment of needs Symptom management Goals of care/ Advance care planning
Screening and Identification WHO WOULD BENEFIT FROM PRIMARY PALLIATIVE CARE
Identifying Patients for Assessment: General Indicators
Decreasing activity/ functional performance Limited self-care Co-morbidity General physical decline Advanced disease Decreasing response to treatments Choice of no further active treatment Progressive weight loss (>10%) in past six months Repeated unplanned admissions/ ED visits Sentinel event
The Surprise Question
Would you be surprised if the patient were to die within the next 2 years? Few months, weeks?
Prognosis and Information Sharing SETTING THE STAGE FOR GOALS OF CARE
End of Life Trajectories
10 Steps to Better Prognostication
Concept 10 Steps to Better Prognostication Action Steps
Foresee
Science
Disease Start with Anchor Point Obtain details/ Speak to expert
Function Assess changes in performance status
Use functional status tool: PPS, KPS, ECOG
Tests Known physical signs/ labs related to prognosis Eg. Dyspnea, delirum
Tools Utilize palliative or end-stage prognostic toolls
PPS, PaP, PPI, SHFM, CCORT, CHESS, etc
Skill Judgement Clinician prediction of survival Adjust for prognostic factors/ bias
10 Steps to Better Prognostication
Concept 10 Steps to Better Prognostication Action Steps
Foretell Art
Center What is important to my patient/ the family?
Who/what do they want to know? How long/what will happen? Goals/hopes
Frame it Use probabilistic planning and discussion
Average survival/ time blocks, ranges
Cautions Share limitations of your prognosis Exceptions, changes
Changes Review and reassess periodically
Evaluate EOL trajectories
Follow up Stay connected Discuss ACP Symptom control Coordinate care
Assessment of Needs
Areas of Palliative Care Requiring Regular Assessment and Documentation
Area Examples Physical • Pain
• Depression/Anxiety • Dyspnea • Nausea/ Anorexia
Psychological • Caregiving burden • Stress/Grief • Coping
Social • Family structure/ Relationships • Access/ Resources • Finances • Culture
Spiritual • Spiritual beliefs/ communities • Life completion tasks
Example Questions
What do you understand about your illness? As you look ahead along the progress of your
illness: What are your expectations? Hopes?
How can we help address concerns and needs of those around you?
How is our treatment working for you? What abilities are most important to you to
maintain?
Symptom Management
Pain
Pain: Short acting opiates
Good for dose titration and breakthrough pain Initial Routine Dosing:
Opioid naïve: (severe pain): Oral morphine liquid 10-20 mg IR q 4 hr/ 5 mg in elderly/frail
Opioid tolerant: May need to increase dose by 50-100%
Consider opioid rotation
Pain: Breakthrough Pain
Use IR preparation of same opioid used for baseline dosing
When baseline opioid is methadone or transdermal fentanyl, use alternative IR form like morphine or hydromorphone
Each breakthrough dose is about 10% of total 24 hr dose
Pain: Opioid Titration
With short acting opioids, best pain control achieved within 24 hours
If pain is uncontrolled: Increase by amount equal to total dose of
breakthrough medication Increase by 25-50% for mild to moderate pain,
50-100% if severe pain
Pain: Convert to ER Preparation
Calculate total morphine dose required Calculate equianalgesic 24 hour dose and
correct for cross-tolerance Divide dosing according to pharmacokinetics Recalculate breakthrough dose
Pain: Opioid choice Opioids 90-95% eliminated by the kidney
Dehydration or acute renal failure will impair clearance
Increase dosing interval or decrease dose size Consider stopping scheduled dosing and go
to prn only Hydromorphone has fewer active metabolites
than morphine or oxycodone Fentanyl is metabolized only by liver Avoid meperidine, propoxyphene, agonists-
antagonists
Pain: Opioid side effects
Sedation, constipation, nausea, confusion Treat adverse effects Opioid rotation Adjuvant pain therapy
Pain: Other pain medications
Acetaminphen/ NSAIDs Gabapentin, anticonvulsants TCAs Corticosteroids Topical lidocaine
Opioids: Side effects: Nausea/ Vomiting: Dopamine- acting antiemetics
(metoclopramide, haloperidol) Ondansetron or benzodiazepines if refractory
Constipation: Stimulant laxatives (senna, bisacodyl)rather than stool softeners Osmotic agents (MOM, lactulose, sorbitol),
enemas Sedation: Dosing or opioid change,
psychostimulant Delirium: Work up, dosing or opioid change, Haldol,
donepezil
Depression SSRIs/ SNRIs
Duloxetine and venlafaxine can be used for adjuvant pain treatment
TCAs Atypical antidepressants Psychostimulants Start dosing low and titrate slowly
Depression: Psychostimulants Methylphenidate 5mg qAM and q 12 noon, max
40 mg/day Modafinil 100 mg qAM, max 200 mg/ day Dextroamphetamine 5 mg qAM and a 12 noon,
max 40 mg/ day
Dyspnea
Treat underlying cause Symptomatic management:
Oxygen Opioids Anxiolytics
Cool air across patient’s face
Dyspnea: Opioids
Hydrocodone: 5 mg q 4 hr, q 2 hr prn Morphine IR: 5-15 mg po q 4 hr Oxycodone: 5-10 mg po q 4 hr Hydromorphone: 0.5-2 mg p q 4 hr Tolerance not usually a problem Keep to low doses, dosing guidelines.
Advance Care Planning/ Goals of Care
Potential Goals of Care Cure of disease Avoidance of premature death Maintenance/ improvement of function Prolongation of life Relief of suffering Optimized quality of life Maintenance of control A good death Support for families and loved ones
BUMC PROCEEDINGS 2001;14:134–137
7 Steps in Negotiating Goals of Care
1. Create the right setting 2. Determine what the patient and family knows 3. Explore what they are expecting or hoping for
the future 4. Suggest realistic goals 5. Respond empathetically 6. Make a plan an follow through 7. Review and revise periodically as appropriate
BUMC PROCEEDINGS 2001;14:134–137
Language about palliative care that has negative connotations
Do you want us to do everything possible? Will you agree to discontinue care? It’s time we talk about pulling back. I think we should stop aggressive therapy I’m going to make it so he won’t suffer
BUMC PROCEEDINGS 2001;14:134–137
Language about palliative care with more positive connotations
We will concentrate on improving the quality of your child’s life
I’ll do everything I can to help you maintain your independence.
I want to ensure that your father receives the kind of treatment he wants.
I will focus my efforts on treating your symptoms. Let’s discuss what we can do to fulfill your wish to
stay at home. BUMC PROCEEDINGS 2001;14:134–137
Advance Medical Directives http://www.iha4health.org/our-services/advance-directive/
Medicare Billing for Advance Care Planning 99497: Initial 30 minute advance care
planning consultation (wRVU 1.5) 99498: Add-on code for additional 30
minute time blocks needed for advance care planning (wRVU 1.4)
Summary Primary palliative care is complementary of
disease-modifying care Primary care has unique capabilities and
responsibilities in providing primary palliative care
Primary palliative care should be provided throughout the continuum of serious illness
Domains of physical, psychological, social and spiritual needs should be assessed and addressed on an ongoing basis
Goals of care are dynamic