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Screening for Palliative Care: Implementation of the NCCN Guideline at a Comprehensive Cancer Center (418-A)
Vol. 43 No. 2 February 2012
Schedule With Abstracts
believed to be an uncommon act in hospice and there is little information in the literature about the epidemiology or risk factors for suicide in this population. Methods. We conducted a case series of all completed suicides at a large community-based hospice. Cases were identified by cross-referencing medical examiner records with the hospice registry. Data sources included Medical Examiner reports and hospice documentation. The review included information about demographics, intensity of clinical care, risk factors, and interventions by clinicians. Results. Ten cases of suicide occurred during the course of treatment in hospice over a 6 year period (2004-2010). The average age was 80.5 years, and nearly all were men (90%). Six subjects were married. The hospice diagnosis was cancer in nine cases. The most common method was a gunshot wound (70%). The average duration of hospice care was 134 days, and the interval between the last team visit and the suicide was 4.15 days. Five patients appeared to have a mental illness, but none received care from a psychiatrist. The hospice team was aware of the risk for suicide in six cases, but in only one were there clear measures taken to address those risks. Conclusion. Consistent with studies in other populations, suicides in hospice occurred predominately among men of advanced age, with firearms being the most common method. Mental illness, also a risk factor, appeared to be an issue for several patients in this series. Of note, suicides occurred despite a long duration of contact with hospice, including clinical encounters shortly before the event. Further study may help to elucidate some of the clinical, psychological, and spiritual issues that underlie suicide attempts in this population, thereby improving care for patients at risk for suicide and their families.
A Retrospective Case Series of Suicide Attempts Leading to Hospice Admission (417-C) Nathan Fairman, MD MPH, UC Davis School of Medicine, Sacramento, CA. Scott Irwin, MD PhD, The Institute for Palliative Medicine at San Diego Hospice, San Diego, CA. (All authors listed above for this session have disclosed no relevant financial relationships.)
387
Objectives 1. Recognize the demographics of patients who enter hospice as a consequence of injuries sustained in a suicide attempt. 2. Discuss the unique role of withdrawal of care as a central component of hospice care in patients who enter hospice as a consequence of injuries sustained in a suicide attempt. Methods. A case series of all completed suicides at a large community-based hospice, from January 2004-December 2010, was conducted. Data was gathered from medical examiner reports, hospice records, and documentation from referring institutions. The review focused on demographics, epidemiology, risk factors, withdrawal of care, and the use of bereavement services. Results. Twenty-nine cases of completed suicide were identified, of which eight (28%) involved patients referred to hospice due to injuries sustained in the suicide attempt. The average age was 46 years, and nearly all were men (n ¼ 6). Most of the cases involved a drug overdose (n ¼ 5); other methods included jumping from a balcony (n ¼ 1), hanging (n ¼ 1), and being hit by a car (n ¼ 1). Anoxic brain injury was the major medical complication in all cases. All but one of the patients had a significant psychiatric illness, but active substance use at the time of the attempt was uncommon (n ¼ 2). A decision to withdraw life-sustaining care was a major intervention in nearly all cases, and in most, family members were directly involved in end-of-life decision-making. Bereavement services were utilized by family members in two cases. Conclusion. Suicide attempts can cause lifelimiting injuries that lead to hospice admission. Patients with serious mental illness are likely to be overrepresented in this population, and hospice interventions may revolve around family members’ decisions to withdraw care. Further study may help to explore some of the unique clinical, spiritual, and ethical dimensions involved in caring for these patients and their families.
Screening for Palliative Care: Implementation of the NCCN Guideline at a Comprehensive Cancer Center (418-A) Paul Glare, MBBS FACP, Memorial Sloan Kettering Cancer Center, New York, NY. Kathy Plakovic, FNP AHPCN AOCNP, Memorial Sloan
388
Schedule With Abstracts
Kettering Cancer Center, New York, NY. Barbara Egan, MD, Memorial Sloan Kettering Cancer Center, New York, NY. David Kelsen, MD, Memorial Sloan Kettering Cancer Center, New York, NY. (All authors listed above for this session have disclosed no relevant financial relationships.) Objectives 1. Describe the outcomes of implementing a program of screening for palliative care needs in a cancer center. 2. Determine if they wish to implement palliative care screening in their own setting. Background. The most severely ill cancer patients are in hospital. Referral to the hospital palliative care (PC) team has been the prerogative of the primary attending physician. The National Comprehensive Cancer Network PC Guideline now recommends screening for PC needs and calling a consult when referral criteria (RC) are met. Research objective. To evaluate implementation and impact of this Guideline on one floor of a comprehensive cancer center where less than 10% of patients are normally referred. Method. From 11/1/10 to 1/28/11, the admitting nurse screened all patients hospitalized under Team A and Team B of the Gastrointestinal Oncology Service at Memorial Sloan-Kettering Cancer Center. PC consults were triggered in Team A’s patients who met the RC. Measures included: symptom scores (at screening and after 4 days), patient satisfaction; nurses’ acceptability and satisfaction with screening; utilization data in last month of life (admissions, hospital deaths, ICU, chemotherapy, hospice). Result. 229/254 (90%) admissions were screened, 113 from Team A and 116 from Team B. Screening took less than 5 minutes per patient. The RC triggered consults in 72 (64%) Team A patients. They were significantly more likely to die within 6 months (63% vs. 39%, p < 0.02). Patients who had consultations had the same length of stay (LOS, median 4 days), somewhat better pain relief and significantly more hospice discussions (35% vs. 14%, p < 0.05). Nurses reported screening was simple, quick and helpful. Impact on other metrics is being analyzed. Conclusion. It is feasible to screen hospitalized patients for PC needs, and the prevalence of
Vol. 43 No. 2 February 2012
needs is very high. Screening identified many more patients for PC referral than is usual. Consulting the PC team did not prolong LOS and led to more hospice discussions. Implications for research, policy, or practice. More data are needed to support the widespread dissemination and implementation of the Guideline. Adequate resources are needed to support a 500% increase in workload.
