We will cover the topic of Palliative Care – specialized medical care for people with serious illnesses. It focuses on providing patients with relief from the symptoms and stress of a serious illness. The goal is to improve quality of life for both the patient and the family. Presented by Dr. Jean S. Kutner, MD, MSPH a tenured Professor of Medicine in the Divisions of General Internal Medicine (GIM), Geriatric Medicine, and Health Care Policy and Research at the University of Colorado School of Medicine (UC SOM)

1. Palliative Care
Research Advocacy Training and Support Program
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2. • Speaker(s): Jean S. Kutner, MD, MSPH
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3. What is a RESEARCH ADVOCATE?
A research advocate brings a patient viewpoint to
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collective patient perspective
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Support (RATS) Program:
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6. Speaker:
Dr. Kutner is a tenured Professor of Medicine in the
Divisions of General Internal Medicine (GIM), Geriatric
Medicine, and Health Care Policy and Research at the
University of Colorado School of Medicine (UC SOM).
She is Board Certified in internal medicine, geriatric
medicine and hospice and palliative medicine and
cares for patients on the palliative care service and in
general internal medicine clinic.
Her research focuses on improving symptoms and
quality of life for hospice and palliative care patients
and their family caregivers. On July 1, 2014, Dr. Kutner
became the inaugural Chief Medical Officer of
University of Colorado Hospital and Associate Dean for
Clinical Affairs, UC SOM.

7. Palliative Care
Fight Colorectal Cancer Webinar
January 29, 2016
Jean S. Kutner, MD, MSPH
Professor of Medicine, University of Colorado School of Medicine
Chief Medical Officer, University of Colorado Hospital

8. Palliative Care

9. LT’s story
• LT – 43 year old woman, previously healthy
• Worsening hip pain – thought to be a running
injury
• Diagnosed with metastatic cancer by MRI
• Confirmed as colorectal cancer
• Sources of suffering:
– Pain
– Sudden serious illness diagnosis
– Uncertain future
– Decision making about treatments

10. What is Palliative Care?
• Specialized medical care for people with serious illness and
their families
– Focused on improving quality of life as defined by patients and
families.
– Provided by an interdisciplinary team that works with patients,
families, and other healthcare professionals to provide an added layer
of support.
– Appropriate at any age, for any diagnosis, at any stage in a serious
illness, and provided together with disease treatments.
Definition from public opinion survey conducted by ACS CAN and CAPC
http://www.capc.org/tools-for-palliative-care-programs/marketing/public-opinion-
research/2011-public-opinion-research-on-palliative-care.pdf

12. Palliative Care Components
Hospice
CarePalliative Care
Advance
Directives
Improve
Communication
Pain
&
Symptom
Management
Goals of Care
Difficult Decisions

13. Palliative Care: Concurrent with
Disease-Directed Therapies
Medicare
Hospice
Benefit
Life Prolonging Care Not
this
Palliative Care
Hospice Care
Life Prolonging
Care
But
this
Dx Death
13

14. Hospice
• focus is on pain and
symptom management
• patient has a terminal
diagnosis with life
expectancy of less than six
months
• not seeking curative
treatment
Palliative Care
• focus is on pain and
symptom management
• patient does not have to be
terminal
• may still be seeking
disease-directed treatment
• is not linked to
reimbursement
Hospice vs. Palliative Care
Hospice
Palliative
Care

15. Have serious or advanced illness and:
• Bothersome or difficult to control psychological or
physical symptoms
• Desire for more information about what the
future holds, wanting to make informed decisions
• Frequent hospitalizations or ER visits
• Progressive inability to care for self
• Caregiver distress
• Long hospitalization without evidence of progress
• In ICU setting with poor prognosis
Who Might Consider Palliative Care?

17. Palliative Care: Key Components
• Multidimensional assessment
– Sources of distress
– Unmet needs
• Physical symptoms
• Psychological issues
• Social concerns
• Family difficulties
• Spiritual distress
• Treatment to improve sources of distress
– Skills in pain and symptom control
– Ability to have conversations about tough issues
• Know about referral resources and be willing to refer for additional
specialist palliative care

18. • Managing symptoms that cause suffering
• Communication
 Exploring values and patient-centered goals
 Helping patients assess risk, benefit, burdens
 Creating care plans (and back-ups) to meet
goals
Palliative Care Integrates with Disease-
focused Treatments

19. Palliative Care as a Specialty
 Medicine:
 American Board of Medical Specialities and American Osteopathic
Association Board of Specialities formally recognized Hospice and
Palliative Medicine as a new specialty in 2006 (www.abms.org)
 First board exam October 2008.
 First ACGME fellowship certification 2009
 Nursing:
 National Board for Certification of Hospice and Palliative Nurses
(www.nbchpn.org)
 Social work
 Advanced Certified Hospice and Palliative Social Worker
(www.socialworkers.org)
 Chaplaincy
 BCC-HPCC (board certified chaplain - hospice/palliative care
certified) (http://bcci.professionalchaplains.org/palliative)

20. • Clarification of care goals
• Pain and other symptom management
• Emotional, social, and spiritual support
• Coordination of care
Common Reasons for Palliative Care
Consultation

22. EXISTING EVIDENCE – BRIEF
SUMMARY

23. Palliative Care = Quality Care
Research shows that palliative care:
• Relieves pain and distressing symptoms
• Clarifies goals of care and supports decision-making
• Improves quality of life
• Increases patient and family satisfaction with care
• Eases burden on providers and caregivers
• Helps patients complete life prolonging treatments
• Enhances the value of health care
Bakitas: JAMA 2009; Gade: JPM 2008.

