supportive & palliative care service: professional...
TRANSCRIPT
Supportive & Palliative Care
Service:
Professional Practice
Conference
Conference
Caroline Olney, RN MSN NP
October 21, 2010
San Francisco General Hospital
What we hope you will learn:
•Identify the relationship between
palliative care and hospice care
•Become familiar with new palliative care
•Become familiar with new palliative care
resources for pts/families/staff at SFGH
•Recognize where and how to document
a patient’s wishes
•Identify other resources in the Bay Area
AK1
Slide 2
AK1
Picky picky: would keep the bullet points parallel, i.e. points one and 2 start w/ verbs, so would do the same w/ 3 and 4, for ex:
Recognize where and how to document a patient's wishes; Identify other palliative care resources in the Bay Area
kinderm
ana, 9/30/2010
What is Palliative Care?
•“Palliative care is the m
edical subspecialty
focused on preventing, treating and relieving
the pain and other debilitating effects of
serious and chronic illness.”
•“Palliative care is not dependent on prognosis
andcan be delivered at the same time as
curative treatment. The ultimate goal: to
improve quality of life for patients and families
facing serious illness.”
Center to Advance Palliative Care, 2009
Palliative Care
•Patient and family as unit of care
•Attention to physical, psychological, social
and spiritual needs
•Interdisciplinary team approach
•Education and support of patient and family
•Extends across illnesses and settings
•Bereavement support
http://www.nhpco.org
Traditional Approach to
End-of-Life Care
%100
Palliative or
Hospice Care
“Nothing m
ore we can do”
Curative care
%
Focus
Time
Death
Term
inal phaseHospice Care
0
Ad
ap
ted
fro
m S
Pa
nti
lat,
PC
LC 2
00
5
Integrated M
odel for
End-of-Life Care
Curative care
100
“Best care possible”
Bereavement
Curative care
%
Focus 0
Time
Death
Term
inal phase
Ad
ap
ted
fro
m S
Pa
nti
lat,
PC
LC 2
00
5
Hospice Care
Palliative Care
The Palliative Care Spectrum
Life-Prolonging
Therapy
Hospice
Pain
Management
Therapy
Palliative Care vs. Hospice Care
Palliative Care
•Eligibility does not
Hospice Care
•Usually only accessible
Both involve comprehensive m
anagement of physical,
psychosocial, emotional, spiritual components of care, to
enhance quality of life for patients and families
•Eligibility does not
depend on prognosis
•Can be given at the same
time as life-prolonging
interventions
•Provided in hospital,
SNFs, outpatient clinics,
or home
•Usually only accessible
for pts with very limited
prognosis (<6 months)
•Best for patients who
choose to forego life-
prolonging treatm
ents
•Can be provided at
inpatient hospice, in
SNF/RCFE, or home
AK5
Slide 9
AK5
This is the slide I usually use
kinderm
ana, 9/30/2010
Early Palliative Care for Patients with
Metastatic Non-Small-Cell Lung
Cancer
“Among patients with metastatic non small-cell
lung cancer, early palliative care led to
significant improvements in bothquality of
significant improvements in bothquality of
life and mood. As compared with patients
receiving standard care, patients receiving early
palliative care had less aggressive care
at the
end of life but longer survival”
N Engl J Med 2010; 363:733-742
New York Times Aug 19, 2010
AK2
Slide 10
AK2
Cool -- very timely. Can m
ention that this was also written up in the NY Times.
kinderm
ana, 9/30/2010
Supportive &
Palliative Care Service
•Inpatient Consult Service, launched
December 2009
•An interdisciplinary team including:
–Physicians:
•Anne Kinderm
an, MD, Medical Director
•Heather Harris, MD, Associate M
edical Director
–Nurse: Caroline Olney, RN M
SN NP
–Social Worker: Regina Epperhart, MSW
–Chaplains: Eric Nefstead, MDiv and Elizabeth
Welch, MDiv
Supportive &
Palliative Care Service
•Expertise in:
–Communicating with patients and families
(explaining diagnoses or prognoses, establishing
goals of care, and facilitating family m
eetings)
goals of care, and facilitating family m
eetings)
–Treating refractory or complex symptoms
–Addressing psychosocial or spiritual concerns
–Coordination of care across health care settings
–Facilitating transitions from life-prolonging care
to comfort care or hospice care
SPCS: 443-5063
•Available to all patients in the hospital
Monday-Friday 8am-5pm (except holidays)
•Consult requests must come directly from
the inpatient primary physician
the inpatient primary physician
–All providers (nurses, social workers,
nutritionists, etc.) are encouraged to recommend
consults to the primary team
AK6
Slide 13
AK6
Would remove the bit about us being available by phone after hours...this is definitely true for hospital providers, but I don't think we
want to open up 24/7 for everyone in the DPH just yet.
Would also emphasize here that consult has to come from SFGH physician, not PCP.
kinderm
ana, 9/30/2010
How do you request a consult?
•The best way to ensure that your patient
gets a palliative care consult is to
include this in your note in LCR.
include this in your note in LCR.
•Also, contact the admitting team directly
to ensure your request for a consult was
received.
