palliative care in oklahoma: looking back, looking forward jeffrey alderman, m.d. associate...

Palliative Care in Oklahoma:Looking Back,

Looking Forward

Jeffrey Alderman, M.D.Jeffrey Alderman, M.D.

Associate ProfessorAssociate Professor

Director, Palliative Medicine Director, Palliative Medicine

OU College of Medicine – TulsaOU College of Medicine – Tulsa

ObjectivesObjectives

• Learn about the current state of Palliative Learn about the current state of Palliative Care in OklahomaCare in Oklahoma

• Understand the benefits/pitfalls of Understand the benefits/pitfalls of Inpatient Palliative Care ConsultationInpatient Palliative Care Consultation

• Explore reasons why physicians have Explore reasons why physicians have difficulty with Advance Directivesdifficulty with Advance Directives

• Learn what you can do to help patients Learn what you can do to help patients receive appropriate Palliative Carereceive appropriate Palliative Care

Case Study: Zelda S.Case Study: Zelda S.

• Zelda is 73 years old.Zelda is 73 years old.

• She has DM-2, Stage III CKD, and She has DM-2, Stage III CKD, and worsening PVDworsening PVD

• She has been admitted to St. John 4 She has been admitted to St. John 4 times in the last 6 months with times in the last 6 months with symptoms from her ischemic leg.symptoms from her ischemic leg.

Case Study: Zelda S.Case Study: Zelda S.

• Zelda is widowed, but Zelda is widowed, but has 3 children and 5 has 3 children and 5 grandchildren.grandchildren.

• Her true love is golf.Her true love is golf.

• Her goal of care is to Her goal of care is to continue playing golf continue playing golf for as long as for as long as possible.possible.

Case Study: Zelda S.Case Study: Zelda S.

• Zelda’s golf playing is limited by pain.Zelda’s golf playing is limited by pain.

• Social Isolation. Social Isolation.

• Unclear if Zelda can continue to live alone.Unclear if Zelda can continue to live alone.

• Unclear if Zelda ever executed an Advance Unclear if Zelda ever executed an Advance DirectiveDirective

How can we help Zelda?How can we help Zelda?What if Zelda lives in Oklahoma?What if Zelda lives in Oklahoma?

How Does Your State Rate?

Oklahoma

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Oklahoma South Region United States 8/43 401/983 1294/2452 www.capc.org

State by State Report Card

TULSA WORLDSaturday October 4, 2008

State gets failing health-care grade

BY KIM ARCHER (World Staff) Writer

Oklahoma is failing to care adequately for the sickest of its residents and is one of only three states in the country to receive an “F” for access to palliative care, according to a report released Thursday Alabama and Mississippi also received failing grades, according to the study by the Center to Advance Palliative Care and the National Palliative Care Research Center. The study appears in the October issue of the Journal of Palliative Medicine. Palliative care refers to treatment that concentrates on reducing the severity of symptoms rather than striving to halt, delay or cure the disease itself. The goal is to prevent and relieve suffering and improve a patient’s quality of life. Nineteen percent of Oklahoma’s hospitals with 50 beds or more have a palliative care program, the report said. Most are in larger hospitals in Tulsa and Oklahoma counties.

What was measured?

• Patient access to palliative care services in hospitals

• Patient access to board-certified palliative medicine physicians

• Medical student access to clinical training in palliative medicine

• Physician access to specialty-level training in palliative medicine

Morrison, RS. et al. AMERICA’S CARE OF SERIOUS ILLNESS: A State-by-State Report Card on Access to Palliative Care in Our Nation’s Hospitals. Center to Advance Palliative Care/National Palliative Care Research Center , 2008, p.14

Why did we fail?

• Clearly too few Oklahoma hospitals have Palliative Care Programs

• Too few Board-Certified Palliative Care Physicians

• Not enough Palliative Care Education for Medical Students

• No Fellowship Training Programs

Conclusions

• More Oklahoma Hospitals need to develop Palliative Care Programs

• More Oklahoma clinicians need training in Palliative Medicine

• We must educate the next generation of providers in Palliative Care

University of Oklahoma -St. John Medical Center

Palliative Care Service

University of OklahomaSt. John Palliative Care Service

• Started in October 2004 - CAPC

• Interdisciplinary Team

• Inpatient Consults

• Close relationship with Hospice

St. John Palliative Care IDTSt. John Palliative Care IDT

University of OklahomaSt. John Palliative Care Service

• The Clinical Imperative• The Financial Imperative• Patient/Family Satisfaction• Coordination of Care across

Venues of Care• The Educational Imperative

• The Quality Imperative• Effective, Patient-centered, Timely, Efficient and

Equitable

Education

OU School of Community Medicine in Tulsa

• 130 Faculty

• 70 – 80 MSIII and MSIV Students

• 54 Internal Medicine Residents

Curriculum in Palliative Care

• All Senior Internal Medicine Residents spend 60 clinical hours rotating on the Palliative Care Service

