Palliative Consideration.

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Percent of Palliative Care Families Satisfied or Very Satisfied ... Social dispositions about utilization of Palliative Care. Site with honest data about ...
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Palliative Care Tom Smith Thomas Palliative Care Program Massey Cancer Center Virginia Commonwealth University Health System Richmond, Virginia *"It\'s difficult to characterize it, yet you know it when you see it." - George Parker, MD

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Objectives and arrangement What is palliative consideration, and why isn\'t that right? How we did what we did, and Some examination open doors

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The Tao of Cancer… Berrill Yushomerski Yankelowitz, altered by Smith Felson\'s Law: to take thoughts from one individual is written falsification; to take from numerous is exploration.

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Why we did it The SUPPORT Study JAMA 1995;274:1591-98 46% of DNR requests were composed inside 2 days of death. Of patients leaning toward DNR, <50% of their MDs knew about their desires. 38% of the individuals who passed on burned through >10 days in ICU. Half of patients had moderate-extreme torment >50% of most recent 3 days of life. Neighborhood needs evaluation: 6+ malignancy patients passing on at any one time, numerous needing better care

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Pain information from SUPPORT Desbiens & Wu. JAGS 2000;48:S183-186. % of 5176 patients reporting moderate to serious torment between days 8-12 of hospitalization: colon cancer 60% liver failure 60% lung cancer 57% MOSF + cancer 53% MOSF + sepsis 52% COPD 44% CHF 43%

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Also: 20% of Medicare patients beginning NEW chemo with 2 weeks of death Hospice referrals coming later, if by any stretch of the imagination… .

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Health care experts Lack of time? Absence of preparing Lack of interest Lack of repayment Hard to get/stay included ("burnout") It\'s simply hard Patients Don\'t have elevated standards Suffering is great Be a decent patient If I tell the specialist… She/he will abandon me It implies that the tumor is developing Why the crisscross between what we need, what could be given?

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Why we did it - Educational Meier, Morrison & Cassel. Ann Intern Med 1997;127:225-30. Insufficiencies in restorative training. Billings & Block JAMA 1997;278:733. 74% of residencies in U.S. offer no preparation in end of life consideration. 41% of medicinal understudies never saw a going to chatting with a diminishing individual or his family, and Medically underserved and minorities more averse to utilize hospice/palliative consideration… around half expected usage Oncologists reliably report absence of preparing in side effect administration, and nobody to refer

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Costs are an issue: National Health Expenditure Growth 1970-2003 1/eighth of Medicare $ spent in most recent 60 days of life New medications: Oxaliplatin, Erbitux $4000/cycle; Avastin $100,000/12 months, includes 2 months life "Medicare doesn\'t pay me enough to converse with individuals."

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There was some experience proposing that consideration could be enhanced… frequently drastically

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Du Pen SL, et al. RCT of 81 pts Algorithm of AHCPR rules versus standard practice J Clin Oncol 1999;17:361-70 Smith TJ et al. The Cancer Pain Trial. Randomized trial of intra-spinal torment solutions versus common consideration. JCO 2002:20:4040-49. Oncology persistent agony administration is not ideal, and can be enhanced by focusing, taking after calculation, … .

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Coordinated Care Models Raftery JP et al. Palliat Med 1996;10:151 Intervention: a medical caretaker organizer in control with the goal that families had somebody to call every minute of every day Outcomes did not change for in critical condition growth patients Costs diminished from £8814 to £4414 (- 41%) Savings originated from diminished healing center days, outpatient care Keep patients out of the ER

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Project Safe Conduct: Ireland CC + Hospice of Western Reserve. 233 NSCLC pts seen simultaneously with HWR APN/HWR, MSW, pastor + oncologist Hospice use ↑ 13% to 80%, and LOS 10 to 44 days Once extend over, ICC enlisted group from HWR to grow the system Pitorak E, J Pall Med2003;6: 645-655

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RCT of normal oncology versus normal oncology + simultaneous hospice care. J Finn, ASCO 2002 167 Pts on simultaneous consideration versus 166 on regular consideration had safeguarded QOL longer utilized less chemo lived somewhat more Caregiver weight less Intervention spared $2500/pt in hosp days Intervention cost an extra $17,500/pt for 6 months

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Improvement in Symptoms for 2500 Mount Sinai Hospital Patients Followed by the Palliative Care Service (6/97-10/02) Severe Pain Nausea Moderate Dyspnea Mild None

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Percent of Palliative Care Families Satisfied or Very Satisfied Following Their Loved Ones Death With: Control of torment - 95% Control of non-agony indications - 92% Support of patient\'s personal satisfaction - 89% Support for family stretch/nervousness - 84% Manner in which you were recounted patient\'s terminal ailment - 88% Overall consideration gave by palliative consideration program-95% Source: Post-Discharge/Death Family Satisfaction Interviews, Mount Sinai Hospital, New York City

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So, what did we do?

