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Palliative Care in Kingston and the SE LHIN
Dr. Natalie Kondor
DFM Grand Rounds
Jan 20 2015
Outline
What is palliative care?Why is palliative care important?Trends in palliative care provisionRegional and local resources for palliative
care provisionFAQs
What is Palliative Care?
Palliative care is a philosophy of care that aims to help individuals and families to:
Address physical, psychological, social, spiritual and practical issues
Prepare for and manage end of life choices and the dying process
Cope with loss and griefTreat active issues and manage symptomsPrevent new issues from occurringPromote opportunities for meaningful and valuable
experiences
Why do we need palliative care?
1900 Average age of death 46 years Usually a rapid death Leading causes: infectious disease, childbirth, accidents
2015 Average age of death 85 Only 5% die sudden deaths, 95% decline over time 2-4 years of decline
Functi on
High
Low
Time
Sudden Death
Death
Our Reality
By 2036, seniors will account for 23-25% of the total population
32 % of Canadians suffer from a chronic illness • 39% have a sufferer in their immediate family
74% of seniors have one or more chronic conditions
24% of seniors have three or more chronic conditions
Chronic diseases account for 70% of all deaths
Palliative Care – Not Just End of Life Care
The Need for Palliative CareESAS symptom profile for cancer patients
Benefits of Earlier and Integrated Palliative Care
Leads to better outcomes for Patients & Families:• Reduced symptom burden• Less anxiety and depression• Less caregiver burden• Better quality of life• Less aggressive treatments• More appropriate referral to and use of hospice• Lower health care costs
Smith et al., 2012; Temel et al., 2010; Bakitas et al., 2009; Myers et al., 2011; Zimmerman et al 2013
Benefits of Earlier and Integrated Palliative Care - Improved Survival
Longer and better survivalBetter understanding of prognosis Less IV chemo in last 60 daysLess aggressive end of life careMore and longer use of hospice$2000 per person savings to insurers and society
Temel J, et al. NEJM 2010; Temel J, et al, JCO 2011; Greer, et al. Proc ASCO 2012
Current state of Palliative Care in Canada
Only 16-30% of Canadians have access to formalized palliative/end-of-life care services
At least 25% of the total cost of palliative care is borne by families
Approximately 70% of deaths occur in hospital• 40% of terminally ill cancer patients visit the emergency department
within the last 2 weeks of life• 41% of long term care home residents have at least one hospital
admission in their last 6 months of life
96% of Canadians believe it is important to have conversations with their loved ones about their wishes for care• 34% have actually had a discussion• 13% have completed an Advanced Care Plan
CHPCA Fact Sheet – Hospice Palliative Care in Canada (2014)
Building capacity for palliative care
A palliative approach to care should be practiced by all providers caring for people with life-threatening illnesseso Primary, Secondary and Tertiary care settingso Community settings
Not a “one size fits all” approach, but key common elementso Person-centred careo Inter-professional teamo Single access pointo 24/7 care to ensure continuity & coordinationo Building community capacity
Regional Implementation – Results in Alberta Edmonton & Calgary: 1993 to 2000
Acute care
Hospice care
Costs for last year of
life Services Introduced:Hospices
Community consult teams
Results• Health system costs
reduced
• Acute care costs reduced (from 83% to 63% )
• In-hospital days reduced (from 39 to 27 days)
• # of deaths in acute hospitals reduced
• # of home deaths increased
Fassbender K et al. Utilization and costs of the introduction of system-wide palliative care in Alberta, 1993 to 2000. Palliative Medicine. 2005:19-513-520
Regional Implementation – Results in Ontario
Pockets of palliative care excellence in rural & urban areas
Community capacity building initiatives across Ontario have created innovative programs
A recent analysis of community based, specialist palliative care teams found:o Reduced acute care use o Reduced hospital deaths at the end of life
What’s Next in Ontario
The Provincial HPC Steering Committee & the Clinical Council are now active
HPC now a priority for system transformation in all LHINs
All LHINs have committed to:o 10% reduction in one or more of the following areas:
Overall palliative-related ALC daysInpatient days per capita among patients that died in
hospital;Palliative-related avoidable hospitalizations (repeat ER
visits/readmissions) o Implementing regional HPC programs
Work underway to develop palliative care indicators
Palliative Care In Our Region - SE LHIN Regional PrioritiesStrengthen capacity of local communities in providing hospice palliative care
• Increase capacity in providing palliative care in all care settings especially primary care
• Support the uptake of common palliative care plans, guidelines and tools• Promote use of shared information among care settings
Create regional mechanisms to enable early identification of patients who would benefit from hospice palliative care
• Implement the adapted Gold Standards Framework for Early Identification
Increase the understanding and implementation of Health Care Consent and Advance Care Planning
Strengthen caregiver support including bereavement
Palliative Care in Our Region - ResourcesInpatient Consult ServicesCommunity Palliative Care Services
• CCAC – Nursing, PSW, SW, OT, PT, Dietician• Physicians
Inpatient Palliative Care Units• SMOL PCU, Brockville PCU
Community Hospices• Inpatient, ambulatory
Outpatient Ambulatory Clinics• KRCC, Advanced dyspnea management clinic
Hospice Palliative Care Nurse Practitioners
Community Palliative Care Services
For patients with PPS < 50%FamMD makes CCAC referralFamMD +/- colleague follows patient at home and
provides 24/7 call coverageFamMD refers to community palliative care physician for
concurrent care or transfer of care Patients are seen same day to within 2 weeks depending on
urgency On referral, helpful to indicate whether you are requesting
community, PCU assessment or clinic visit. If unsure, feel free to phone to suss out which might be most appropriate (548-2485)
Helpful to indicate urgency, PPS, decline in PPS, symptom issues, whether want concurrent vs. transfer of care
Palliative Care Unit – at SMOL
13 beds – 10 private and 3 semi-private roomsAll referrals are to go through the palliative care
office and are directed to the intake physician who manages a running list
Wait time often less than 2 weeks, can be as soon as same day
Patients at home get priority over patients waiting at KGH
Prognosis less than 3 monthsIf survive longer, may get transferred to LTC
Palliative Care Clinic at KRCC
Referrals from specialists (often oncologists), Family MD
For symptom management for ambulatory patients (PPS =/>50%)
For cancer-related symptoms or symptoms related to cancer therapy
Patient continues to receive primary care from Family MDPalliative MD is generally 1st contact regarding symptom
management issues
Hospice Palliative Care Nurse Practitioners
Some FAQs
What is a PPS and why is it important?
