WRHA Palliative Care Program November 2012 Lori Embleton, Program Director
What Is Palliative Care? Palliative Care is an approach to care which focuses on comfort and quality of life for those affected by lifelimiting/life-threatening illness. Its goal is much more than comfort in dying; palliative care is about living, through meticulous attention to control of pain and other symptoms, supporting emotional, spiritual, and cultural needs, and maximizing functional status.
What Is Palliative Care? Not defined by: – Body system (compare with dermatology, cardiology) – What is done (compare with anesthesiology, surgery) – Age (compare with pediatrics, geriatrics) – Sex of patient (such as with gynecology) – Location of Care (compare with ER, critical care) Any illness, any age, any location…
What Is Palliative Care? The spectrum of investigations and interventions consistent with a palliative approach is guided by goals and expectations of patient and family and by accepted standards of health care, rather than being bound by preconceptions of what is or is not "palliative".
Potential Palliative Care Interventions Generally Not Palliative Support Emotional Spiritual Psychosocial Control of • • Pain Dyspnea Nausea Vomiting Variable CPR Ventilation Transfusions Infections Hypercalcemia Tube Feeding Dialysis Highly burdensome Interventions
Winnipeg Palliative Care Services: Pre-Regionalization Seven Oaks Hospital Grace Hospital Victoria Hospital Concordia Hospital HSC C o m m u n i t y Jocelyn House • 5 beds SBGH • 20 beds • served SBGH and local area 39 PCHs Inpatient attending & consulting RHC • 30 beds • patients primarily from HSC & community No Community Outreach Home consultative support No formal services
Winnipeg Palliative Care Services: Post-Regionalization C o m m u n i t y Seven Oaks Hospital Grace Hospice • 12 beds Grace Hospital Inpatient attending & consulting HSC Children’s Hospital SBGH C • 15 beds RHC • 30 beds Concordia Hospital Jocelyn House • 4 beds Victoria Hospital Home & facility consultative support 39 PCHs Completely new component
Palliative Care Program Two streams of service delivery: 1. Registration on Program 2. Consultative Services
REGISTRATION ON PALLIATIVE CARE PROGRAM
Registration on Program Patients can be “registered” on the Palliative Care Program if they meet program criteria: – Prognosis of less than 6 months – No longer receiving aggressive treatment which requires on-going monitoring for and treatment of serious complications – Have chosen a comfort-focused approach including a decision to decline attempted resuscitation
Registration on Program Once registered with the program, patients are eligible for: – Case management through Palliative Care Coordinator – Access to Community Palliative Care Nursing 24/7 • Palliative Care Nurses have access to Palliative Care Physician – Admission to Palliative Care Units (PCU) and Hospice – if bed available – Enrollment on Provincial Palliative Care Drug Access Program
When to Register a Patient on Palliative Care Program • Patients are considering going home from acute care – Need to plan for services to be in place • Patients being transferred to Long Term Care Setting
How to Register a Patient on PC Program • Complete the “Application for Registration” form – 2 page form – “completed” forms can be processed more quickly • Completed forms are reviewed by PC coordinator – Accepts on to Program – Rejects application – all reviewed by Manager, Program Director or Medical Director
Acute Palliative Care Units St. Boniface Hospital • 15 bed unit • Access to tertiary care services Riverview Health Centre • 30 bed unit (2 beds currently closed) • Long term care facility
Acute Palliative Care Units (PCU) • Admission to PCU for symptom issues – Physical symptoms – Psycho-social distress – Caregiver distress • Admissions managed centrally by PC program staff – Bed management guidelines
Acute Palliative Care Units Once symptoms are controlled, actively discharge to appropriate site – Approximately 75% of patients die on PC unit – Approximately 20% of patients are discharged home from Palliative Care Units – Lack of care options if home not possible • PCH • Chronic Care • Hospice
Hospice settings in WRHA • Grace Hospice • 12 beds in stand alone facility near Grace hospital • RN staffing 24/7 • Limitations in care that can be provided
Hospice settings in WRHA • Jocelyn House • 4 beds in split-level home in St. Vital • RN staffing 4 hours a day – 5 days a week • HCA provide care 24/7
Hospice is appropriate when: – Symptoms well controlled – Care needs are not complex – Prognosis of 1 – 3 months – Patients cannot or do not wish to be cared for in the community
Care in the Community • Majority of patients on Palliative Care program are in the community • Recently expanded community model of care to incorporate an Inter-professional approach
Community Teams: • Community Nurses • CNS • MD • Coordinator • Psychosocial
Inter-professional Community Model • Each community team considers patients in their area as their “ward” – Inclusive of all care settings – home, acute care and long term care – Team meetings to discuss patient care needs especially when transitioning between care settings – Focus on meeting needs in a proactive way – Opportunity to strengthen networks with other care teams to support patients and families including the opportunity to model “palliative care”
Care at Home • Palliative patients in community have same service limitations as all Home Care clients – HCA and PSW services provided by Home Care Program • Families/caregivers must be very involved in providing care
CONSULTATION SERVICES
Consultative Services • Available to anyone with a life limiting illness in any care setting for symptom management, psychosocial support or assistance with discharge planning • Consultation services are provided by interprofessional team members including: – Palliative Care Physician – Palliative Care Clinical Nurse Specialist – Psycho-social Support Specialist
When should Palliative Care be consulted? • Assistance with symptom issues – Managing Physical symptoms • MD to MD consults for advice 24/7 – Psycho-social • Assistance with care planning – What might care team expect as patient nears end of life? • Will oral route be available? • Could symptoms escalate?
When should Palliative Care be consulted? • Goals of care not clear – Discrepancy between patient, family and/or members of care team with plan of care • Discharge to community or LTC is anticipated – Does patient need to be or are they currently “registered” on Palliative Care program? – Would it be appropriate for Palliative Care nurse to see the patient in the community?
What information is needed on consult? • Main reason for consult – What is the main symptom issue? • Urgency of consult • Is the physician aware of the consult?
Consult Service Community Palliative Nursing • Case Coordinator • Admission Eligibility • Medication Coverage • comfort-focused • prognosis “ 6 mo. or less” • some treatment limitations (DNAR, no TPN, no chemo. Tx with high adverse effects • aggressive, often toxic treatment focused on cure or life-prolonging disease modification Diagnosis of Life-Limiting Illness Transitioning to Palliative
Increase capacity s through education, ce r ou advocacy, s Re partnerships Palliative Care as a philosophy of care Formal Program
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