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TPCU of VCU-Massey Cancer Center 11 bed inpatient committed unit, 5/1/00 ~1800 nursing and medicinal counsels a year 2 APNs (Pat Coyne  clinical executive) 4 oncology attendings + geriatrician (1 FTE), Shared MSW and Care Coordinator Chaplain

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100% Palliative Care Bereavement Clinical Effort Curative Care 0% Death Dx Disease Course Where do doctor\'s facility based PC programs center?

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TPCU of VCU-Massey Cancer Center Start up assets restricted Hospital rebuilt one wing of old doctor\'s facility Jessie Ball duPont Foundation $300K Thomas (Hospice) Foundation $150K

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TPCU of Massey Cancer Center and VCUHS ALL institutionalized requests RNs decide, oversee by calculations 10-15% lessening in expenses with institutionalized consideration. Smith, Desch, Hillner. J Clin Oncol. 2001 Jun 1;19(11):2886-97. High Volume, Standardized consideration Limited Attendings, much supervision Strong "high volume=good result" relationship in the greater part of tumor drug. Hillner, Smith. J Clin Oncol. 2000 Jun;18(11):2327-40 Feedback: tests, $/day spent

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TPCU of VCU-Massey Cancer Center Only half have malignancy CVAs, MOSF, renal/hepatic disappointment, AIDS 1% BMTU Sickle cell (when beds accessible) 52% of confirmations end in death Of releases, 90% in hospice in the long run Average age ~55 African-American 56%, same as VCU Medical Center general Main alluding focus to 4 hospices

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TPCU Objective: a Good Death - 29% of all passings - 64% of all disease passings Better Care - 94% very fulfilled - 90+% amazing side effect control

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Symptoms are enhanced by PC discussion or exchange ESAS scale 0-3 30 pts with no less than 2 counsel days and indications >0 Khatcheressian J, et al. Oncology September 2005

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PC administration improves care than normal, on most measures Khatcheressian J, et al. Oncology September 2005

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TPCU Education It is "typical" to have great EOL consideration, and this is a feasible objective Fellowship in Palliative Care Elective in palliative consideration Work intimately with GYN Onc, Surg Onc, Rad Onc, ICU staff, esp. Neurosurgery JCAHO help "Magnet assignment" help

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TPCU of Massey Cancer Center and VCUHS regardless we do the cool stuff, and research intrathecal torment administration hypofractionated and stereotactic radiation palliative stents bisphosphonates chemotherapy nerve removal, celiac pieces needle therapy music, pet, knead treatment

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TPCU of Massey Cancer Center and VCUHS Research Dyspnea scrutinize The most widely recognized end of life side effect, after torment 20% of all growth patients Major reason for family and patient enduring Phase II trial of 25 mcg fentanyl in 2 ml NS nebulized saline

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Nebulized fentanyl for dyspnea Coyne P, Smith T, et al. Torment and Symptom Mgmt, 2002. Patients said that it helped Improved 26/37 (79%) Unsure 3/27 (9%) None 4/37 (12%) P=0.002 P=0.03

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Implantable Drug Delivery Systems Research 52% 39% Significantly enhanced agony control with IDDS (p=0.055 as randomized; p=0.007 as treated).

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As treated, there was noteworthy decrease in 7/15 indications measured * p  0.05.

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Overall Survival was better with IDDS (Kaplan-Meier, aim to treat) OS  PS, p<0.05 P=0.06

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Other trials RCT of nebulized fentanyl versus fake treatment RCT of Zinc versus fake treatment for chemo-impelled dysgeusia Cultural states of mind about utilization of Palliative Care. Site with honest data about guess, alternatives, survival "What might you do another way?" longitudinal investigation of the choices patients make PET treatment

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Be set up for the whole deal Umstead 100 MMTR 50+++

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Sounds extraordinary… who\'s going to pay for it?

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TPCU Fiscal Evaluation Smith, Coyne, Cassel, Hager. J Pall Med 2003 On PCU consideration is less costly and variable than somewhere else in doctor\'s facility. "Taken a toll evasion" In the first 2 years, TPCU lost $90,000 however spared the wellbeing framework ~$1,800,000

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Impact of Palliative Care on Cost every Day for Deaths

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Lower Cost Per Day After Transfer To Palliative Care Cohort study: 60% less cost Case Control study: 67% less cost Have "the discussion": Review orders oxygen anti-microbials tube sustains numerous meds Standard calculations POS remedy High volume, master attendings

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Even Palliative Care (MCVH) can be beneficial

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"In the event that you listen deliberately to your patients they will let you know what isn\'t right with them as well as what isn\'t right with you." Walker Percy MD, Love in the Ruins 1971

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TPCU and the ICUs NP makes rounds to recognize patients for counsels, MD-MD Earlier exchange of biting the dust patients may enhance EOL mind and lessen cost. "Off-burdens" ICUs and dodges redirection.

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TPCU Evaluation Clinical consideration amazing Health System sway Helps bed accessibility Profitable for direct concedes Save VCUHS $900,000 to $1,200,000 Research developing, vital to NCI Educational advancement over the Health System Little staff turnover, better VCUH

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