- Email: [email protected]
Serving Two Masters: Should One Act as Ethics Consultant and Palliative Care Consultant? (525)
Vol. 41 No. 1 January 2011
Schedule with Abstracts
of the surgeon and palliative care provider can cause stress, confusion, and distrust from the patient and family. Keeping patient goals utmost in priority and to reconcile the surgical and palliative care perspectives in end-of-life care cases will be presented by surgeons from different specialties. These presentations will provide a forum for palliative care practitioners to identify the unique surgical perspectives on palliative care. Complementing the case presentations will be a series of ‘‘cutting edge’’ questions and answers to further clarify the surgeons’ viewpoints. Using the knowledge from the cases and Q&A, the session participants will have insights into how to effectively interact with surgeons to institute appropriate palliative care for dying patients without jeopardizing either the surgical or the palliative perspective. These techniques will be broadened so after the session the participant will be able to identify and recruit local surgical ‘‘champions’’ to assist in implementing appropriate palliative care interventions in challenging surgical cases. Domain Structure and Processes of Care; Physical Aspects of Care
Palliative Care for Veterans with PTSD (524) Bettina Kehrle, MD, VA Greater Los Angeles Healthcare System, Los Angeles, CA. Jillisa Steckart VA Greater Los Angeles Healthcare System, Los Angeles, CA. Deborah Moran VA Greater Los Angeles Healthcare System, Los Angeles, CA. (All speakers for this session have disclosed no relevant financial relationships.) Objectives 1. Identify special considerations for veterans with posttraumatic stress disorder (PTSD) at the end of life. 2. Discuss appropriate and practical pharmacological and psychological interventions and management skills for veterans with PTSD at the end of life and how to use them in daily practice. Posttraumatic stress disorder (PTSD) is a condition characterized by intrusions of traumatic memories, symptoms of avoidance and numbing, and hyperarousal. It has been reported that more than 30% of veterans suffer from PTSD and suggest that this is likely an
267
underestimate of actual prevalence. The volume of veteran deaths is significant (25% of all American deaths in 2006) with most veteran deaths occurring in non-VA facilities or at home. These realities make it important for providers to understand the unique needs of veterans, particularly those with PTSD. A single-site VA study found that 17% of patients reported PTSD-related symptoms in the last month of life. Physical ill health was the most significant risk factor associated with reactivation of PTSD symptoms in late life. PTSD may be exacerbated at the end of life due to re-exposure, pain, and reaction to diagnosis of terminal illness. Often goals of care are constrained by the patient’s psychopathology and clinicians need to accept limitations on their ability to provide optimal medical treatment. Anxiety associated with PTSD may negatively influence the ability for patients to develop a trusting relationship with their medical provider and contribute to ill-feeling in their caregivers or providers. Pharmacological interventions must be considered carefully. Intense PTSD symptoms can mimic ‘‘terminal restlessness’’; however, the antidepressants, anxiolytics, and antipsychotics used to treat terminal restlessness may have a paradoxical reaction in veterans experiencing PTSD agitation. This session will use literature review, case study, and vignette to identify special considerations for veterans with PTSD at the end of life; provide an overview of appropriate and practical pharmacological and psychological interventions; and teach recognition and management skills. By the end of the session, participants will be able to identify/manage constellations of symptoms common in PTSD that could affect quality of end-of-life treatments. Domain All domains
Serving Two Masters: Should One Act as Ethics Consultant and Palliative Care Consultant? (525) Ryan Nash, MD, University of Alabama at Birmingham, Birmingham, AL. Catherine Kelso, MD MS, McGuire VA Medical Center, Richmond, VA. Farr Curlin, MD, University of Chicago, Chicago, IL. (All speakers for this session have disclosed no relevant financial relationships.)
