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Life is pleasant. Death is peaceful. Its the transition thats troublesome.The Case forPalliative Care

1The Eperc ProjectHow Americans died in the pastEarly 1900saverage life expectancy 50 yearschildhood mortality highadults lived into their 60sPrior to antibiotics, people died quicklyinfectious diseaseaccidentsMedicine focused on caring, comfortSick cared for at homewith cultural variations

Medicines Shift in FocusMarked shift in values, focus of North American societydeath denyingvalue productivity, youth, independencedevalue age, family, interdependent caringDeath the enemyorganizational promisessense of failure if patient not savedMedicines Shift in FocusScience, technology, communicationPotential of medical therapiesfight aggressively against illness, deathprolong life at all costImproved sanitation, public health, antibiotics, other new therapiesincreasing life expectancy2010 avg 78.7 yearsWe Hope toDie in my sleepDie suddenly

The Reality90% of us will die after a progressive decline from chronic illness.

ResultsMore than 70% of Americans say they would prefer to die at home

25% of deaths occur at home

(Robert Wood Johnson Foundation)From This

To This

The number of people over age 85 will double to 10 million by the year 2030People living longer with chronic disease.The 23% of Medicare patients with > 4 chronic conditions account for 68% of all Medicare spendingAggressive treatment at end of life often leads to a decrease in quality of life for patients and their familiesSignificant association between increased cost and lower quality of death in the final week of life

The Demographic ImperativeChronically Ill, Aging Population is growing9000 Patients with life-threatening illness, 50% died within 6 monthsHalf of patients had moderate-severe pain, >50% in the last 3 days of life.38% of those who died spent >10 days in ICU, in a coma or on a ventilatorSuffering in U.S. Hospitals- National Data on the Experience of Advanced Illness in 5 Tertiary Care Teaching HospitalsJAMA 1995,274;1591-98WhyDifficult to discussIll die in my sleepMagical thinking If I talk negatively, it will happenSeen as giving upFamily doesnt want to discussSome would argue that in general we have lost faith in transcendent lifeAdvance care planning consists mostly of funeral arrangement

Most people say they want to discuss their values and wishes about end of life care with their physicianand they expect the physician to bring up the topic

Physicians feel patients will have difficulty discussing these sensitive issues

Most people are never asked about their wishes

Only 10-15% of Americans have Advance Directives

Barriers: What Research SaysIntro to Palliative Care"The relief of suffering and the cure of disease must be seen as twin obligations of a medical profession that is truly dedicated to the care of the sick. Physicians failure to understand the nature of suffering can result in medical intervention that (though technically adequate) not only fails to relieve suffering but becomes a source of suffering itself." The Nature of Suffering and the Goals of Medicine- Eric Cassell

Intro to Palliative CareMedical code of ethics and clinical guidelines explicitly indicate the importance of respecting patients rights, goals and values, as well as good communication, advance care planning, and recognizing when continuing treatment is more harmful than beneficial.

Patient and family centered careOptimizes quality of life by anticipating, preventing and treating sufferingThroughout the course of illnessA holistic approach that includes physical, intellectual, emotional, social and spiritual needs Facilitates patient autonomy, provides information and choiceWhat is Palliative CareTraditional Care ModelCurative CareHospiceCare