Impact of Systematic Palliative Care Screening Program Across a Tertiary Care Hybrid Health System (418-B) Kirsten Edmiston, MD, Inova Fairfax Hospital, Fairfax, VA. Jessica Heintz, MD, Inova Fairfax Hospital, Fairfax, VA. Anne Rizzo, MD FACS, Inova Fairfax Hospital, Fairfax, VA. (All authors listed above for this session have disclosed no relevant financial relationships.) Objectives 1. Recognize the benefits of a system wide palliative care screening program. 2. Identify strategies to implement a case management based palliative care screening program. 3. Recognize the components of electronic palliative care screening tool. Background. Across the care continuum, there is an increasing need for systematic palliative care and hospice screening to meet the needs of all patients. Historically, many post discharge scoring systems and strategies have been developed to stratify patient need for palliative and hospice care. A model for case management based electronic palliative care screening and referral was developed and evaluated in a hybrid academic and community health system. Case Description. A multidisciplinary palliative care team and governance structure was created with representation from all five hospitals of a hybrid health system in Northern Virginia. An evidence-based palliative care screening tool was developed and implemented in Allscripts, an electronic case management database. Domains of the tool included both general and ICU elements. Reporting functions in Allscripts provided the capability to measure both the screening compliance in identified subsets and utilization of primary and secondary palliative care and hospice. A palliative care scorecard was created to measure the program’s impact on quality, service and community metrics.
Schedule With Abstracts
believed to be an uncommon act in hospice and there is little information in the literature about the epidemiology or risk factors for suicide in this population. Methods. We conducted a case series of all completed suicides at a large community-based hospice. Cases were identified by cross-referencing medical examiner records with the hospice registry. Data sources included Medical Examiner reports and hospice documentation. The review included information about demographics, intensity of clinical care, risk factors, and interventions by clinicians. Results. Ten cases of suicide occurred during the course of treatment in hospice over a 6 year period (2004-2010). The average age was 80.5 years, and nearly all were men (90%). Six subjects were married. The hospice diagnosis was cancer in nine cases. The most common method was a gunshot wound (70%). The average duration of hospice care was 134 days, and the interval between the last team visit and the suicide was 4.15 days. Five patients appeared to have a mental illness, but none received care from a psychiatrist. The hospice team was aware of the risk for suicide in six cases, but in only one were there clear measures taken to address those risks. Conclusion. Consistent with studies in other populations, suicides in hospice occurred predominately among men of advanced age, with firearms being the most common method. Mental illness, also a risk factor, appeared to be an issue for several patients in this series. Of note, suicides occurred despite a long duration of contact with hospice, including clinical encounters shortly before the event. Further study may help to elucidate some of the clinical, psychological, and spiritual issues that underlie suicide attempts in this population, thereby improving care for patients at risk for suicide and their families.
A Retrospective Case Series of Suicide Attempts Leading to Hospice Admission (417-C) Nathan Fairman, MD MPH, UC Davis School of Medicine, Sacramento, CA. Scott Irwin, MD PhD, The Institute for Palliative Medicine at San Diego Hospice, San Diego, CA. (All authors listed above for this session have disclosed no relevant financial relationships.)
