Med-Learning on the Go: May 2015

AAHPM 2015

Saturday 2/28

ACTION ITEMS

✔️Redefine roles:

MD: symptom assessment

RN: care coordination; follow up all team recommendations; expressive writing and patient needs assessment; educate & empower other RNs

SW: ACP, social services

SC: emotional, spiritual, psychosocial needs

✔️heart failure clinic ACP

How to help patients make valuebased medical decisions: Promoting adaptive coping and prognostic awareness

Prognostic awareness is the patient's capacity to understand the likely disease trajectory and prognosis. With deeper prognostic awareness patients can

–Weigh burdens and benefits of treatment

–Have more meaningful discussions of their goals and values

–Match treatment decisions to goals and values

When goals and values are informed by low prognostic awareness, patients make unrealistic treatment decisions

Patients express varying degrees of prognostic awareness by swinging between hope and realism

The cultivation of prognostic awareness is a process that happens over time

Palliative care helps temper the fear of dying by embracing the joy of living

- our job is to help patients simultaneously acknowledge both realities and manage the ambivalence

- to help patients more easily acknowledge both realities

- When patients can acknowledge both realities, they can better incorporate them into more informed decision making

Cultivating prognostic awareness

Skills for well times

1. Assess prognostic awareness

•"What is your understanding about what to expect with your cancer?"

•"What discussions have you had about the big picture with your care team or your family?"

•"What are you hoping for?"

•"What are you most worried about?"

2. Create a framework to focus on living and tolerate the possibility of dying

A. Focus on living

- Manage symptoms; improve QOL

- Develop rapport & trust - makes it easier to have harder conversations

i. Identify and encourage diverse coping behaviors

- Elicit and reinforce behaviors that the patient is already using

- Identify areas where the patient may benefit from a new strategy

ii. Respond to and build positive emotions

–"Are there still moments of happiness and joy even when you are going through such a tough time? Can you tell me about them?"

–"What are you hoping for?"

iii. Help with practical problem solving

B. Tolerate the possibility of dying

i. Milligram strength words

- Help patient to tolerate the possibility of dying by recognizing that words have different milligram strengths

ii. The box

- The "box" metaphor can help powerful emotions feel more manageable when discussing difficult topics

iii. Explore what the patient wants to know

- Patient's ambivalence about deepened prognostic awareness is evident in changing information preferences. We need to keep asking what a patient wants to know repeatedly. It changes.

iv. Hypothetical questions

Cachexia in Post-Hospital Care Focus on Heart Failure

james_judge@optum.com

Cachexia

• a complex metabolic syndrome associated with underlying illness and characterized by loss of muscle with or without loss of fat mass.

• The prominent clinical feature of cachexia is weight loss in adults (corrected for fluid retention)

• Anorexia, inflammation, insulin resistance and increased muscle protein breakdown are frequently associated with cachexia.

• Cachexia is distinct from starvation, age-related loss of muscle mass, primary depression, malabsorption and hyperthyroidism and is associated with increased morbidity".

Dying in America: what is the hospice and palliative care community's role in implementation?

End of life decisions should not be made at end of life.

Beatease.org

Www.iom.com/endoflife for report

Resolutioncare.com

The Polypharmacy Police vs. The Patient Advocate: An Evidence‐Based, Patient‐Tailored Approach to Medication Simplification Strategies for the Palliative Care Patient

⚫️Key Polypharmacy References

•Scott IA, Gray LC, Martin JH, PillansPI, Mitchell CA. Deciding when to stop: towards evidence‐based deprescribingof drugs in older populations. Evidence Based Medicine 2012:ebmed‐2012‐100930.

•Hanlon JT, SchmaderKE, SamsaGP, et al. A method for assessing drug therapy appropriateness. Journal of clinical epidemiology 1992;45:1045‐51.

- Hardy. J Pharm Pract Research 2011.

⚫️Deprescribing

• Process of tapering, withdrawing or stopping medications to reduce polypharmacy, adverse drug effects and inappropriate or ineffective medication use by re‐evaluating the ongoing reasons for, and effectiveness of medications

- Engage the original prescribers of the medications to assure patient / loved ones to ensure coordination amongst providers and build trust.

⚫️Systematic Review of Dementia Practice Guidelines

• Vascular dementia

–Only one guideline recommends cholinesterase inhibitors (CI) (donepezil);

- other guidelines discourage use.

- Conflicting recommendations for memantine.

• Dementia with Lewy Bodies

–CI recommended; rivastigmine agent of choice

–No recommendation for memantine

• Frontotemporal dementia

–CI considered harmful;

- memantine not recommended

[Ngo, Age and Ageing 2015]

Bottom Line: Dementia Drugs

• Dementia medications are LESS HELPFUL and MORE HARMFUL in advanced disease (see adverse effects)

• NOT indicated or provided with FAST 7 without clear and ongoing benefit in managing identifiable and distressing behaviors.

• MAY be covered with FAST 6; discuss goals/outcomes with hospice physician or pharmacist

• 2 week tapering supply should be provided if medication discontinued

⚫️Antibiotics for Palliation of Symptoms

- Antimicrobials improved symptoms in a majority of patients with urinary tract infections, but less successful for infections of the respiratory tract, mouth/pharynx, skin/subcutaneous tissue, or blood Reinbolt ,

[JPSM 2005]

⚫️Warfarin vs ASA in AF for stroke prevention

Cochrane Review 2011

• 8 randomized trials, n=9,598, 1.9 year followup

• All stroke risk less in warfarin group by 30%, but higher incidence of intracranial hemorrhage

• ASA reduced risk by 20% versus no therapy

• All cause mortality the same

- use 325 mg

State of the Science: Update in Hospice & Palliative Care

Key Issues to Be Considered

Is the question important?