• All Residents attend 7 didactic lectures

• All complete online training in pain and non-pain symptom management

Stanford Curriculum

• Introduction to Palliative Medicine• Pain Management• Non-Pain Symptom Management• Communication in Palliative Care• Legal Issues• Terminal Care• Palliative Care Health Care Policy

Clarehouse

Curriculum in Palliative Care

• All Medical Students spend ~9 clinical hours rotating on the Palliative Care Service

• All Medical Students attend 3 didactic lectures

Future Directions

• No formal measurement of Palliative Care Training

• Exploring pre/post rotation testing tools

• Expand training to the College of Nursing

CONSULT SERVICE

Demographic Data

Service Cases

2008 Consults Requested 354

2007 Consults Requested 286

2006 Consults Requested 250

2005 Consults Requested 119

Consult Numbers

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Patient Volume

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Patient Volume

Disease Cases

Patients Seen 354

Average Age 67.9

Age Range 20 - 98

% Female 53%

Referring Physicians 100

Admission DRG’s 118

ICU Referrals 10.2%

% Expiring at St. John 31.1%

% Entering Hospice After Discharge 33.3%

Patient Demographics

Disease Cases

% Medicare 72.0%

% Medicaid 15.5%

% Commercial Insurance 6.0%

No Payor Source 6.5%

Patient Payor Source

Disease Cases %

Cancers 140 39.5

Cardiovascular Diseases 64 18.1

Pulmonary Diseases 37 10.5

Neurodegenerative Diseases 28 7.9

Bone Disease/Fractures 26 7.3

Infectious Diseases 21 5.9

Gastrointestinal Diseases 18 5.1

Renal Diseases 10 2.8

Other Diseases 10 2.8

Background Illness

Number %

Pain Management 139 39.3

Direction of Care 109 30.8

Terminal Care 64 18.1

Non-Pain Symptom Management

40 11.3

Other 2 0.6

Reason for Consult

Nephrology 1%OB/GYN <1%Emergency Med 1%Neurosurgery 1%Cardiology 2%Non-OU Internal Med 27%Family Medicine 5%Cardiovasc. Surgery 1%Hospitalists 20%General Surgery 1%Oncology 5%OU Internal Med 35%

Referring Physicians

LTAC/SNF – 9.9%Other – 2.7%

Expired – 31.1%

Clarehouse* – 2.3%

Nursing Home – 14.7%Home – 39.3%

*’Clarehouse’ is a hospice home in Tulsa, providing care to patients in the last month of life

Discharges

Clinical Outcomes

Initial Evaluation Final Evaluation

Severe

Mod.

Mild

None

Reported Pain Scores

130 Patients seen on the SJMC Palliative Care Consult Service: Oct 2005 – Oct 2006

212 Patients

212 Patients seen on the SJMC Palliative Care Consult Service: Oct 2006 – Oct 2007

Initial Evaluation Final Evaluation

Severe

Mod.

Mild

None

Initial Evaluation Final Evaluation

OU/St. John Mt. Sinai Hospital, NYC*

Comparison of Pain Scores

212 Patients 3707 Patients

*Data Reported by R. Sean Morrison, MD. Presented at ‘Building Hospital Based Palliative Care Programs.’ sponsored by the Center to Advance Palliative Care (CAPC), San Diego, CA October 2005.

Initial Evaluation Final Evaluation

Severe

Mod.

Mild

None

Reported Dyspnea Scores

112 Patients

112 Patients seen on the SJMC Palliative Care Consult Service: Oct 2006 – Oct 2007

Initial Evaluation Final Evaluation

Severe

Mod.

Mild

None

Initial Evaluation Final Evaluation

OU/St.John Mt. Sinai Hospital, NYC* 112 Patients 2219 Patients

Comparison of Dyspnea Scores

*Data Reported by R. Sean Morrison, MD. Presented at ‘Building Hospital Based Palliative Care Programs.’ sponsored by the Center to Advance Palliative Care (CAPC), San Diego, CA October 2005.