387
Objectives 1. Recognize the demographics of patients who enter hospice as a consequence of injuries sustained in a suicide attempt. 2. Discuss the unique role of withdrawal of care as a central component of hospice care in patients who enter hospice as a consequence of injuries sustained in a suicide attempt. Methods. A case series of all completed suicides at a large community-based hospice, from January 2004-December 2010, was conducted. Data was gathered from medical examiner reports, hospice records, and documentation from referring institutions. The review focused on demographics, epidemiology, risk factors, withdrawal of care, and the use of bereavement services. Results. Twenty-nine cases of completed suicide were identified, of which eight (28%) involved patients referred to hospice due to injuries sustained in the suicide attempt. The average age was 46 years, and nearly all were men (n ¼ 6). Most of the cases involved a drug overdose (n ¼ 5); other methods included jumping from a balcony (n ¼ 1), hanging (n ¼ 1), and being hit by a car (n ¼ 1). Anoxic brain injury was the major medical complication in all cases. All but one of the patients had a significant psychiatric illness, but active substance use at the time of the attempt was uncommon (n ¼ 2). A decision to withdraw life-sustaining care was a major intervention in nearly all cases, and in most, family members were directly involved in end-of-life decision-making. Bereavement services were utilized by family members in two cases. Conclusion. Suicide attempts can cause lifelimiting injuries that lead to hospice admission. Patients with serious mental illness are likely to be overrepresented in this population, and hospice interventions may revolve around family members’ decisions to withdraw care. Further study may help to explore some of the unique clinical, spiritual, and ethical dimensions involved in caring for these patients and their families.
Screening for Palliative Care: Implementation of the NCCN Guideline at a Comprehensive Cancer Center (418-A) Paul Glare, MBBS FACP, Memorial Sloan Kettering Cancer Center, New York, NY. Kathy Plakovic, FNP AHPCN AOCNP, Memorial Sloan
388
Schedule With Abstracts
Kettering Cancer Center, New York, NY. Barbara Egan, MD, Memorial Sloan Kettering Cancer Center, New York, NY. David Kelsen, MD, Memorial Sloan Kettering Cancer Center, New York, NY. (All authors listed above for this session have disclosed no relevant financial relationships.) Objectives 1. Describe the outcomes of implementing a program of screening for palliative care needs in a cancer center. 2. Determine if they wish to implement palliative care screening in their own setting. Background. The most severely ill cancer patients are in hospital. Referral to the hospital palliative care (PC) team has been the prerogative of the primary attending physician. The National Comprehensive Cancer Network PC Guideline now recommends screening for PC needs and calling a consult when referral criteria (RC) are met. Research objective. To evaluate implementation and impact of this Guideline on one floor of a comprehensive cancer center where less than 10% of patients are normally referred. Method. From 11/1/10 to 1/28/11, the admitting nurse screened all patients hospitalized under Team A and Team B of the Gastrointestinal Oncology Service at Memorial Sloan-Kettering Cancer Center. PC consults were triggered in Team A’s patients who met the RC. Measures included: symptom scores (at screening and after 4 days), patient satisfaction; nurses’ acceptability and satisfaction with screening; utilization data in last month of life (admissions, hospital deaths, ICU, chemotherapy, hospice). Result. 229/254 (90%) admissions were screened, 113 from Team A and 116 from Team B. Screening took less than 5 minutes per patient. The RC triggered consults in 72 (64%) Team A patients. They were significantly more likely to die within 6 months (63% vs. 39%, p < 0.02). Patients who had consultations had the same length of stay (LOS, median 4 days), somewhat better pain relief and significantly more hospice discussions (35% vs. 14%, p < 0.05). Nurses reported screening was simple, quick and helpful. Impact on other metrics is being analyzed. Conclusion. It is feasible to screen hospitalized patients for PC needs, and the prevalence of
Vol. 43 No. 2 February 2012
needs is very high. Screening identified many more patients for PC referral than is usual. Consulting the PC team did not prolong LOS and led to more hospice discussions. Implications for research, policy, or practice. More data are needed to support the widespread dissemination and implementation of the Guideline. Adequate resources are needed to support a 500% increase in workload.
Impact of Systematic Palliative Care Screening Program Across a Tertiary Care Hybrid Health System (418-B) Kirsten Edmiston, MD, Inova Fairfax Hospital, Fairfax, VA. Jessica Heintz, MD, Inova Fairfax Hospital, Fairfax, VA. Anne Rizzo, MD FACS, Inova Fairfax Hospital, Fairfax, VA. (All authors listed above for this session have disclosed no relevant financial relationships.) Objectives 1. Recognize the benefits of a system wide palliative care screening program. 2. Identify strategies to implement a case management based palliative care screening program. 3. Recognize the components of electronic palliative care screening tool. Background. Across the care continuum, there is an increasing need for systematic palliative care and hospice screening to meet the needs of all patients. Historically, many post discharge scoring systems and strategies have been developed to stratify patient need for palliative and hospice care. A model for case management based electronic palliative care screening and referral was developed and evaluated in a hybrid academic and community health system. Case Description. A multidisciplinary palliative care team and governance structure was created with representation from all five hospitals of a hybrid health system in Northern Virginia. An evidence-based palliative care screening tool was developed and implemented in Allscripts, an electronic case management database. Domains of the tool included both general and ICU elements. Reporting functions in Allscripts provided the capability to measure both the screening compliance in identified subsets and utilization of primary and secondary palliative care and hospice. A palliative care scorecard was created to measure the program’s impact on quality, service and community metrics.