Service Delivery Flashcards
1
Q
Areas of focus for improved delivery of palliative care
A
As per the WHO:
- Improved drug availability
- Education
- Policy development
- Quality of care
- Research
2
Q
Social barriers to access to palliative care
A
- Not defined as a human right, and is rather a principle available to the few
- Global barriers
- Just 15% of countries have an integrated palliative care service
- Not yet defined as a human right - Economic barriers
- Access to basic healthcare is a barrier for many
- Aging population, rising costs, increasing global demand on healthcare services due to chronicity
- PC may not be a funding priority - Drug availability
- Access to opioids may be limited by legal methods
- Drug cost can be an issue
- Providers may be reluctant to prescribe opioids - Ethnicity
- Uptake of palliative care services by patients in ethnic minorities is less
- Services may struggle to deliver culturally appropriate care
- Patients may lack understanding of the role of hospices
- Communication barriers - Elderly
- Many elderly patients in LTC do not have access to palliative care
- Barriers include delivery system barriers, financial issues, and regulatory factors
- Link nurses in LTC may be helpful - Homelessness
- Difficulty in providing reliable care
- Chronic health problems, increased incidence of trauma
- Illicit drug use and lack of trust - Community barriers
- Community HCPs play a significant role, but many are unwilling or unable to provide home visits
- Advanced care planning may not occur for a variety of reasons, including time management, prognostic uncertainty, limited collaboration with secondary care - Incarceration
- Prison population is also aging, and an increasing number will die in prison
- Social determinants may play a significant issue
- Social supports for optimal care often unavailable
3
Q
Professional barriers to palliative care
A
- Attitudes
- ‘Learned helplessness’ amongst oncologists where there is ineffective medication to manage symptoms
- Reluctance to refer
- Fear of palliative care resulting in a patient no longer engaging in life prolonging treatment - Knowledge
- Education regarding symptom management, role confusion, and whether PC is appropriate for non-malignant disease
4
Q
Barriers to palliative care in key disease groups
A
- Cardiac
- Underused, despite evidence supporting its importance in symptom management
- Prognostic uncertainty - Respiratory
- Lack of evidence and guidelines, yet patients have significant symptoms
- Reluctance to negotiate EOL decisions in patients and families - HIV/AIDS
- Prognostication is difficult
- Communication may be challenging, especially in terms of the rapport needed to discuss EOL
- Stigma towards LGBTQ+ status or substance abuse - Renal failure
- Prognostic difficulties
- Infrequent palliative care input to dialysis patient, despite clear needs
5
Q
Main disease groups identified as needing/being eligible for palliative care in Canada (CSPCP)
A
- Advanced cancers
- End stage organ failure (heart, lung, kidney, liver)
- Neurodegen diseases (ALS, Huntington’s, AD, MS)
6
Q
Model of palliative care (pyramid model) according to need
A
- Community supports (base)
- Social aspects of care not provided by the healthcare system
- E.g. financial support through compassionate leave/EI, bereavement support through volunteer groups and society, family care - Primary Palliative Approach to Care
- Patients who will require care within the scope of primary care (provided by non-palliative care specialists, GPs, nurses, etc.) with appropriate training and support - Specialist Palliative Care
- Care for those with needs not met by PCP and non-palliative care specialists
- Provided by either enhanced primary palliative care (e.g. non-specialists with additional training in palliative care) or a palliative care specialist physician (less available and must be allowed time and resources to train and support colleagues in other disciplines to develop capacity) - (side of the pyramid): Patients who would not be eligible for palliative care (e.g. sudden death) - will never require even primary palliative approach to care, but their family will require community supports (#1) through the bereavement process
7
Q
Components of a specialist palliative care service
A
- Direct care to complex patients and families
- Provide education and support to generalists
- Untertake or collaborate in research to improve care of patients and families in the future
8
Q
Joint models of palliative care provision
A
- Relatively new models
1. Early integrated palliative care with oncology (at the time of diagnosis)
2. Breathlessness clinic with palliative and COPD
Previously, palliative care only begin once curative treatment stopped, whereas now palliative care overlaps with curative treatment, with palliative care being a large component over time
9
Q
Definition of Palliative Care Unit
A
- Department specialised in the treatment and care of palliative care patients
- May be standalone (eg. inpatient hospice) or part of a hospital.