24. Palliative Care Improves Quality, Reduces Cost
RCT of palliative care vs. usual home care for heart failure, chronic
obstructive pulmonary disease, or cancer patients (1999–2000)
13.2
11.1
2.3
9.4
4.6
35.0
5.3
0.9
2.4
0.9
0
10
20
30
40
Home health
visits
Physician
office visits
ER visits Hospital days SNF days
Usual Medicare home care Palliative care intervention
Brumley, R.D. et al. JAGS 2007

25. Concurrent palliative care
Randomized trial: simultaneous standard cancer care with
palliative care co-management from diagnosis vs standard cancer
care only (non small cell lung cancer):
– Improved quality of life
– Reduced major depression
– Reduced ‘aggressiveness’ (less chemo < 14d before death,
more likely to get hospice, less likely to be hospitalized in
last month)
– Improved survival (11.6 mos. vs. 8.9 mos., p<0.02)
Temel et al. Early palliative care for
patients with non-small-cell lung cancer
NEJM. 2010;363:733-42

26. Temel et al. Early palliative care for patients with non-
small-cell lung cancer NEJM2010;363:733-42.

28. Kaplan-Meier estimates of 1-year survival by treatment group.
Marie A. Bakitas et al. JCO doi:10.1200/JCO.2014.58.6362
©2015 by American Society of Clinical Oncology

29. Benefits of Outpatient Palliative Care
Four well-designed randomized interventions as well as a growing body of
nonrandomized studies indicate that outpatient palliative care services can:
1) improve patient satisfaction
2) improve symptom control and quality of life
3) reduce health care utilization, and
4) lengthen survival in a population of lung cancer patients.

30. Morrison, R. S. et al. Arch Intern Med 2008;168:1783-1790.
Mean direct costs per day for palliative care patients who were
discharged alive (A) or died (B) before and after palliative care consultation
Died:
Adjusted net
savings =
$4908 direct
costs/
admission;
$374 direct
costs/day
Discharged
alive:
Adjusted net
savings =
$1696 direct
costs/
admission;
$279 direct
costs/day

32. Consultation within 6 days reduced costs by -$1,312 (95% CI, -$2,568 to -$56; P .04) = 14%
reduction in cost of hospital stay.
Consultation within 2 days reduced costs by -$2,280 (95% CI, -$3,438 to -$1,122; P .001) =
24% reduction in cost of hospital stay.

33. Palliative Care Improves Value
Quality improves
– Symptoms
– Quality of life
– Length of life
– Family satisfaction
– Family bereavement
outcomes
– MD satisfaction
Costs reduced
– Hospital cost/day
– Use of hospital, ICU,
ED
– 30 day readmissions
– Hospitality mortality
– Labs, imaging,
pharmaceuticals

34. RECOMMENDATIONS AND
GUIDELINES

35. Palliative care is
essential to
quality
8 Relevant IOM
Reports:

36. IOM Report: Delivering High-Quality
Cancer Care
To read the report online:
www.iom.edu/qualitycancercare

37. Cancer Care Continuum

38. IOM Report:
“Dying in America”
iom.edu/endoflife
Released 9/17/14

39. Key Areas for Findings and
Recommendations
• Delivery of person-centered, family-oriented care
• Clinician-patient communication and advance
care planning
• Professional education and development
• Policies and payment systems
• Public education and engagement

40. American Society of Clinical Oncology
(ASCO)

42. STANDARD 2.4 Palliative Care Services Palliative
care services are available to patients either on-site
or by referral.

43. COMMUNICATION IN THE SETTING
OF SERIOUS ILLNESS

44. https://www.ariadnelabs.org/wp-content/uploads/sites/2/2015/12/Serious-Illness-
Conversation-Guide-10.30.15.pdf

47. AVAILABILITY OF PALLIATIVE CARE
IN US

48. Hospital Setting:
• Palliative care consultation
• Palliative care unit
• In-hospital hospice beds
Community-based Setting:
• Home-based palliative care
• Clinic-based palliative care
• Nursing home-based palliative care
• Hospice (at home, dedicated facility, nursing home,
assisted living)
Where Can I Get Palliative Care?

49. State-by-State Rating (2015)
Center to Advance Palliative Care (https://reportcard.capc.org/)

50. 2015 Report Card On Access To Palliative Care At US
Hospitals
Center to Advance Palliative Care (https://reportcard.capc.org/)
2008 2011 2015
A
B
C
D

51. Access differs by hospital characteristics
►100% of the U.S. News 2014 – 2015 Honor Roll Hospitals Have a
Palliative Care Team
►100% of the U.S. News 2014 – 2015 Honor Roll Children’s
Hospitals Have Palliative Care Teams
Center to Advance Palliative Care (https://reportcard.capc.org/)

52. Where Can I Get More Information?

54. Treating the person beyond the disease.

55. www.ariadnelabs.org

57. getpalliativecare.org

59. LT’s story
• Began seeing palliative care before oncologist
• Over course of the next 11 months, LT cared for by both palliative
care and oncologist
– Palliative care: symptoms, support, decision making
– Oncology: CRC treatment
• Partnership between palliative care and oncology allowed LT to
participate in first, second and third line treatments
• Palliative care supported LT and her family in her final weeks when
she decided that the burdens of cancer treatment were
outweighing the potential benefits
– Allowed her to achieve important goals and spend meaningful time
with her family

60. “A life ended with much
unfinished business
or uncontrolled
suffering has not
been met with due
respect, and does not
leave good
memories.”
Dame Cecily Saunders

61. QUESTIONS AND DISCUSSION

62. Question & Answer:
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