Palliative Care Consult Service Overview and Case Examples
Palliative Care Consult Service Overview and Case Examples
Palliative Care Consult Service Overview and Case Examples
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<strong>Palliative</strong> <strong>Care</strong> <strong>Consult</strong> <strong>Service</strong><br />
<strong>Overview</strong> <strong>and</strong> <strong>Case</strong> <strong>Examples</strong><br />
Shoshana Helman, M.D.<br />
Medical Director, <strong>Palliative</strong> <strong>Care</strong><br />
Gary Lee, M.D.<br />
Associate Medical Director, <strong>Palliative</strong> <strong>Care</strong><br />
Santa Clara Valley Medical Center
What is <strong>Palliative</strong> <strong>Care</strong>?<br />
♦ Goals of palliative care<br />
Prevent <strong>and</strong> relieve suffering<br />
Support the best quality of life for patients <strong>and</strong> their families<br />
♦ Both a philosophy of care <strong>and</strong> a structured system<br />
♦ Exp<strong>and</strong>s traditional disease-model treatments<br />
Quality of life for patient <strong>and</strong> family<br />
Optimizes function<br />
Help with decision-making<br />
from Clinical Practice Guidelines for<br />
Quality <strong>Palliative</strong> <strong>Care</strong>
What services are provided<br />
♦ Management of pain <strong>and</strong> other symptoms<br />
♦ Psychosocial <strong>and</strong> spiritual care (according to needs,<br />
values, beliefs, <strong>and</strong> culture)<br />
♦ Focus on patient <strong>and</strong> family goals<br />
♦ Guidance <strong>and</strong> assistance with making decisions<br />
♦ Team approach: physicians, nurses, social workers,<br />
chaplains, pharmacists, others<br />
♦ Coordination <strong>and</strong> communication<br />
from Clinical Practice Guidelines for<br />
Quality <strong>Palliative</strong> <strong>Care</strong>
Curative / remissive therapy<br />
Presentation<br />
Death<br />
<strong>Palliative</strong> care<br />
Hospice
Who should get palliative care?<br />
♦ Unacceptable pain or other symptoms<br />
♦ Help with complex decision-making <strong>and</strong><br />
determining goals of care<br />
♦ Uncontrolled psychological or spiritual issues<br />
♦ Prolonged stay without evidence of improvement<br />
♦ Repeat hospital admissions<br />
♦ Terminal, or rapidly progressive, illness
Where is palliative care provided?<br />
♦ Hospital<br />
Inpatient palliative care consultation service<br />
Inpatient palliative care or hospice unit<br />
♦ Skilled Nursing Facilities, including Subacute<br />
facilities<br />
♦ Home<br />
♦ Outpatient clinics
Inpatient <strong>Consult</strong> <strong>Service</strong> – <strong>Case</strong> 1<br />
♦ 53-yo Caucasian man on home hospice for<br />
terminal gastric CA<br />
♦ Admitted with abdominal pain, N/V<br />
♦ Pain unrelieved by methadone tid <strong>and</strong> prn<br />
morphine elixir<br />
♦ Nausea unrelieved by phenergan, ativan or haldol
<strong>Case</strong> 1 (continued)<br />
♦ On exam, pt is/has:<br />
Jaundiced, lying very still<br />
Decreased bowel sounds<br />
Mildly distended abdomen<br />
Jumps off bed with light touch<br />
Unwilling to allow deep abdominal palpation
<strong>Case</strong> 1 (continued)<br />
♦ Asked patient/family to describe situation at home<br />
Identified inability of family to watch patient ATC<br />
Wife not strong enough to assist with toileting or<br />
bathing needs alone<br />
♦ Asked about care concerns<br />
Identified fear of poor pain control<br />
Patient “never wanted to be in a nursing home”, but<br />
family cannot afford hired caregiver
<strong>Case</strong> 1 (continued)<br />
♦ Placed an NGT to relieve bowel obstruction<br />
(which was very uncomfortable for patient)<br />
♦ Gave IV anti-emetics until nausea improved<br />
♦ Started on Morphine PCA with both a basal rate<br />
<strong>and</strong> bolus doses available<br />
♦ Symptoms resolved within 24 hours, <strong>and</strong> NGT<br />
successfully discontinued
<strong>Case</strong> 1 (conclusion)<br />
♦ Patient agreed to discharge to SNF hospice for<br />
24-hour nursing availability<br />
♦ Patient completed advance directives to avoid<br />
repeat hospitalization:<br />
If bowel obstruction returns, hospice to place patient<br />
on SQ morphine drip, rather than admit for NGT<br />
If nausea unresponsive to oral meds, hospice to order<br />
suppositories or IM/IV formulations
<strong>Consult</strong> <strong>Service</strong> – <strong>Case</strong> 2<br />
♦ 88-yo Japanese woman with end-stage multiinfarct<br />
dementia, living in SNF<br />
♦ Admitted with “altered mental status”<br />
♦ Second admission in two weeks (first for UTI)<br />
♦ Patient bedbound <strong>and</strong> non-verbal at baseline<br />
♦ Decreased po intake<br />
♦ Already DNR/I
<strong>Case</strong> 2 (continued)<br />
♦ Coordinated family meeting with:<br />
Doctors<br />
Family (daughter <strong>and</strong> son-in-law)<br />
Social worker
<strong>Case</strong> 2 (continued)<br />
♦ Asked family’s impression of patient’s condition<br />
<strong>and</strong> prognosis<br />
♦ Asked permission to share diagnosis, prognosis<br />
♦ Explained natural course of dementia <strong>and</strong> signs of<br />
“terminal phase”<br />
♦ Explained no proven benefit to PEG tubes for her<br />
condition
<strong>Case</strong> 2 (conclusion)<br />
♦ Offered hospice<br />
♦ Family preferred to go back to same SNF, which<br />
did not contract with hospice, but did provide<br />
<strong>Palliative</strong> <strong>Care</strong><br />
♦ PC MD spoke with family after discharge to<br />
answer questions about plan of care
Summary<br />
♦ Focus on the patient as a whole, <strong>and</strong> their family<br />
♦ Attend to any suffering (physical, psychosocial,<br />
spiritual)<br />
♦ Discuss difficult issues openly (e.g. – mortality)<br />
♦ Align care to the patient’s goals, disease <strong>and</strong><br />
prognosis
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