Improving End-of-life Care in the Emergency Department

Improving End-of-Life Care in the Emergency Department

Michael A. Gisondi, MD Associate Professor and Program DirectorMedical Education Fellowship DirectorDirector, Feinberg Academy of Medical EducatorsNorthwestern University Feinberg School of Medicine

Presented to:Palmetto Richland Emergency Medicine ResidencyUniversity of South Carolina School of MedicineAugust 2016

In a 1996 Gallup survey,

over 90% of respondents

expressed a desire to die at home.

Instead, 80% of patients die

in hospitals or institutions.

Over 200,000 Americans die

in emergency departments

each year.

Can we meet patient preferences

at the time of death?

Objectives

Define ‘Primary Palliative Care’

Describe The EPEC-EM™ Project

Identify opportunities and strategies for

palliative care education and research in the

field of emergency medicine

6

Disclosures

(1) NIH Co-Investigator

“Palliative Care for Cancer Patients in

Emergency Wards” – 2007-2011

NCI - 1R25CA116472-01A1 (PI= Emanuel)

$1,298,000

(2) Faculty, The EPEC-EM™ Project

7

What is Palliative Care?

World Health Organization

“…the active total care of patients whose

disease is not responsive to curative

treatment.”

“Control of pain.. and of psychological, social

and spiritual problems is paramount.”

“The goal of palliative care is the achievement

of the best possible quality of life for patients

and their families.”9

What is Palliative Care?

Palliative care actively addresses the physical,

spiritual, psychological, therapeutic, and social

needs of patients and families affected by

terminal illness, from the time of diagnosis of

a terminal illness to death, as well as

bereavement services for survivors.

10

Palliative Care Mandates

Prevent and relieve suffering

Affirm the dignity of the living

Do not hasten or postpone death

Offer a support system

Utilize multi-disciplinary approach

11

Team Goals

Pain and symptom management

Information sharing

Advanced care planning

Psychosocial support

Coordination of access to care

Bereavement counseling

12

Active Comfort Care

Both patient and family centered

Improves the quality of life

Regards dying as a normal process

13

Patient Expectations

Patients and families expect that their

physician is competent in facilitating the dying

process

Until recently, end-of-life care was absent from

medical school and residency curricula

14

Death = Failure?

Many emergency providers see death as a failure

We are often uncomfortable with loss

We were not trained in the expected

pathophysiology of normal dying

15

Care Comes Too Late

We recognize dying very late

The average length of hospice care is 15 days

16

When should “End-of-Life”

care begin?

17

Palliative Care

Medicare

Hospice

Benefit

Disease Progression

Life Prolonging Care

Hospice CareLife Prolonging

Care

Diagnosis Death

The EPEC-EM Project™

The EPEC-EM™ Project

The mission of The EPEC-EM™ Project is to

educate all emergency healthcare

professionals on the essential clinical

competencies of emergency palliative care

Education and research to drive performance

change

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‘Primary’ Palliative Care

The basic level of knowledge and skills that all

practitioners should have to relieve suffering

- Pain and symptom management

- Communication skills

- Ethical and responsible care

20

‘Tertiary’ Palliative Care

Hospice and Palliative Medicine (HPM)

- Co-sponsored by ABEM

- Training and Practice Pathways

Unique clinical, research and service model of

emergency palliative medicine practice

21

Emergency Palliative Care

Identification of ED patients who will benefit

from pain and symptom management

ED providers committed to relief of suffering

through validated interventions

22

EPEC-EM™ Grant Timeline

Year 1: Define a body of knowledge

Year 2: Disseminate core content

Year 3: Create symptom assessments

Year 4: Test interventions

23

FY 1: Body of Knowledge

Goal: EPEC-EM™ Core Content

Developed by an expert, multi-disciplinary

advisory board

Adaptation of materials from original EPEC,

as well as ABHPM core content

24

The EPEC-EM Curriculum is produced by the EPECTM Project with major funding provided by NCI.

Education in Palliative and End-of-life Care – Emergency Medicine

The

Project

EPEC-EMTM

26

Emergency Medicine and

Critical Care 2008; Oct;

4:46-8

FY 1: EPEC-EM Curriculum

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1. Death Trajectories

2. Rapid Assessments

3. Goals of Care

4. Advance Directives

5. Hospice

6. Communication Skills

7. Withdrawing Care

8. Witnessed Resuscitation

9. Death Disclosure

10. Symptom Management

11. Chronic Pain

12. Malignant Pain

13. Cancer Complications

14. Last Hours of Life

FY 2: Dissemination

Goal: ‘Become an EPEC-EM Trainer’ Course

2 day, train-the-trainer program

400+ page course manual, teaching videos

www.epec.net

29

Module 1:

Trajectories &

Prognoses

E

P

E

C

E

M

EPEC -EMThe

TM

ProjectEducation in Palliative and End-of-life Care – Emergency Medicine

How do we die?