Agitation 61.1% Reduction

Nausea 82.1% Reduction

Constipation 67.3% Reduction

Dry Mouth 62.9% Reduction

Insomnia 75.9% Reduction

Other Clinical Outcomes

Satisfaction Outcomes

Question: ExcellentVery Good

Good Fair Poor

Degree to which pain was controlled 68.4% 15.8% 7.9% 5.3% 2.6%

Degree to which symptoms (other than pain) were controlled

77.1% 11.4% 5.7% 2.9% 2.9%

Degree to which team addressed Emotional needs

71.4% 14.3% 7.1% 3.6% 3.6%

Degree to which team addressed Spiritual needs

76.9% 15.4% 0.0% 3.8% 3.8%

Degree to which team included you in decisions about care

71.0% 22.6% 6.5% 0.0% 0.0%

Degree to which team treated you with respect and dignity

73.5% 20.6% 5.9% 0.0% 0.0%

Degree to which team addressed your overall well-being & comfort

63.9% 19.4% 2.8% 5.6% 8.3%

Degree to which discharge process was smooth/hassle free

62.1% 24.1% 0.0% 10.3% 3.4%

Overall assessment of Palliative Care team 68.6% 14.3% 14.3% 0.0% 2.9%

Telephone Survey of 67 patients/families following discharge date of at least 30 days. Patients were picked at random. Responses from 43 completed surveys are recorded above.

• 83 – 94% responded very favorably, reporting ‘excellent’ or ‘very good.’ satisfaction with Palliative Care at St. John

Satisfaction Results

• We received our highest scores in the areas of ‘treatment with dignity,’ ‘inclusion of patients in decisions about care’ and ‘addressing spiritual needs.’

• The highest number of negative comments focused on the discharge process from the hospital.

Satisfaction Results

Financial Outcomes

Service Cases LOS

Usual Care 1329 11.1

Palliative Care 130 8.5

Savings/Case 2.6 days

Length-of Stay-Savings 2008

Year Days Saved

2008 918

2007 1730

2006 931

2005 188

Length-of-Stay Savings

Service Cases Charges/Case

Usual Care 1329 $44,602

Palliative Care 130 $30,153

Savings/Case $14,449

Charge Avoidance - 2008

$2,000.00

$2,500.00

$3,000.00

$3,500.00

$4,000.00

$4,500.00

UsualCare

PalliativeCare

Mean Charges Per Day11 Days Prior to Death

11 10 9 8 7 6 5 4 3 2 1Days Before Death

Ch

arg

es/D

ay

Year Charges Saved

2008 $5,114,847

2007 $3,062,573

2006 $3,911,365

2005 $619,750

Charge Avoidance

Putting it Together,LOS and Cost Savings

Total Days Saved 2004 - 2008

3,767

Total Charges Saved 2004 - 2008

$12,618,554

Year Days Saved Charges Saved

2009 1343 $5,089,942

2010 1544 $5,852,808

2011 1775 $6,728,228

Looking Ahead into the Future…

Assume 15% Annual Growth Rate

Should the Palliative Care Team See Every Patient in

the Hospital?

Proactive palliative care in the medical ICU: effects on length of stay for selected

high-risk patients

Norton SA, Quill TE, et al. Critical Care Medicine

2007; 35:1530-1535

17-bed medical ICU at a tertiary care hospital in Rochester, New York.

Primary Outcome: LOS

ICU admission following a current hospital stay 10 days or longer– Age >80 years with 2 or more life-threatening

comorbidities– Active metastatic cancer– Status post cardiac arrest;– Intracerebral hemorrhage requiring mechanical

ventilation

Study Design

Norton SA, Quill TE, et al. Crit Care Med. 2007; 35:1530-1535

Optional PC Consult Required PC Consult

Mortality in the ICU

55 59

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ality

Norton SA, Quill TE, et al. Crit Care Med. 2007; 35:1530-1535

P > 0.10

17.7 17.6

9

16.3

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Total Days = 26.7

Non ICU Days

Total Days = 33.9

ICU Days

Required PC Consult Optional PC Consult

Length of Stay

Norton SA, Quill TE, et al. Crit Care Med. 2007; 35:1530-1535

Conclusions

• Mandatory ICU Palliative Care Consultation reduced ICU stay over 7 days, without substantially changing mortality.

• Non-ICU Hospital LOS did not decrease with the intervention

Norton SA, Quill TE, et al. Crit Care Med. 2007; 35:1530-1535

Bottom Line

• “Blanket” Palliative Care Consultation can substantially reduce ICU days

• Implied in the study is significant cost savings, but not explicitly reported.

• More analysis could reveal clinical outcomes, satisfaction level, and referral patterns

The Oklahoma Advance The Oklahoma Advance DirectiveDirective

a document only a a document only a lawyer could love…lawyer could love…

Advance DirectivesAdvance Directives

•Statement of one’s wishes regarding End-of-Life Care

•Only goes into effect when patients permanently lose decision-making capacity

•Allows one to opt out of life-sustaining care and/or Artificial Nutrition and Hydration

• Cumbersome document poorly understood by physicians and patients

• Only executed by 15 - 20% of eligible patients

Gillick, et al., Ann Int Med. 1995;123:621-624

OKLAHOMA ADVANCE DIRECTIVE

FOR HEALTH CARE

If I am incapable of making an informed decision regarding my health care, I direct my health careproviders to follow my instructions below.

