Palliative Care in Navajo Area GARY J VAUGHN MD

Objectives

Review the philosophy of Palliative Care and how the discipline benefits patients.

Review the development of Palliative Care resources across Navajo Area and the current state of programs .

Gain an understanding of the Pain and Palliative Care Program at Gallup Indian Medical Center

Discuss strategies to improve advance care planning discussions with Navajo patients.

Nothing to disclose!

The Nature of Suffering

“The relief of suffering and the cure of disease must be seen as twin obligations of a medical profession that is truly dedicated to the care of the sick. Failure to understand the nature of suffering can result in medical intervention that (though technically adequate) not only fails to relieve suffering but becomes a source of suffering itself.”

-Eric J Cassell

Definition

Palliative care, also known as palliative medicine, is specialized medical care for people living with serious illnesses. It is focused on providing patients with relief from the symptoms and stress of a serious illness—whatever the diagnosis. The goal is to improve quality of life for both the patient and the family.

Palliative care is provided by a team of doctors, nurses, and other specialists who work with a patient's other doctors to provide an extra layer of support. Palliative care is appropriate at any age and at any stage in a serious illness, and can be provided together with curative treatment.

-Center to Advance Palliative Care

“Old Model”

Curative care

% Focus

Time Death Terminal phase

100

0

“Nothing more we can do”

“New model”

Curative care %

focus

0

100

time death terminal phase

“Best care possible”

bereavement

Palliative care

Benefits of Palliative Care

Improves quality of life in patients with serious illness as well as caregivers.

Dionne-Odom et al

There is evidence that suggests patients may

live longer. Temel et al

Decreases utilization of health care resources

and cost of care. Morrison et al

Differences in Disease Between AI/AN and General Population

Overall improvement in Life expectancy over the last 30 years of 15%.

Increased rates of chronic illnesses with heart disease and cancer being the top two causes of mortality.

Mortality rates compared to general population: Alcohol related-520% higher

Chronic liver disease/cirrhosis: 368% higher

Diabetes Mellitus-177% higher

Motor Vehicle Crashes-207% higher

Trends in Indian Health 2014 Edition

Palliative Care Programs in Navajo Area and Zuniland Northern Navajo

Medical Center

Gallup Indian Medical Center

Chinle Comprehensive Health Care Facility

Zuni Comprehensive Healthcare Facility

Geriatrics and Palliative Care Program at Gallup Indian Medical Center

2010 2011 2012 2013 2014 2015 2016

Why Start the Outpatient Clinic?

Curative care %

focus

0

100

time death terminal phase

Minimal Bereavement Services

Palliative care

Missed Opportunity

Minimal Home Health/Hospice

Where we want to be

Curative care %

focus

0

100

time death terminal phase

bereavement

Palliative care

Division of Geriatrics and Palliative Care

Department of Family Medicine

Division of Geriatrics and Palliative Care

Symptom Management

Clinic

Chronic Noncancer Pain Clinic

Inpatient Palliative

Care Consult Service

Geriatric Clinic

Strategies to improve advance care planning discussions with Navajo and Zuni Patients.

Can end of life discussions even occur?

Yes!

Can end of life discussions even occur?

Discussions with our Office of Native Medicine

Experience of providers across IHS and other facilities

Experience with our patients

Experience from our colleagues at academic programs Marr et al

Advice from Navajo Cancer Survivors and Caregivers of Cancer

Patients Above all else, show empathy. Be sensitive about our culture and beliefs. Give us time to absorb information. Utilize interpreters. Ask us what we want to know. Do not take away hope.

COPE Cancer Coalition Meeting 10/27/16

Strategies to improve advance care planning discussions

Offer qualified translators, even if the patient/family speaks English. Explain to the patient/family who you are and why you are there. Have a clear understanding of the patient’s cultural beliefs. Ask how the patient or family wishes to receive information. Be prepared to explain the clinical status several times. Be prepared for a larger locus of decision making. Speak in the third person to avoid the impression of wishing misfortune on the

patient. Always express hope. Schedule family meetings when it works best for the family. Offer consultation with traditional healers, clergy. Allow time for decisions to be made. Discuss whether it is okay to die at home.

Marr et al

Offer qualified translators even if the patient/family speaks English

Explain to the patient/family who you are and why you are there.

Have a clear understanding of the patient’s cultural beliefs.

Ask how the patient or family wishes to receive information.

Be prepared to explain the clinical status several times.

Be prepared for a larger locus of decision making.

Speak in the third person to avoid the impression of wishing misfortune on the patient.

Always express hope.

Schedule family meetings when it works best for the family.

Offer consultation with traditional healers, clergy.

Allow time for decisions to be made.

Determine whether it is okay for the patient to die at home.

Summary

Palliative Care can provide tremendous comfort and improve quality of life for our Navajo and Zuni Patients.

Palliative care services are expanding across Navajo Area and Zuni Land.

It is possible to have end-of-life discussions with Navajo and Zuni patients.

As with all patients, discussions surrounding death and dying must be done with respect and empathy.

There are techniques that can be utilized to facilitate end-of-life discussions for our Navajo and Zuni patients.

References

Dionne-Odom JN, Azuero A, Lyons KD, Hull JG, Tosteson T, Li Z, Li Z, Frost J, Dragnev KH, Akyar I, Hegel MT, Bakitas MA. Benefits of Early Versus Delayed Palliative Care to Informal Family Caregivers of Patients With Advanced Cancer: Outcomes From the ENABLE III Randomized Controlled Trial. J Clin Oncol. 2015 May 1;33(13):1446-52. doi: 10.1200/JCO.2014.58.7824. Finke B, Bowannie T, Kitzes J. Palliative care in the Pueblo of Zuni. J Palliat Med. 2004 Feb;7(1):135-43. Marr L, Neale D, Wolfe V, Kitzes J. Confronting myths: the Native American experience in an academic inpatient palliative care consultation program. J Palliat Med. 2012 Jan;15(1):71-6. doi: 10.1089/jpm.2011.0197. Morrison RS, Penrod JD, Cassel JB, et al. Cost savings associated with US hospital palliative care consultation programs. Arch Intern Med. 2008;168:1783–1790. Morrison RS, Dietrich J, Ladwig S, Quill T, Sacco J, Tangeman J, Meier DE. Palliative care consultation teams cut hospital costs for Medicaid beneficiaries. Health Aff (Millwood). 2011 Mar;30(3):454-63. doi: 10.1377/hlthaff.2010.0929. Kitzes J, Berger L. End-of-life issues for American Indians/Alaska Natives: insights from one Indian Health Service area. J Palliat Med. 2004 Dec;7(6):830-8. Indian Health Service Fact Sheets: Disparities https://www.ihs.gov/newsroom/factsheets/disparities/ Indian Health Service Fact Sheets: Year 2016 Profile. https://www.ihs.gov/newsroom/factsheets/ihsyear2016profile/ Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non–small- cell lung cancer. N Engl J Med. 2010;363:733-742.