Global trajectories

• Terminal illness (e.g. cancer)

•Organ failure (e.g. CHF)

• Frailty (e.g. failure to thrive/SNF)

• Sudden death (e.g. trauma, V Fib)

• Lunney, Lynn et al. JAMA 2003.

Cancer

• Complications accelerate prognosis

Untreated Brain Mets

Treated Brain Mets

4-8 weeks

3-6 months

Malignant Hypercalcemia(except breast ca and myeloma)

8 weeks

Malignant Effusion 8 weeks

Carcinomatous Meningitis 8-12 weeks

Prognosis drives goals and

interventions

Prognosis Days Weeks Months Years

Goals Comfort only Prioritize quality

of life over

longevity

Try

Interventions,

but stop if they

are not working

Full efforts to cure

Interventions Pain control

Family presence

by bedside

Refer to hospice

Treat for comfort

Refer to hospice

Attempt

resuscitation;

Stop if signs of

instability

persist after

reasonable

efforts

Full resuscitation

efforts; maximal

efforts to stabilize;

transfer to ICU

Video 1:

Trajectories &

Prognoses

E

P

E

C

E

M

EPEC -EMThe

TM

ProjectEducation in Palliative and End-of-life Care – Emergency Medicine

FY 2: Outcome

12 EPEC EM conferences since 2007

Approximately 500 trainers

Over 25,000 end-users

Met NIH goal: 1 trainer at 50% of EM pgms.36

FY 2: Secondary Outcome

EPEC-EM curriculum can be successfully

adapted to various types of learners and

instructional formats

Mini-EPEC

Asynchronous Learning

37

• EPEC EM adapted materials were effective

• Synchronous and asynchronous instructional

methods were similarly effective

38

FY 3: Assess Symptoms

42

Goal: Develop a validated symptom

assessment tool for use in the ED

FY 3 Outcome: SPEED tool

Validated, brief

Likert scale 0-10 with threshold values linked

to proposed interventions

SPEED-short (5 item version)

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SPEED question

How much are you suffering from pain?

(threshold ≥ 4)

How much difficulty are you having getting

your care needs met at home? (threshold ≥ 3)

How much difficulty are you having with your

medications? (threshold ≥ 3)

How much are you suffering from feeling

overwhelmed? (threshold ≥ 5)

How much difficulty are you having getting

medical care that fits with your goals?

(threshold ≥ 3)

FY 4: Test Interventions

Goal: Develop meaningful interventions

linked to the symptom burden uncovered by

SPEED

Employ multi-disciplinary approach

48

Post ED Visit

Admit / Discharge

3. Clinical Care

Primary Assessment

EPEC-EM Protocol Flow Chart

Triage Patient presents to Emergency Department (ED)

How much are

you suffering

from pain?

Threshold = 4

2. First SPEED questions

0-10 point scale

1. Active cancer screen

How much

difficulty are you

having getting your

care needs met at

home?

Threshold = 3

How much

difficulty are you

having with your

medications?

Threshold = 3

How much are

you suffering from

feeling

overwhelmed?

Threshold = 5

How much

difficulty are you

having getting

medical care

that fits with

your goals?

Threshold = 3

If pt. scores above threshold values,

the Palliative Care Resource Nurse

is notified to interact with the ED

Power Plan. Power plan includes

specific interventions triggered by

SPEED categories above threshold.

(S)

Palliative Care

Consult

(S)

Social Work

Consult

(S)

Pharmacy Consult

(focused

medication

teaching)

(S)

Palliative Care

Consult

(S)

Social Work

Consult

(S)

Chaplaincy

Consult

(S)

Palliative Care

Consult

Patient perspective of care:

A survey of patient centered

outcomes only for questions with

above threshold score at first

SPEED

How much are

you suffering

from pain?

How much

difficulty are

you having

getting your

care needs met

at home?

How much

difficulty are you

having with

communication

with your

medications?

How much are

you suffering

from feeling

overwhelmed?

How much difficulty

are you having

getting medical

care that fits with

your goals?

