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PALLIATIVE CARE UPDATE

PALLIATIVE CARE UPDATE. BY SALLY SAMPLE, MD. LIFE IS SHORT. Employment Affiliations. Medical Director Vitas Innovative Hospice , Sacramento Valley Medical Director End-of-life pilot for Medi-Cal administered by APS Healthcare starting 2010 Hospitalist

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PALLIATIVE CARE UPDATE

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  1. PALLIATIVE CAREUPDATE BY SALLY SAMPLE, MD

  2. LIFE IS SHORT

  3. Employment Affiliations Medical Director Vitas Innovative Hospice, Sacramento Valley Medical Director End-of-life pilot for Medi-Cal administered by APS Healthcare starting 2010 Hospitalist Woodland Memorial Hospital

  4. FINANCIAL DISCLOSURE • I have no financial gains or incentives for this talk

  5. GOALS • To have everyone thinking of Palliative Care when dealing with their chronically ill patients • To encourage discussions with those patients • To realize that just because we CAN do a treatment doesn’t mean we SHOULD • To remember: Everyone dies--it is not a failure

  6. SUMMARY • DEFINITIONS • HISTORY stigma of death and dying • PC Today and the HCP role • Some relevant references to the literature • Legislation • National and State Trends

  7. PC DEFINITIONS --Care of the entire person and family--physical, psychological, social and spiritual • Care to minimize Suffering • Cassell,E.J.(1982).The nature of suffering and the goals of medicine. NEJM 306(11),639-45

  8. PC DEFINITIONS

  9. GRAPH

  10. HISTORY

  11. HISTORY • PALLIATIVE CARE: OLDEST FORM OF MEDICINE • NEWEST SUBSPECIALTY

  12. PALLIATIVE CARE 19th century and before: approach to illness involved family, church, very few life prolonging treatments family at death bed dying was part of life

  13. PALLIATIVE CARE • 19th century and before • Health Care Provider Role: Diagnosis and Prognosis • Whether the patient would succumb

  14. PALLLIATIVE CARE • Civil War changed nature of death and dying--no longer family at death bed • This Republic of Suffering. By Drew Gilpin Faust

  15. PALLIATIVE CARE • Mid 20th Century---life prolonging Rx • Prognosis gave way to treatment • Antibiotics in WWII • CPR • Gastrostomy tubes • ICU’s • Other life sustaining/prolonging treatments

  16. PALLIATIVE CARE • mid 20th century • Prognosis took lesser role • Emphasis on treatment

  17. PALLIATIVE CARE • mid 20th century • Care of the terminally ill given less importance in medical training • Talk of death and dying became socially unacceptable and seen as medical failures

  18. WHERE ARE WE TODAY?

  19. CARTOON

  20. PALLIATIVE CARE TODAY • Cost Reduction 1. 27-30% Medicare dollars spent last year of life 2. Palliative care services in hospitals save money* 3. Hospice referrals save money *Center for Advancement of Palliative Care Website:CAPC.org

  21. PALLIATIVE CARE TODAY ALLEVIATE SUFFERING

  22. PALLIATIVE CARE TODAY • HCP’s Role • Prognosis • Giving patients choices • Talk of death and dying when appropriate • Referral to palliative care and hospice when appropriate

  23. PALLIATIVE CARE TODAY • HCP’s Role • Prognosis

  24. DEATH TRAJECTORY and PROGNOSIS

  25. DEATH TRAJECTORY and PROGNOSIS

  26. DEATH TRAJECTORY and PROGNOSIS

  27. DEATH TRAJECTORY • Prognosis dwindling patient

  28. DWINDLING PATIENT

  29. DWINDLING PATIENT

  30. HCP’S ROLE • Prognostication • Difficult at best--little or no training • Foreseeing and Foretelling • Doctors are overly optimistic • Christakis, N.A. and Lamont, E.B. (2000).Extent and determinants of error in doctor’s prognoses in terminally ill patients: prospective cohort study; BMJ 320, 469-72.

  31. PALLIATIVE CARE TODAY • HCP’s Role • Giving patients choices

  32. PALLIATIVE CARE TODAY • Giving patients choices: • POLST--Cal Legislation AB 3000 effective January 1, 2009

  33. HEALTH CARE PROVIDER’S ROLE

  34. HEALTH CARE PROVIDER’S ROLE • TALK OF DEATH AND DYING • Legislation “Patient Self Determination Act” of 1991 • Requires inpatients be asked about advance care directives

  35. HEALTH CARE PROVIDER’S ROLE • TALK OF DEATH AND DYING • California law “Right to Know End-of-Life Options” Act AB 2747 • Enacted 5/2008 • Patients that have a terminal illness have to be given accurate info about treatment options and pain management

  36. HEALTH CARE PROVIDER’S ROLE • NEXT YEAR in Contra Costa County: • A Pilot program for Medi-Cal and End-of-Life administered by APS Healthcare--more next year

  37. HEALTH CARE PROVIDER’S ROLE • Talk of Death and Dying • Why is it so hard for us

  38. HEALTH CARE PROVIDER’S ROLE • Talk of Death and Dying--Myths • The hard conversation will depress patients • Patients will lose hope • Saying it will make it happen

  39. HEALTH CARE PROVIDER’S ROLE

  40. HEALTH CARE PROVIDER’S ROLE

  41. HEALTH CARE PROVIDER’S ROLE

  42. HEALTH CARE PROVIDER’S ROLE

  43. SUMMARY • Dying and death are inevitable • Palliative care or hospice--can alleviate suffering • Choices--we have them--think about them; discuss them • With life-limiting illnesses • Aggressive disease modifying treatment • Palliative care • Hospice

  44. THANK YOU • Sally Sample, MD • Email sasample@comcast.net

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