WRHA Palliative Care ProgramNovember 2012

Lori Embleton, Program Director

What Is Palliative Care?

Palliative Care is an approach to care which focuses on

comfort and quality of life for those affected by life-

limiting/life-threatening illness. Its goal is much more

than comfort in dying; palliative care is about living,

through meticulous attention to control of pain and

other symptoms, supporting emotional, spiritual, and

cultural needs, and maximizing functional status.

What Is Palliative Care?

Not defined by:– Body system (compare with dermatology,

cardiology)– What is done (compare with anesthesiology,

surgery) – Age (compare with pediatrics, geriatrics)– Sex of patient (such as with gynecology)– Location of Care (compare with ER, critical care)

Any illness, any age, any location…

What Is Palliative Care?

The spectrum of investigations and interventions

consistent with a palliative approach is guided by goals

and expectations of patient and family and by accepted

standards of health care, rather than being bound by

preconceptions of what is or is not "palliative".

Potential Palliative Care Interventions

Palliative

EmotionalSpiritualPsychosocial

Support

Control of

• Pain• Dyspnea• Nausea• Vomiting

Variable

Infections

Transfusions

Hypercalcemia

Dialysis

Tube Feeding

CPR

Ventilation

Highly burdensomeInterventions

Generally Not Palliative

No Community Outreach

Seven Oaks

Hospital

Seven Oaks

Hospital

HSCHSCConcordia Hospital

Concordia Hospital

VictoriaHospitalVictoriaHospital

GraceHospitalGrace

HospitalSBGH

•20 beds•served SBGH and local area

SBGH•20 beds•served SBGH and local area

39 PCH

s

39 PCH

s

RHC•30 beds•patients primarily from HSC & community

RHC•30 beds•patients primarily from HSC & community

JocelynHouse

•5 beds

JocelynHouse

•5 beds

Winnipeg Palliative Care Services: Pre-RegionalizationWinnipeg Palliative Care Services: Pre-Regionalization

Inpatient attending & consulting

Home consultative support

No formal services

CC

Seven Oaks

Hospital

Seven Oaks

HospitalHSCHSC Concordia

HospitalConcordia Hospital

VictoriaHospitalVictoriaHospital

GraceHospitalGrace

Hospital

SBGH•15 beds

SBGH•15 beds

39 PCHs

39 PCHs

GraceHospice

•12 beds

GraceHospice

•12 beds

RHC•30 beds

RHC•30 beds

JocelynHouse

•4 beds

JocelynHouse

•4 beds

Winnipeg Palliative Care Services: Post-Regionalization

Inpatient attending & consulting

Home & facility consultative support

Children’sHospital

Children’sHospital

Completely newcomponent

Palliative Care Program

Two streams of service delivery:1. Registration on Program2. Consultative Services

REGISTRATION ON PALLIATIVE CARE PROGRAM

Registration on Program

Patients can be “registered” on the Palliative Care Program if they meet program criteria:

– Prognosis of less than 6 months–No longer receiving aggressive treatment which

requires on-going monitoring for and treatment of serious complications

–Have chosen a comfort-focused approach including a decision to decline attempted resuscitation

Registration on Program

Once registered with the program, patients are eligible for:

– Case management through Palliative Care Coordinator– Access to Community Palliative Care Nursing 24/7

• Palliative Care Nurses have access to Palliative Care Physician

– Admission to Palliative Care Units (PCU) and Hospice – if bed available

– Enrollment on Provincial Palliative Care Drug Access Program

When to Register a Patient on Palliative Care Program

• Patients are considering going home from acute care– Need to plan for services to be in place

• Patients being transferred to Long Term Care Setting

How to Register a Patient on PC Program

• Complete the “Application for Registration” form – 2 page form– “completed” forms can be processed more quickly

• Completed forms are reviewed by PC coordinator– Accepts on to Program– Rejects application – all reviewed by Manager, Program