Second SPEED questions are

administered upon admission or

discharge only for questions above

threshold at first SPEED

(M)

Pain Protocol

(M)

Secondary

Chronic Pain

Assessment

(M)

Secondary

Social Needs

Assessment

(M)

Secondary

Medication

Assessment

(M)

Secondary

Mental Health

Assessment

(M)

Encourage

verbalization

of goals

4. Summary of care provided by ED

What could providers have done better to assess and respond

to...(your pain, your care needs, your difficulty with medications,

your feeling of being overwhelmed, your goals)?

Patient feedback opportunity:

Only for questions with above

threshold score at first SPEED

(S)

Palliative Care

Consult

(S)

Palliative Care

Consult

(M)

Secondary

Goals of Care

Assessment

(M)

Bedside

counseling

(M)

Goals of care

conversation

5. Admit/ Discharge survey

(M) = Mid-level provider

intervention (e.g.,

physician, nurse)

(S) = Sub-specialty

intervention

(e.g., social work,

chaplaincy, pharmacy,

patient liason)

How much did providers do everything they could to help

with...(your pain, your care needs, your difficulty with medications,

your feeling of being overwhelmed, your goals)? NEVER,

SOMETIMES, USUALLY or ALWAYS

6. Follow-up surveyPatient follow-up survey conducted by

research assistant

Palliative Care Resource Nurse (PCRN) notified of patients scoring above threshold values on any SPEED category

SPEED Screening for Cancer Patients

How much are you suffering from pain?

0

1

2

3

4

5

6

7

8

9

10

How much difficulty are you having getting your care needs met at home (e.g. bathing, dressing, and meals?)

0

1

2

3

4

5

6

7

8

9

10

How much difficulty are you having with your medications?

0

1

2

3

4

5

6

7

8

9

10

How much are you suffering from feeling overwhelmed?

0

1

2

3

4

5

6

7

8

9

10

How much difficulty are you having getting medical care that fits with your goals?

0

1

2

3

4

5

6

7

8

9

10

Submit

Not at all A great deal

Ask the patient:

Threshold

values

Pain

Blue Text:

provider

decision

support

Pain Location:____________________Pain Onset:______________________

Pain Scale UsedNumericFacesFLACCBehavioral/Physiological

Pain Score: 0-10 radio buttons

Pain managed to pts. satisfaction?YesNo

Pain CharacteristicsNoneDullSharpAchingBurningStabbingPressure-likeCrampingCrushingSorenessConstantIntermittentRadiatingNon-radiatingGeneralizedDeniesChest PainIncisionalHeadacheMusculoskeletalOther:________________

Pain Radiation:___________________

Secondary Pain Assessment

Behavioral IndicatorsGrimacingMoaningSplintingTensenessRestlessnessAgitationIrritabilityShakingCryingGuarding

Physiologic IndicatorsIncreased respirationsIncreased blood pressureIncreased heart rateNoneOther:_______________

Aggravating FactorsNoneBreathingMovementPalpationOther:_______________

Alleviating FactorsNoneAssistive devicesCold therapyDeep breathingExerciseImmobilizationMassageMoist heatRepositioningOther:_______________

Associated SymptomsNoneNauseaPalpitationsShortness of breathSweatingVomitingOther:______________

Side Effects from Pain Medications*ConstipationNausea/vomitingConfusionDrowsinessJerking movementsOther _______________

Daily Laxative Use*Yes No

Physician administers Pain Protocol (refer to Screenshot 3)

Physician/ midlevel requests palliative care consultation (as needed)

BLUE TEXT with

CHECKBOX:

Pain is uncontrolled,

Would you like to

order a palliative care

consult?

Yes – palliative care

Care Needs

At home, are you having difficulty…?Using the toiletDressing yourselfTaking care of your hygieneMoving around (mobility problems)Managing medicationsPreparing mealsHome-makingGetting around to places (transportation)

Are you having financial difficulty with…?Utility bills (such as water, lights)Groceries and foodEquipment (such as a wheelchair, harness)Medications

Secondary Social Needs Assessment

Nurse requests social work consultation (as needed)

BLUE TEXT with

CHECKBOX:

Social needs are

unmanaged.

Would you like to

order a social work

and/ or palliative care

consult?

Yes – social work


Physician/ midlevel provider requests palliative care consultation (as

needed)

MedicationsSome questions about your medications…

Do you feel like your medications are ineffective?

Do you find the side effects of your medications burdensome?

Do you have trouble physically taking your medications?

Do you have trouble getting your medications?

Do you understand how to take your medications?

Do you feel uncomfortable taking your medications?