Goal:
- Alleviate disease and therapy-related discomfort
- Stabilize patient status
- Provide patient and carers psychological and social support in such a way that may allow for discharge or transfer to another care setting
10
Q
Palliative Care Hospital Consultation Teams
A
- Provide specialist palliative care advance and support to other clinical staff, patients, families, and carers in the hospital environment
- Part of job is formal and informal education and liaison with other services
- Core aim is symptom management
11
Q
Palliative Care Home Care Consultation Teams
A
- Provide specialist palliative care in the home
- Support families
- Provide specialist advice to family docs, nurses, others providing home care
- May either take over from GP or advise GP
- Increases odds of dying at home (doubles)
12
Q
Palliative Care outpatient services
A
- Clinics where patients can receive PC consultation
- May be offered jointly with oncology/resp/neuro etc.
- Meet the need to integrate services and may introduce patients to PC earlier, in a non-threatening way
13
Q
Palliative Care Day care
A
- Day hospices
- Designed to provide additional support to patients in the community and their families
- Typically patients are only eligible if they are already under the care of the home palliative care team at that centre
14
Q
Short term-integrated palliative care
A
- In general, PC has seen patients and ‘kept’ them until they died (even if not as an inpatient)
- Given earlier integration of PC and longer trajectories of some disease, allows a service to see a patient and assess, provide recommendations, then discharge back to other service
15
Q
Professionals involved in a Palliative Care Team
A
- Specialist PC physician
- RNs
- Social workers
- Pharmacists
- PT
- OT
- Psychology
- Chaplain
16
Q
Assessment in the Emergency Department: Framework
A
ABCD (Advanced Directive, Better Symptom Control, Caregivers, Decision-making capacity)
Advance Directive
Better symptom control
- Attend to sx, avoid invasive directions in near time to allow time to evaluate whether appropriate or not
Caregivers
- provide reassurance to patient
- Contextualise patient goals, recent functional/medical changes to ground discussion and ensure reasonableness when discussing decisions
Decision-making capacity
- Assess patient’s ability to reliably participate in dialogue about medical goals/interventions
17
Q
Discussion of goals of care in the Emergency Department
A
Seven step process:
- Getting started
- Acquire sufficient info and limit environmental distractions
- “We want to provide the best care possible and we need to determine which investigations/interventions are most beneficial” - Assess what is known
- Ensure patient and family have similar understanding of disease and prognosis - What is expected/hoped for?
- Ask what the patient has ever mentioned about others who have died or been critically ill. What care did they find acceptable/unacceptable? What is important to the patient (suffering, etc.?)
- Ask, “Under X circumstances, what would be acceptable for you?” - Suggest goals
- “People with only weeks to months to live often focus on avoiding the risk of dying in an ICU . . .” - Make a recommendation
- Confirm understanding
- Summarize available options to support the patient’s goals, assure understanding and agreement - Plan
- Initial focus may be symptom management
- Other needs may be addressed by interdisciplinary team members
- if life-sustaining critical care is initiated, there should be a timeframe and condition for future discussion (e.g. trial of 24 hrs of antibiotics etc.)
