Palliative Care Overview

  • Primary vs Secondary Palliative Care
    • Primary – skills applicable to all clinicians (basic pain and symptom control, having goals of care discussions)
    • Secondary – “specialty” palliative care skills
  • Values-based Goals of Care discussion
    • Connect:  get curious, active listening, create a safe place for any emotion
    • Active listening means entering a conversation with NO idea where it’s going to go and what you’re going to say…that way, you’re in the moment!
    • Back A, et al. Mastering Communication with Seriously Ill Patients, 2009
      • Prepare yourself; explore what they understand; assess readiness to talk; explore values/goals/hopes; identify fears/concerns; offer to make a recommendation; propose a care plan; ask for feedback about the proposal
      • Avoid temptation to jump readiness to talk and the exploration of hopes/values, fear/concerns!
      • It’s about 50/50 whether people will want a recommendation of a care plan or not – and some just want a recommendation for certain aspects of their care.
      • Also see Gawande A, 2012 – Being Mortal – Serious Illness Conversation Guide (Ariandne Labs)
  • MOST form
    • In CO, since 2010.  Only half of patients with DNR orders want “comfort care only.”
    • For MOST forms:  verify – make sure the form is valid, signed, up-to-date.  Are there other applicable directives?
    • Review the MOST from time to time, walk through the form together, discuss concerns/fears/goals/hopes, offer to make recommendations.
    • There’s no such thing as a partial code – so, if the patient wants CPR, we are likely going to be giving aggressive care.
    • Finding better words:  Not “what do you want to do, family?” but “Your mother is nearing the end of her life soon.  She’s comfortable now.  She has made clear that she does not want to go back to the hospital, and we are going to honor those wishes.”
  • How to overcome procrastination in end-of-life planning
    • Obstacles:  patient-family (too depressing, too complicated, not sure what I’d want, etc.); clinician (not enough time, patient not ready, don’t want to take away hope); system (other priorities, no budget for that, like death panels) – all of it boils down to “I’ll get to it later…”
    • “The Now Habit” – Neil Fiore:  procrastination is about fear.  How to overcome procrastination:  1.  don’t “raise the board” (making a straightforward task fraught); 2. increase immediacy (“push” or “pull”); 3.  hang a “safety net” (give yourself support, self-forgiveness, support of team or experts).
Palliative care:
– for people with serious illness
– hospice is a subset of palliative care
– goal is to improve quality of life
– extra layer of support in addition to ongoing medical care
– palliative care can be provided with curative treatment
– over last 10 years, hospital palliative care teams have more than doubled
Only 1/4 of Colorado hospitals have inpatient palliative care services.  Only 5 of 47 rural counties have ANY access to palliative care services from a hospital or hospice provider.
Temel JS, et al. NEJM 2010; Greer JA, et al. J Clinical Oncol 2012. – early integration of outpatient palliative care improved cancer care:  less IV but same PO chemo, less-aggressive end-of-life care, longer survival, longer hospice stays.
O’Connor NR, et al. J Palliative Med 2015 – goals of care discussions linked with lower readmission rates; palliative care involvement associated with lower 30-day readmission rate (AOR 0.66).
Quantifying palliative-care-appropriate population (who is appropriate for palliative care?) – Szenkendi MK, et al., J Palliative Med 2016.
Exploring “branding” palliative care as “supportive care” – Dalai S, et al.  Oncologist 2011. – “Supportive care” increased consult rates, shorter duration of hospital admit to first consult; longer survival time from palliative consultation.
Some are experiencing “embedded” palliative care – specialty-trained SWs, nurses in primary care, or working in high-severity areas of inpatient setting with the care team.  Avoids need for consultations, earlier involvement.
On making mistakes:  Westney, The Perfect Wrong Note: Learning to Trust Your Musical Self (2003):  Honest mistakes are not due to inattention, and are a reflective process.  They give texture and nuance to our learning.
– from Rocky Mountain Hospital Medicine Symposium, 2016, Johnson

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