Secondary Medication Assessment

Trouble getting medicationsCannot get insurance approval for medicineCannot get to pharmacyCannot pay for medications

Trouble taking medicationsForm of medications (tablet, liquid, etc.)Pill sizeDifficulty swallowingTaste of medication

Burdensome side effectsConstipationNausea/ vomitingDrowsinessFatigueDizzinessConfusionFlushing

Trouble understandingDon’t understand regimenUnfamiliar with regimenDifficulty with literacyVision impairmentsHearing impairments

I

F

Y

E

S

.

.

.

S

H

O

W

D

R

O

P

D

O

W

N

T

A

B

L

E

(S)

Nurse requests pharmacist consultation for focused medication teaching

(as needed)


needed)

Perceived inefficacyNo symptom reliefPartial symptom reliefWaning symptom relief

DiscomfortUncomfortable with regimenFear of addictionFear of overdose

BLUE TEXT with

CHECKBOX:

Medication

communication needs

are unmanaged.

Would you like to order a

pharmacy and/ or

palliative care consult?

Yes – pharmacy


Overwhelmed

Depression screenAre you depressed?

YesNo

Anxiety screenAre you suffering from anxiety?

YesNo

Overwhelmed Assessment

Do you have anyone I can call to be with you right now?Yes – contact support directlyNo

I could use support in the following areas:Coping with IllnessSpiritualityCounselingSupport GroupsGetting support for caregiver(s)

Nurse provides bedside support and elicits information to inform potential

consult choice

CHECK BOX:

Provided bedside

counseling

If yes (depressed):

Suicidality Screen

Are you suicidal?YesNo

Normal procedures of hospital

to address suicidality

Nurse requests social work consultation (as needed)

BLUE TEXT with

CHECKBOX:

Patient is

overwhelmed.

Would you like to

order a social work,

chaplaincy, and/ or


Yes – social work

Yes – chaplaincy



needed)

Nurse requests chaplaincy consultation (as needed)

Goals of Care

Goals of Care Alignment Assessment

Physician/ Midlevel has goals of care conversation with patient and encourages verbalization with

primary care physician

Do you feel you are…?Having trouble getting information that you need regarding your illness?Receiving more medical interventions than you would like?Having difficultly communicating your wishes to your medical providers?In need of a healthcare proxy or advance directives?

BLUE TEXT with

CHECKBOX:

Goals of care need to

be discussed.

Would you like to

order a social work,

chaplaincy, and/ or


Yes – social work

Yes – chaplaincy


Physician/ midlevel provider requests palliative care consultation (as needed)

Nurse requests chaplaincy consultation (as needed)

CHECK BOX:

Discussed goals of

care and encouraged

verbalization with

primary care physician

Patient reassessed at end of stay

Post ED Visit

Admit / Discharge

Patient perspective of care:

A survey of patient centered

outcomes only for questions with

above threshold score at first

SPEED

How much are

you suffering

from pain?

How much

difficulty are

you having

getting your

care needs met

at home?

How much

difficulty are you

having with

communication

with your

medications?

How much are

you suffering

from feeling

overwhelmed?

How much difficulty

are you having

getting medical

care that fits with

your goals?

Second SPEED questions are

administered upon admission or

discharge only for questions above

threshold at first SPEED

4. Summary of care provided by ED

What could providers have done better to assess and respond

to...(your pain, your care needs, your difficulty with medications,

your feeling of being overwhelmed, your goals)?

Patient feedback opportunity:

Only for questions with above

threshold score at first SPEED

5. Admit/ Discharge survey

How much did providers do everything they could to help

with...(your pain, your care needs, your difficulty with medications,

your feeling of being overwhelmed, your goals)? NEVER,

SOMETIMES, USUALLY or ALWAYS

6. Follow-up surveyPatient follow-up survey conducted by

research assistant

Future Considerations

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Fiscal Imperatives

Emphasis on symptom assessments and

interventions with improved quality of life

outcomes and decreased hospitalization

Early ED palliative care has been shown to

decrease hospital stay and increase quality

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Education and Research

Addition of core domains of palliative care to

the Model of Clinical Practice in EM

Define quality of life indicators, identify those

that can be addressed in ED

Focus on interventions, consultation

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Summary

Palliative care is the active treatment of physical symptoms and social needs experienced by patients with terminal illness

EPEC-EM™ has defined core domains of palliative care are pertinent to EM practice

There are numerous opportunities for new knowledge and skills in palliative ED care62

EPEC-EM 2016Omni Chicago HotelSeptember 8 & 9www.epec.net

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Improving End-of-life Care in the Emergency Department

Healthcare

Transcript of Improving End-of-life Care in the Emergency Department