AK7
Slide 14
AK7
Would say that if you're charting on the pt as you're sending the pt to the ED for admission, would include that in your note.
(Otherw
ise they m
ay get confused about trying to order a consult somehow in LCR, and then not call the admitting service.) Would
emphasize that the m
essage often gets lost in the ED, so m
aybe wait until the pt's actually admitted, then talk w/ the primary team
kinderm
ana, 9/30/2010
Which patients might benefit from a
SPCS consult?
•Patients with ANY advanced or life-limiting illness and:
–Unclear goals of care
–Frequent ED visits or hospitalizations
–Uncontrolled pain or other symptoms
–Uncontrolled pain or other symptoms
–Psychosocial/spiritual distress (pt/family member)
–Difficult decision-m
aking with pt/family or difficult
communication with pt/family
•Patients who are transitioning to comfort-oriented care or
who m
ay die in the hospital
SPCS: Resources for Patients and
Families
•Comfort Care Suites
–2 double rooms converted into single room suites located on 5A (9 & 12)
–Suites redecorated with the help of grant support from the SFGH
Foundation and Healing Environments (new flooring, furniture and art)
–Occupancy triaged by 5A charge nurse and SPCS. Patients who are
imminently dying are prioritized over med/surg patients.
imminently dying are prioritized over med/surg patients.
–More room for visitors to stay with the patient; visiting hours 24/7
–5A nurses have additional training, experience with end-of-life care
•Social Work
–Provide inform
ation on community resources (hospice, funeral
arrangements, bereavement support, etc.)
•Chaplaincy
–Sojourn chaplaincy: 206-8500
–Catholic priest: 206-8119
SPCS: Resources for Staff
•Provide education and training
–Physicians & Nurses
–Rehab specialists, social workers, interpreters, etc.
•Support/debrief difficult patient or family
interactions, particularly regarding end-of-life
interactions, particularly regarding end-of-life
issues
•Provide inform
ation on community resources
(hospice, funeral arrangements, bereavement
support, etc.)
Communication Toolbox
•3 questions:
–What do you know?
–What do you want to know?
–Who do you want with you?
•3 techniques:
–Clarify ambiguity
–Talking / listening / silence
–Affect vs. cognition
Communication Toolbox
•Helpful open-ended questions:
–What led to your diagnosis?
–What do you know about your diagnosis?
–What does that mean to you?
–What does that mean to you?
–What is life like for you now?
–What concerns you the most?
–What are you hoping for?
–What gives you strength?
Communication Toolbox
•Other helpful questions:
–Are you comfortable?
–Do you feel that your treatments are causing you more harm
than good?
–Do you feel like you have a good quality of life right now?
–Do you feel like you have a good quality of life right now?
–If we could do one thing other than cure your illness, what
would it be?
•Helpful phrases:
–Your diagnosis is beyond our control but we can still control
your symptoms
–While we are hoping for a miracle, we are preparing for the
worst
•For more inform
ation: www.caringinfo.org
Communication Toolbox
•Sit down
•Active listening
•Silence
•Avoid m
edical jargon
•Avoid m
edical jargon
•Be respectful
•Be honest
•Do not be afraid to use the words death/dying
Ira Byock: The 4 Things That
Matter Most
•Please forgive me
•I forgive you
•Thank you
•Thank you
•I love you
•(G
oodbye)
(Byock, 2004)
Communicating Goals of Care:
Advanced Directive & POLST
•Advanced directive note in LCR
•Advanced directive in LCR: can be
completed by ANY health care provider
completed by ANY health care provider
•POLST in LCR: can be printed and filled
out by any physician or nurse
practitioner
•California Advance Directive: available
in Spanish and Chinese
AK9
Slide 25
AK9
Probably will need to take some time to explain what POLST is...lots of people probably won't know. Also, would be clear that the
"POLST in LCR" isn't a separate thing from the Advance Directive, it's just the printed form
of the Advance Directive in LCR. Also, it's
an "Advance Directive" note, not an "advance care planning" note. Would also talk about the "California Advance Directive" that pts can
fill out, available in Spanish and Chinese.
kinderm
ana, 9/30/2010
Advanced Directive:
CPR/Medical Interventions tab
AK8
Slide 26
AK8
You should let them know that the location of the Advance Directive has changed from these initial slides. It's now located under
"Patient Overview."
kinderm
ana, 9/30/2010
Advanced Directive:
Agents/Health Advocate tab
Advanced Directive:
Organ Donation tab
Advanced Directive:
Document Location tab
Advanced Directive:
Confirm
ation panel
Partial view of Advance Directive
in LCR
Medical alert bracelet
•May indicate
advanced directive
and code status
and code status
•Can be linked to
the medical record
Local Resources
In-home support:
–Health at home
–Sutter VNA
•AIM Program
Inpatient Hospices:
–Gift of Love Home
–Laguna Honda Hospice
•AIM Program
•Hospice
–Hospice By The Bay
–Pathways Hospice
–Maitri: HIV/AIDS patients
–SFVA
–Coming Home Hospice
–Zen Hospice (Guest
House)
Questions?
Thank You
Thank you for joining us today. We
appreciate your participation and
helping us to develop our palliative care
helping us to develop our palliative care
team. Thank you for all that you do.