Do I have to have CCAC involved to care for my patient at home?
Yes – the short answerWhy:
CCAC is the “umbrella” organization that designates one of the nursing agencies to be the first call to patients/families
Coordinate and provide OT/PT/SW support, equipment (hospital beds, nebulizer machines etc)
Supplies needles, syringes, dressings, sc sets, catheters, some personal care items, etc.
Patient not eligible for CADD pumps or SRKs without CCAC involvement
Do I have to have CCAC involved to care for my patient at home?
How to get CCAC support:Fill in a CCAC Service RequisitionCan simply write: “please see for palliative
symptom assessment and management” and the ball will start rolling
How many hours of CCAC PSW and nursing support can my patient receive?Not 24/7 bedside care!CCAC’s “End-of-Life” Program
PPS less than 30Life expectancy/need for 30 days or lessPSW - Up to 360 hrs allotted for 30 days or 12 hrs per
dayNursing – visits as often as needed up to 4 times per
dayOption of hiring PSW support and nursing
privately but lack of manpower and expensive$60-80/hr for nurse$30-40/hr for PSW
Compassionate Care Benefits
Family member at risk of dying within 26 weeksDoctor completes application formEI programBenefits for up to a maximum of six weeks To be eligible for compassionate care benefits, you must be
able to show that:your regular weekly earnings from work have decreased
by more than 40 percent; and you have accumulated 600 insured hours of work in the
last 52 weeks, or since the start of your last claim (this period is called the qualifying period).
The basic benefit rate is 55 percent of your average insurable earnings, up to a yearly maximum insurable amount ($48,600 in 2014). This means that, in 2014, you can receive a maximum payment of $514 per week.
Compassionate Care Benefits
Do I have to refer my palliative patient at home to the community palliative care team?
No!If Dr. You is comfortable with and readily
available to provide symptom management and end of life care to your patients at home, you can do it
You or a colleague covering for you must be available to be called 24/7
The Queen’s palliative care team has a physician available to call for advice 24/7 (548-2485 or ask for the PC doctor on call through the KGH operator if after-hours)
Why do referrals to community palliative care need to come from the Family MD?Specialists (eg. CTU resident discharging
patient home, oncologist at KRCC) can refer patient to community palliative MD but must get confirmation of agreement (verbal or in writing) from patient’s Family MD
To ensure Family MD is aware of situation and give opportunity for Family MD to decide whether prefer they vs. community PC follow pt at home
If a patient does not have a Family MD, any MD can refer to community palliative care
What is a Symptom Response Kit and how do I order one?
What is a Symptom Response Kit and how do I order one?
Palliative Care Facilitated Access List
Can Bloodwork be done at home?
Yes, but not urgent b/wOrder on LifeLabs req and write HOME VISIT in the
“additional clinical information” areaLifeLabs will come to patient’s home usually “within the
next week” – may be as soon as next day depending on geography
Results available day after b/w is doneCosts the patient approximately $35 per visitOccassionally home care nurse can do b/w with an order
but only if b/w obtained via a PICC (generally don’t do peripheral venipuncture anymore) and if b/w taken immediately to lifelabs by nurse or family member
Can my patient receive IVF or blood transfusions at home?Patients can receive fluid hydration at home –
set up by the nurses through CCACRequires faxed order to CCACNS is easiest to obtain (vs. 2/3 1/3, NS with KCl, etc) IVF – can order if pt has IV access eg. PICC or Port-a-
Cath. CCAC provides pump for administrationHypodermoclysis – fluids run sc through a sc set by
gravity, generally overnight/over 8 hoursBlood transfusions cannot be done at home, can
be done through ER or KRCC as outpatient (with pre-orders)
What is a Yellow Folder?
SE LHIN initiative for “expected death at home”
Contains information on who/when to call for what situation
Contains SRK RxContains DNR confirmation form
What is a DNR Confirmation Form and does my DNR patient need one?
Does an MD need to pronounce and complete the death certificate?In Ontario, in the case of an expected death and
the death is caused by the expected cause then a nurse (RN or RPN) may pronounce
A physician or NP’s order is required for this to occur and the funeral home should be aware and agreeable
Once pronouncement has happened, the funeral home will retrieve the body with or without the death certificate
A physician or NP is required to submit an original copy of the death certificate to the funeral home as soon as possible (usually within 24 hours)
Summary
Palliative care is growing in scope and importance
By 2036, 25% of Canadians will be seniors and many of them will need some form of palliative care
Tools and resources are readily available for primary care practitioners to provide this care to their patients