What are the results?

Are the results valid?

Can I apply the results to my patients?

Neurolytic sympathectomy in the management of cancer pain-time effect: a prospective, randomized multicenter study

AmrYM, MakharitaMY J Pain Symptom Manage. 2014 Nov;48(5):944-956

✔️Early use of neurolyticblocks leads to 5-9 months of better pain control, less opioid consumption, and better quality of life for patients with abdominal and pelvic cancers.

Randomized controlled trial of expressive writing for patients with renal cell carcinoma

MilburyK, Spelman A, Wood C, MatinS F, TannirN, JonaschE, PistersL, Wei Q, Cohen L J ClinOncol. 2014 Mar 1;32(7):663-70

✔️Renal cancer patients who wrote about their deepest concerns had fewer symptoms and improved function at 10 months. Symptom reduction was partially explained by improved short-term cognitive processing.

Safety of benzodiazepines and opioids in very severe respiratory disease: national prospective study

EkströmM, Bornefalk-HermanssonA, Abernethy A, CurrowD BMJ. 2014 Jan;348:g445

✔️Opioids in lower doses (≤30 mg oral morphine equivalents/day) are not associated with increased hospital admissions or deaths in patients receiving long term oxygen therapy for COPD, whereas benzodiazepines and opioids in higher doses might increase mortality. Lower dose opioids might be safe for reduction of symptoms in those with severe respiratory disease.

An integrated palliative and respiratory care service for patients with advanced disease and refractory breathlessness: a randomized controlled trial

Higginson I, BauseweinC, Reilly C, Gao W, GyselsM, Dzingina, M, McCroneP, Booth S, Jolley C, MoxhamJ Lancet. 2014 December; 2: 979-87

✔️Compared to usual care, a multi-professional breathlessness support service demonstrated higher breathlessness mastery at 6 weeks and better overall survival without affecting overall costs for patients with refractory breathlessness. There were no differences in severity of breathlessness on exertion in prev. 24 hrs., activity, other measures of respiratory function, QOL, palliative needs, depression, anxiety, and spirometry.

Inpatient palliative care for patients with acute heart failure: outcomes from a randomized trial

Sidebottom AC, Jorgenson A, Richards H, KirvenJ, SillahA J PalliatMed. 2015 Feb;18(2):134-142

✔️In patients with heart failure, inpatient palliative care consultation + standard care versus standard care alone is associated with short-term improvement in measures of symptom burden, quality of life and depression.

Intervention to improve care at life's end in inpatient settings: the BEACON Trial

Bailey FA, Williams BR, WoodbyLL, Goode PS, Redden DT, Houston TK, GranstaffUS, Johnson TM, PennypackerLC, Haddock KS, Painter JM, Spencer JM, HartneyT, BurgioKL J Gen Intern Med. 2014 Jun;29(6);836-43

✔️A multi-modal intervention improved some care processes for patients dying in inpatients settings, including medications ordered for symptom management, sublingual administration of medications, and documentation of advance directives.

Association of experience with illness and end-of-life care with advance care planning in older adults

AmjadH, TowleV, Fried T C J Am GeriatrSoc. 2014 Jul;62(7):1304-1309

✔️Older adults with experience with endof-life care of others report greater readiness to participate in advance care planning than those without such experiences.

Friday 2/27

55 Words

⚫️Anne Scheetz, MD, Mary Fry MD. The stories. JAMA 2000;283:1934.

⚫️Colleen Fogarty, MD, Nancy Gross, MA, Donald McLaren, MD. 55-Word Stories: Small Jewels for Staying Soulful. AAHPM Quarterly; Spring, 2011.

⚫️Marchand, Fleming, Mastrocola, Gasper, Marty. AAHPM Quarterly. 2014; 15: 7.

Atul Gawande

Serious illness conversation guide

- serious illness communication trial

Thursday 2/25

TH330 Developing Accountable Payment Models: Key Issues for Hospice and Palliative Care

Description: Can healthcare spending be reduced without harming patients or providers? Must physician practices and hospice programs merge into large health systems in order to deliver "accountable care?" Harold Miller, a nationally recognized expert on payment and delivery reform, will explain why most current efforts at payment reform, such as shared savings, value-based purchasing, and procedural bundles, do little to overcome the problems in the current payment system and can actually make things worse. Miller will describe how properly-designed payment models can enable providers to remain financially healthy while both improving care for patients and reducing spending for purchasers – a win-win-win. He will also discuss how hospice and palliative care providers can help to design Accountable Care Organizations from the bottom up, rather than the top down approach being used in most communities today.

Learning Objectives:
1.) Understand the weaknesses in "value based purchasing" and other current approaches to payment reform
2.) Learn how properly designed accountable payment models can reduce spending for Medicare and other payers without harming patients and without financially harming physician practices, hospices, hospitals, or other care providers
3.) Understand how hospice and palliative care providers can encourage implementation of better payment systems and position themselves to succeed in the future

Www.chqpr.org

Www.paymentreform.org

Building a Successful Interdisciplinary Team- Learning to Love Conflict

1. Competing: my way or the highway

2. Collaborative: 2 heads are better than one

3. Compromising: split the difference; seek middle ground

4. Avoiding: leave well enough alone

5. Accommodating: Unassertive & uncooperative

Individual & Team Expectations

Goals of dialogue:

- learn

- find truth