I. Living WillIf my attending physician and another physician determine that I am no longer able to makedecisions regarding my medical treatment, I direct my attending physician and other health careproviders, pursuant to the Oklahoma Advance Directive Act, to follow my instructions as set forthbelow:

1. If I have a terminal condition, that is, an incurable and irreversible condition that even withthe administration of life-sustaining treatment will, in the opinion of the attending physicianand another physician, result in death within six (6)

Advance DirectivesAdvance Directives

• Surveys show that patients prefer their physicians to address Advance Directives in a controlled setting (e.g. office)

• In reality, most Advance Directives are completed at a point of crisis, such as in a hospital during a critical illness

Advance DirectivesAdvance Directives

Rodriguez, KL, et al., Soc Sci Med. 2006;62:125-133Lo B, et al., Am J Geriatr Cardiol. 2004;13:316-320

Behold: The MismatchBehold: The Mismatch

•When surveyed, a majority of patients expect their Primary Care Physician to address Advance Care Planning.

•Physicians generally do not solicit their patients about completing Advance Directives

Tierney, et al. J Gen Intern Med 2001:16;32-40Lurie, N. et al. J Am Geri Soc 1992:40;1205-8

Office Screening/Prevention Office Screening/Prevention

•Diabetes Screening•Lipid Screening•PAP Smears•Mammography•Colonoscopy•PSA/DRE•Smoking Cessation Counseling

•Advance Directive Completion•Alcohol/Drug Abuse Screening

Why is this conversation missing Why is this conversation missing in Primary Care?in Primary Care?

•Thinking about dying is uncomfortable•Patients value invincibility•Physicians value cure•Physicians lack training •Legally complicated process (Missteps = Lawsuit)

•Ethical hornet’s nest•Religious Implications•Time Issues•Portability Issues

Tulsky J, et al. Ann Intern Med 1998:129;441-449

Can Residents be Trained to Can Residents be Trained to Address Advance Directives?Address Advance Directives?

Study CharacteristicsStudy Characteristics

•10 Internal Medicine Residents

•100 Clinic Patients

•All patients had to have at least one chronic illness to meet entry criteria

•Baseline survey of 100 random charts revealed zero AD’s

Study DesignStudy Design

•IRB approved, prospective survey trial

•Residents were surveyed about their baseline knowledge, skills, attitudes and comfort using Advance Directives with patients.

•Residents received 2-hour training period, reviewing all aspects of Advance Directives

Study DesignStudy Design

•Once trained, each resident encouraged 10 of their ‘at-risk’ continuity patients to complete an Advance Directive

•At the conclusion of the study, residents were re-surveyed about their knowledge, skills, attitudes and comfort using Advance Directives with patients.

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Pre-intervention Post-intervention

p < 0.001

p < 0.001p = 0.004

p < 0.001

Results: ResidentsResults: Residents

ConclusionsConclusions

•Residents significantly improved their knowledge, skills, attitudes, and comfort with Advance Directives in the Outpatient setting

•Patients demonstrated a strong interest in completing Advance Directives

Implications from the StudyImplications from the Study

The authors hoped that residents would apply their research experience to engage future patients in completing Advance Directives in the Outpatient setting.

Did they?

Epi-PhenomenonEpi-Phenomenon

Following the “conclusion” study period, Residents were secretly observed over a period of an additional 6 months

Not one advance directive was completed in that period.

Bottom Line:Bottom Line:

•Despite intensive training, many barriers are stacked against physicians engaging their patients in meaningful conversations about Advance Directives

•The doctor’s office is probably not the right place for patients to complete Advance Directives

Helping Zelda:

What can we do?

What Zelda Needs:What Zelda Needs:

•Pain Management

•Restoration of Function

•Assistance with making difficult decisions

•Workup and Treatment for Depression

•Transition to appropriate venue of care

•Advance Directive

What you can do:What you can do:

•Be a patient advocate

•Recognize and treat patient suffering• Physical Suffering• Emotional Suffering• Social Suffering• Spiritual Suffering

What you can do:What you can do:

•Talk to your colleagues – do they recognize suffering?

•Learn what resources your community offers in geriatrics and palliative care services

What you can do:What you can do:

•If Palliative Care is not in your community, encourage leadership to explore growth opportunities

•www.capc.org

What you can do:What you can do:

• Complete EPEC/ELNEC training

• Become certified in Palliative Medicine

• Educate local providers, hospitals, and nursing homes to about Palliative Care

What you can do:What you can do:

• Familiarize yourself with the Oklahoma laws regarding Advance Directives

• Encourage patients to execute Advance Directives, if they have not already done so.

Thank YouThank You