18
Q
Disclosure of death in the ED
A
- Attend to survivors in the ED
- Staff should receive them on arrival, ensure they are provided with a private room with all staff present to give all relevant information
- Ensure all people are identified, state the full name of the patient and all involved staff - Disclosure
- Open with a flag of “bad news” and give details around immediate circumstances (e.g. “bad news . . . X was in a serious accident”)
- Use the word “dead” or “died” to ensure there is no confusion - Reaction tolerance
- Allow time, presence, and empathy for emotional responses
- Acknowledge, legitimize, empathise with response - Information
- Provide information around circumstances
- Reassure (if possible) about lack of suffering and reinforce interventions used to control pain and suffering prior to death
- Allow family to view body if desired - Closure
- Offer condolences and leave contact information
- If a child, consider offering a lock of hair, etc., to take with them
19
Q
Family presence during resuscitation
A
- Family presence can be encouraged if possible (in limited numbers)
- Ensure there is an identified ‘family support person’ on the resus team to provide information and support
In anticipation of calling it:
- Summarize “Mr. Jones’ heart has stopped beating and he is not responding to therapy thusfar. We have a secure airway, effective CPR etc. etc.”
- Ask for any recommendations from other team members (establishes team concordance, ensures all reasonable medical efforts have been performed and witnessed by the family”
- Indicate to the family that despite all efforts, patient is not responding and invite any other family members to come into the room. Be clear that resuscitation efforts are stopping.
- Confirmation of death and provide quiet space to grieve, remove medical equipment.
20
Q
Cost effectiveness of palliative care
A
- Palliative care results in lower in-hospital or total costs
21
Q
Cost minimization
A
- Decisions and availability of treatment is based upon both clinical outcomes and cost - if two strategies are equal, the lower cost strategy is employed (requires study of a direct comparison)
22
Q
Types of Cost studies
A
- Clinical outcomes alone
- Ignores cost, simply looks at health outcomes - Cost alone
- Ignores cost (rarely used to make decisions unless medical outcomes are already known to be similar) - Cost and clinical outcomes together
- Cost minimization
- Cost effectiveness
- Cost utility
- Cost-benefit
23
Q
Cost Minimization Studies
A
- Combines clinical outcomes with cost by comparing to equally clinically effective strategies, then assesses for lower total cost
- E.g. Methadone equal to SR morphine in pain control, choice depends on cost.
Disadvantages
- Requires direct comparison of drugs or technologies
- May put too much emphasis on immediate treatment cost, rather than long term cost (e.g. may culminate in hospitalization for ineffective rx over time)
Example:
- Palliative and supportive care. Survival is equal, care is at least as good, but cost of palliative care is lower
24
Q
Cost Effectiveness studies
A
Cost Effectiveness
- Compares Years of additional life gained and cost, then assigns a cost per additional year of life saved by the best strategy.
E.g. adjuvant chemo adds 5.1 months of additional life, at a cost of $15000 per year.
Diasadvantage:
- Implies a limit to resources and that there should be a cap on the cost effectiveness ratio
- Equates a single week of added life for 52 people to one full year of added life for an individual
- Assumes all people share the same values (different groups have different interests)
25
Cost Utility Analysis
- Quality of life is converted to a utility ratio
- 0 = death, 1 = full health
- Converts cost-effectiveness into cost per quality adjusted live year (QALY)
Example
- Intervention that costs 100 000 per year of life gained would be converted to $50 000 per QALY if the treatment doubled utility score from 0.5 to 1.0
Disadvantages:
- Controversy in how and who should assign utility ratios to various states of health (HCPs, patients, etc.)