Director or Medical Director

Acute Palliative Care Units

St. Boniface Hospital• 15 bed unit• Access to tertiary care services

Riverview Health Centre• 30 bed unit (2 beds currently closed)• Long term care facility

Acute Palliative Care Units (PCU)

• Admission to PCU for symptom issues– Physical symptoms– Psycho-social distress– Caregiver distress

• Admissions managed centrally by PC program staff– Bed management guidelines

Acute Palliative Care UnitsOnce symptoms are controlled, actively

discharge to appropriate site– Approximately 75% of patients die on PC unit– Approximately 20% of patients are discharged

home from Palliative Care Units– Lack of care options if home not possible

• PCH• Chronic Care• Hospice

Hospice settings in WRHA

• Grace Hospice• 12 beds in stand alone facility near Grace hospital• RN staffing 24/7• Limitations in care that can be provided

Hospice settings in WRHA

• Jocelyn House• 4 beds in split-level home in St. Vital• RN staffing 4 hours a day – 5 days a week

• HCA provide care 24/7

Hospice

Hospice is appropriate when:– Symptoms well controlled– Care needs are not complex– Prognosis of 1 – 3 months– Patients cannot or do not wish to be cared for in

the community

Care in the Community

• Majority of patients on Palliative Care program are in the community

• Recently expanded community model of care to incorporate an Inter-professional approach

PCHs

PCHs

PCHs

NortheastNorthwest

South

Central

Patients at home

Home

PCHs

Patients at home

Patients at home

7 Oaks

HSC

VGH

ConcordiaGrace

CommunityClinics

CommunityClinics

CommunityClinics

Community Teams:•Community

Nurses•CNS•MD•Coordinator•Psychosocial

Inter-professional Community Model• Each community team considers patients in their

area as their “ward”– Inclusive of all care settings – home, acute care and long

term care– Team meetings to discuss patient care needs especially

when transitioning between care settings– Focus on meeting needs in a proactive way– Opportunity to strengthen networks with other care teams

to support patients and families including the opportunity to model “palliative care”

Care at Home

• Palliative patients in community have same service limitations as all Home Care clients– HCA and PSW services provided by Home Care

Program

• Families/caregivers must be very involved in providing care

CONSULTATION SERVICES

Consultative Services

• Available to anyone with a life limiting illness in any care setting for symptom management, psycho-social support or assistance with discharge planning

• Consultation services are provided by inter-professional team members including:– Palliative Care Physician– Palliative Care Clinical Nurse Specialist– Psycho-social Support Specialist

When should Palliative Care be consulted?

• Assistance with symptom issues– Managing Physical symptoms

• MD to MD consults for advice 24/7

– Psycho-social

• Assistance with care planning– What might care team expect as patient nears end

of life?• Will oral route be available?• Could symptoms escalate?

When should Palliative Care be consulted?

• Goals of care are not clear– Discrepancy between patient, family and/or

members of care team with plan of care

• Discharge to community or LTC is anticipated– Does patient need to be or are they currently

“registered” on Palliative Care program?– Would it be appropriate for Palliative Care nurse

to see the patient in the community?

What information is needed on consult?

• Main reason for consult– What is the main symptom issue?

• Urgency of consult• Is the physician aware of the consult?

Diagnosis ofLife-Limiting

Illness

Transitioning to Palliative

Palliative

Consult Service

Community Palliative Nursing

• Case Coordinator• Admission Eligibility• Medication Coverage

• comfort-focusedcomfort-focused• prognosis prognosis ““6 mo. or less6 mo. or less””• some treatment limitationssome treatment limitations

(DNAR, no TPN, no (DNAR, no TPN, no chemoTx with high chemoTx with high adverse effectsadverse effects

• aggressive, often toxic treatment focused on cure or life-prolonging disease modification

Palliative Care as a

philosophy of careFormal

ProgramFormal

Program

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