Palliative vs Hospice Care

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Dr. Jim Meadows Director of Palliative Medicine

Tennessee OncologyBoard certified in Palliative Medicine & Family Medicine

Palliative vs. Hospice Care

Jim Meadows, MD

Director of Palliative Medicine

Tennessee Oncology

Acknowledgement• Certain topics must be approached carefully

Objectives

• What is Palliative Medicine?

• Who can receive Palliative Medicine?

• What are the benefits and risks of Palliative

Medicine?

• Is Palliative Medicine simply hospice care?

• How can I see a Palliative Medicine team?

What is it?

• Palliative care is a medical specialty focused on aggressive symptom management.

• Experts whose primary goal is to improve quality of life.

What is it?

Palliative care is patient and family-centeredcare that optimizes quality of life by anticipating, preventing, and treating suffering.

Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs to facilitate patient autonomy, access to information, and choice.

Why have a specialty?

Why have a specialty?

• Diseases are complex

• Treatments are complex

• Symptoms are complex

• Patients are complex

• The system is complex

Evolution

• With time, new needs are realized

• Focus on quality is growing

• Knowledge is rapidly expanding

• Benefits are being discovered

Who can receive PM

Anyone with a serious condition in

need of improved quality of life,

regardless of prognosis or diagnosis.

What’s Quality of Life

How do you measure quality?

Typically includes

PainNauseaAnxietyDepressionFatigueConstipationPoor AppetiteInsomnia

Shortness of BreathCaregiver DistressSpiritual SufferingFinancial DifficultyLoss of Control

Palliative Medicine in Action

• A patient is referred to a Palliative specialist

• Palliative visits tend to focus less on the actual disease and more on what impact it has on the patient’s life

• Together, a plan of action is reached, which includes multiple modalities

Benefits

• Better control of symptoms

• Better understanding of what effects a disease has on the patient

• Better communication among the patient, caregivers, and treatment team

Patient Benefit:Proof Palliative Medicine

Works“Do Palliative Consultations Improve Patient Outcomes?”

Casarett D, et al, Journal of the American Geriatrics Society 56 (4) (April): 593-599 (2008)

In a multivariable linear regression model, after adjusting for the likelihood of receiving a palliative consultation (propensity score), palliative care patients had higher overall scores: 65 (95% confidence interval (CI)=62-66) versus 54 (95% CI=51-56; P<.001) and higher scores for almost all domains. Earlier consultations were independently associated with better overall scores (beta=0.003; P=.006), a difference that was attributable primarily to improvements in communication and emotional support.

CONCLUSION: Palliative consultations improve outcomes of care, and earlier consultations may confer additional benefit.

Patient BenefitPhase II Study of an Outpatient Palliative Care Intervention in Patients With Metastatic Cancer

Follwell, et al. JCO January 10, 2009 vol 27 no. 2 206-213

This study assessed prospectively the efficacy of an Oncology Palliative Care Clinic (OPCC) in improving patient symptom distress and satisfaction.

• 150 patients enrolled, 123 completed 1-week assessments, and 88 completed 4-week assessments

• The mean improvement in EDS was 8.8 points (P < .0001) at 1 week and 7.0 points (P < .0001) at 1 month

• Statistically significant improvements were observed for pain, fatigue, nausea, depression, anxiety, drowsiness, appetite, dyspnea, insomnia, and constipation at 1 week (all P ≤ .005) and 1 month (all P ≤ .05)

• The mean improvement in FAMCARE score was 6.1 points (P < .0001) at 1 week and 5.0 points (P < .0001) at 1 month.

Patient Preference

Symptom management needs of oncology outpatients Whitmer K, Et al. J Palliat Med. 2006 Jun;9(3):628-30

More than half of surveyed patients would attend a symptom management clinic, if offered, for the following:

• Pain (50%)• Fatigue (40%)• Nausea/Vomiting (30%)• Insomnia (30%)

Caregiver Benefit• 34 million households with caregivers deliver care at home to a

seriously ill older relative (Houser and Gibson 2008)

• On average they’re spending about 21 hours per week in caregiving

• Nearly one-half of all caregivers consider their caregiving responsibilities to be highly stressful, which puts them at a significantly increased risk for death, major depression, and other serious illness (Schulz and Beach 1999)

• A very conservative estimate suggests that family caregivers’ unpaid contributions are approximately $375 billion per year (Houser and Gibson 2008)

Caregiver Benefit

Patients’ families are not very happy with us as a health careindustry either

• Joan Teno and colleagues (2004) studied caregivers of people who died in various institutions in the United States.

• 80% reported that patients and families didn’t have enough contact with their physician and didn’t get enough support

• Half the patients didn’t have enough support or enough information about what to expect in a setting of serious illness

• Thirty-eight percent of families said they didn’t get enough support and one in five said they didn’t get enough help with their own emotional needs.

Landmark Research“Early Palliative Care for Patients with Metastatic Non-Small-Cell Lung

Cancer.”Temel JS, et al. New England Journal of Medicine 363 (8) (August 19 2010): 733-742.

• Patients assigned to palliative care had better quality of life, reflected in a mean FACT-L score of 98.0 at 12 weeks compared with 91.5 for the control group (P=0.03)

• Additionally, only 16% of the palliative care group had depressive symptoms versus 38% of the control group (P=0.01)

• Palliative-care patients were also less likely to receive aggressive end-of-life care. The authors reported that 33% of patients receiving palliative care had aggressive end-of-life care versus 54% of the standard-care group (P=0.05).

• Median survival in the patients who received early palliative care was 11.6 months compared with 8.9 months in the control group (P=0.02).

Landmark Research

Landmark Research

ASCOProvisional Clinical Opinion: Based on strong evidence from a phase III RCT, patients with metastatic non–small-cell lung cancer should be offered concurrent palliative care and standard oncologic care at initial diagnosis. While a survival benefit from early involvement of palliative care has not yet been demonstrated in other oncology settings, substantial evidence demonstrates that palliative care–when combined with standard cancer care or as the main focus of care–leads to better patient and caregiver outcomes. These include improvement in symptoms, QOL, and patient satisfaction, with reduced caregiver burden. Earlier involvement of palliative care also leads to more appropriate referral to and use of hospice, and reduced use of futile intensive care. While evidence clarifying optimal delivery of palliative care to improve patient outcomes is evolving, no trials to date have demonstrated harm to patients and caregivers, or excessive costs, from early involvement of palliative care. Therefore, it is the Panel's expert consensus that combined standard oncology care and palliative care should be considered early in the course of illness for any patient with metastatic cancer and/or high symptom burden. Strategies to optimize concurrent palliative care and standard oncology care, with evaluation of its impact on important patient and caregiver outcomes (eg, QOL, survival, health care services utilization, and costs) and on society, should be an area of intense research.

Palliative vs. Hospice

• Both focus on improved qualify of life

• Both are delivered by specialists

• Both have been shown to improve survival


• Both tend to be delivered by a team of individuals with knowledge of complex symptom management

• Both work with the patient’s other clinicians to provide an additional layer of patient care


• Hospice is a medical insurance benefit, with its own set of regulations

• Hospice care is typically provided in the home, whereas palliative tends to be hospital or clinic based


• Hospice specifically cares for patients with terminal conditions where survival is typically <6 months

• Palliative medicine is delivered irrespective of prognosis

• Both are provided regardless of diagnosis




Involving Palliative Care

• Talk with your oncologist• Palliative Care and Medical Oncology work

as a team

• Use online resources to find local programs

• www.getpalliativecare.org

• Once arranged, have open, honest dialogue



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Palliative vs Hospice Care