- Difficult to use in PC, as PC interventions usually do not change overall utility/quality of life values
26
Cost-benefit analysis
- Compares two interventions, then assigns a monetary value to the added clinical benefit based on the overall economic productivity of an individual
Example:
- A treatment costs $50k to prolong life by one year. Acceptable if that cost is offset by the individual having 50K of economic worth that year
Disadvantages
- Not very relevant in medicine, as it assigns a monetary value to life that is very dependent on SES
- Most palliative interventions do not allow patients to produce income
27
Cost avoidance analysis
- Measures the costs saved by not doing a procedure or moving to a less expensive intervention
- Commonly used as an economic argument for palliative care
Example
- Moving from ICU bed to hospice bed saves $2500 per day
Disadvantages
- Requires patient level cost accounting
28
Opportunity cost in healthcare
- Additional revenue that could have been gained if money had been used in a different way
- E.g. ICU bed filled by someone else who is not improving, may force hospital into diversion, which may be costly (less money made in profit)
- More relevant in for-profit medicine
29
Mortality in hospital
- Concerns that palliative care may increase patient death in hospital and worsen hospital mortality statistics
- Not borne out by data or very relevant in Canada
30
Clinical effectiveness of palliative Care
- Demonstrated repeatedly in literature
| - Concurrent palliative care alongside usual oncology care for all seriously ill cancer patients now recommended by ASCO
31
Impact of Hospice and PC on cost of care
- Hospice care saves money, and the longer hospice is used, the more money is saved
- Occurs in conjunction with improved clinical care
32
LTC - operational background
- Developed separately to palliative care, despite importance of palliative care to many of the patients cared for
- Many function as private businesses and are an 'industry' rather than service
- Patient ratios, unregulated carers, inappropriate transfers to acute care, and conditions can be an issue
- Physician oversight may be through a visiting GP model (may be a new GP to the patient) or doctors employed directly by LTC
33
Interventions to enhance palliative care in LTC
1. Communication, with a focus on identifying patients who would benefit from a specialist palliative care referral and individualised care plans
- May require consultation with other specialists (e.g. geri psych) and case conferences to ensure coordination of all relevant providers
- Appropriate care planning to ensure inappropriate transfers to acute care or other burdensome treatments do not occur
2. Development of palliative care leadership teams with support and education for all staff
- Support timely recognition of dying
3. Targeted symptom control strategies to enhance care
- High symptom burden in LTC population, especially in patients with dementia, depression, and pain
- Those with non-malignant disease are at risk of inadequate symptom control
34
Patient-provider relationship dimensions that shape person-centered care
1. Biopsychosocial perspective (consider interaction of all three as contributing to health)
2. Resident as person
3. Sharing power and responsibility
4. Therapeutic alliance
5. Physician as person
35
Difference between patient centered and person centered care
Patient centered care
- May be episode of care oriented
- Generally centers around management of disease
- Concerned primarily with the evolution of patients' diseases
Person centered care
- Focusses on interrelationships over time and episodes of illness over the lifespan
- Views diseases as interrelated phenomena
- Concerned with the evolution of the experience of health problems, not just the disease itself
36
World Health Organization Chronic Care Model, as applied to palliative care in LTC
1. Domain: Positive Policy Environment to strengthen delivery of a palliative approach in LTC
- Strengthen partnerships (ie. with specialist services)
- Support legislative frameworks to ensure minimum ratios and standards to funding and accreditation
- Integrate policies to align nursing and PC standards, promote advanced care planning
- Provide leadership and advocacy
- Promote consistent finances
- Develop and allocate HHR
2. Domain: Community to enhance palliative approach in LTC
- Raise awareness and reduce stigma (e.g. ageism, value for care in LTC)
- Encourage better outcomes through leadership and support (promote a palliative approach in the community, provide CPD)
- Mobilize and coordinate resources (advance care planning clinics, pre-LTC admission clinics)
- Provide complementary service (embed PC volunteers in LTC)
3. Domain: Health care organization
- Promote continuity and coordination (person-centered care, access to palliative care teams and specialist input PRN, multi-disciplinary case conferencing)
- Encourage quality through leadership and incentives, building workforce capacity
- Use information systems to enhance care through use of EBM and guidelines, EMRs, and symptom assessment tools
- Support self management and prevention (ensure residents and families are engaged in advanced care planning)
37
Components of the WHO Chronic Care Model
1. Positive Policy environment
- partnerships
- funding/financing
- policies
- HHR
2. Community
- raise awareness and reduce stigma
- Leadership and support to encourage better outcomes and awareness
- mobilise and coordinate resources
- provide complementary services (e.g. volunteers, etc.)
3. Healthcare Organization
- Promote continuity and coordination
- Encourage quality through leadership and incentives
- Organise and equp care teams
- Use IT
- Support self-management and prevention
All linked together to ensure that policy supports community partners in being informed, HCPs are motivated, and patients and families experience better outcomes for chronic conditions
