Palliative Care in Kingston and the SE LHIN

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Palliative Care in Kingston and the SE LHIN

• Dr. Natalie Kondor
• DFM Grand Rounds
• Jan 20 2015

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Outline

• What is palliative care?
• Why is palliative care important?
• Trends in palliative care provision
• Regional and local resources for palliative care
  provision
• FAQs

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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 grief
• Treat active issues and manage symptoms
• Prevent new issues from occurring
• Promote opportunities for meaningful and valuable
  experiences

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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

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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

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Palliative Care Not Just End of Life Care
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The Need for Palliative CareESAS symptom profile
for cancer patients
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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
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Benefits of Earlier and Integrated Palliative
Care - Improved Survival

• Longer and better survival
• Better understanding of prognosis
• Less IV chemo in last 60 days
• Less aggressive end of life care
• More 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
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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)
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(No Transcript)
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Building capacity for palliative care

• A palliative approach to care should be practiced
  by all providers caring for people with
  life-threatening illnesses
• Primary, Secondary and Tertiary care settings
• Community settings
• Not a one size fits all approach, but key
  common elements
• Person-centred care
• Inter-professional team
• Single access point
• 24/7 care to ensure continuity coordination
• Building community capacity

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Regional Implementation Results in Alberta

• Edmonton Calgary 1993 to 2000

• 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.
200519-513-520
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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
• Reduced acute care use
• Reduced hospital deaths at the end of life

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Whats 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
• 10 reduction in one or more of the following
  areas
• Overall palliative-related ALC days
• Inpatient days per capita among patients that
  died in hospital
• Palliative-related avoidable hospitalizations
  (repeat ER visits/readmissions)
• Implementing regional HPC programs
• Work underway to develop palliative care
  indicators

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Palliative Care In Our Region - SE LHIN Regional
Priorities

• Strengthen 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

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Palliative Care in Our Region - Resources

• Inpatient Consult Services
• Community 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

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Community Palliative Care Services

• For patients with PPS lt 50
• FamMD makes CCAC referral
• FamMD /- colleague follows patient at home and
  provides 24/7 call coverage
• FamMD 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

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Palliative Care Unit at SMOL

• 13 beds 10 private and 3 semi-private rooms
• All 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 months
• If survive longer, may get transferred to LTC

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Palliative Care Clinic at KRCC

• Referrals from specialists (often oncologists),
  Family MD
• For symptom management for ambulatory patients
  (PPS /gt50)
• For cancer-related symptoms or symptoms related
  to cancer therapy
• Patient continues to receive primary care from
  Family MD
• Palliative MD is generally 1st contact regarding
  symptom management issues

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Hospice Palliative Care Nurse Practitioners
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• Some FAQs

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What is a PPS and why is it important?
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Do I have to have CCAC involved to care for my
patient at home?

• Yes the short answer
• Why
• 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

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Do I have to have CCAC involved to care for my
patient at home?

• How to get CCAC support
• Fill in a CCAC Service Requisition
• Can simply write please see for palliative
  symptom assessment and management and the ball
  will start rolling

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How many hours of CCAC PSW and nursing support
can my patient receive?

• Not 24/7 bedside care!
• CCACs End-of-Life Program
• PPS less than 30
• Life expectancy/need for 30 days or less
• PSW - Up to 360 hrs allotted for 30 days or 12
  hrs per day
• Nursing visits as often as needed up to 4 times
  per day
• Option of hiring PSW support and nursing
  privately but lack of manpower and expensive
• 60-80/hr for nurse
• 30-40/hr for PSW

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Compassionate Care Benefits

• Family member at risk of dying within 26 weeks
• Doctor completes application form
• EI program
• Benefits 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.

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Compassionate Care Benefits
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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 Queens 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)

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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
  patients 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

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What is a Symptom Response Kit and how do I order
one?
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What is a Symptom Response Kit and how do I order
one?
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Palliative Care Facilitated Access List
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Can Bloodwork be done at home?

• Yes, but not urgent b/w
• Order on LifeLabs req and write HOME VISIT in the
  additional clinical information area
• LifeLabs will come to patients home usually
  within the next week may be as soon as next
  day depending on geography
• Results available day after b/w is done
• Costs the patient approximately 35 per visit
• Occassionally home care nurse can do b/w with an
  order but only if b/w obtained via a PICC
  (generally dont do peripheral venipuncture
  anymore) and if b/w taken immediately to lifelabs
  by nurse or family member

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Can my patient receive IVF or blood transfusions
at home?

• Patients can receive fluid hydration at home
  set up by the nurses through CCAC
• Requires faxed order to CCAC
• NS 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
  administration
• Hypodermoclysis fluids run sc through a sc set
  by gravity, generally overnight/over 8 hours
• Blood transfusions cannot be done at home, can be
  done through ER or KRCC as outpatient (with
  pre-orders)

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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 Rx
• Contains DNR confirmation form

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What is a DNR Confirmation Form and does my DNR
patient need one?
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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 NPs 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)

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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