268
Schedule with Abstracts
Objectives 1. Define and distinguish between bias, prejudice, and judgment in the process of ethical discernment, and identify examples of each. 2. Describe a variety of current models for the relationship between palliative care and clinical ethics consultation in the hospital setting. 3. Gain appreciation of varying strategies to control for unjustified moral biases in ethics consultation. These strategies deploy a range of checks and balances. In many clinical settings ethics consultants and palliative medicine consultants overlap significantly in the patients and families they encounter. Though the role of an ethics consultant differs from that of a palliative care consultant, it is common for palliative care team members to be called upon as participants in the resolution of ethical disputes. Given the particularity and limitations of palliative care experience and expertise, it is possible that palliative care consultants are subject to unrecognized moral biases that impact the final resolutions of clinical-ethical conflicts. This session will draw on the experience of a panel of experts who serve both as palliative medicine and clinical ethics consultants to discuss whether palliative care consultants should concomitantly involve themselves in formal mechanisms of addressing clinical ethical disputes. The panel will use clinical cases to address the problem of dealing with moral biases and discerning when they make ethical consultation problematic. The panel will discuss the strengths and weaknesses of a range of models for relating ethics and palliative care mechanisms in the clinical setting with particular focus on how those models accentuate or mitigate unjustified biases. Audience participants will be actively engaged in the discussion. Domain Structure and Processes of Care
No Patient Left Behind: Universal Screening for Palliative Care Needs (526) Mary Hicks, RN ACHPNÒ APN-BC, St. John Hospital and Medical Center, Detroit, MI. Elizabeth Distefano, BSN RN, St. John Providence Health System, Warren, MI. Merry Davis, BA, Durham, NC. Melanie Merriman, PhD MBA, Touchstone Consulting, North Bay Village, FL.
Vol. 41 No. 1 January 2011
Elise McKenna, MPH MSEd RN, New York University, New York, NY. (All speakers for this session have disclosed no relevant financial relationships.) Objectives 1. List three benefits of universal (all patients) screening for palliative care needs. 2. Identify the primary challenges with implementation for universal screening for palliative care needs. 3. Discuss benefits and burdens of universal screening for existing palliative care teams. Are you confident your palliative care service is capturing patients at the appropriate time in their disease trajectory? Many palliative care teams struggle with evaluating patients ‘‘too late’’doften when death is quite near. As part of a 3-year initiative to increase patient access to palliative care, a palliative care screening tool (PCST) was developed and piloted in the MICU and then tested on two medical units and one oncology unit. Patients were screened twice each week during patients care rounds. Findings resulted in refinement of the tool with eventual downsizing to 11 triggers and changes in screening process. We tracked: (1) percentage of patients who had palliative care needs; (2) palliative care team referrals resulting from the PCST; (3) most common criteria leading to palliative care referral; (4) most common palliative needs for patients not referred to the team; and (5) burden reported by users of the tool. All data were analyzed for the MICU and non-MICU, separately. The tool worked well to identify patients in need of palliative care team consultation, but was less successful identifying less urgent palliative care needs. Qualitative data showed that the tool was well received in the MICU, but was a burden to use on other units due to length and complexity, as well as small number of patients it identified. The PCST data revealed ten primary reasons for referral that led to PCST replacement with ‘‘palliative care trigger tool.’’ This tool has been placed on the admission-nursing database and reviewed during dailycare rounds. Use continues to generate high referral rate in the MICU, but has not been found successful on the general inpatient units secondary to user burden and physician reluctance. The use of a screening tool and triggers did help to increase attention to palliative care needs. Domain Structure and Processes of Care
Schedule with Abstracts
of the surgeon and palliative care provider can cause stress, confusion, and distrust from the patient and family. Keeping patient goals utmost in priority and to reconcile the surgical and palliative care perspectives in end-of-life care cases will be presented by surgeons from different specialties. These presentations will provide a forum for palliative care practitioners to identify the unique surgical perspectives on palliative care. Complementing the case presentations will be a series of ‘‘cutting edge’’ questions and answers to further clarify the surgeons’ viewpoints. Using the knowledge from the cases and Q&A, the session participants will have insights into how to effectively interact with surgeons to institute appropriate palliative care for dying patients without jeopardizing either the surgical or the palliative perspective. These techniques will be broadened so after the session the participant will be able to identify and recruit local surgical ‘‘champions’’ to assist in implementing appropriate palliative care interventions in challenging surgical cases. Domain Structure and Processes of Care; Physical Aspects of Care
Palliative Care for Veterans with PTSD (524) Bettina Kehrle, MD, VA Greater Los Angeles Healthcare System, Los Angeles, CA. Jillisa Steckart VA Greater Los Angeles Healthcare System, Los Angeles, CA. Deborah Moran VA Greater Los Angeles Healthcare System, Los Angeles, CA. (All speakers for this session have disclosed no relevant financial relationships.) Objectives 1. Identify special considerations for veterans with posttraumatic stress disorder (PTSD) at the end of life. 2. Discuss appropriate and practical pharmacological and psychological interventions and management skills for veterans with PTSD at the end of life and how to use them in daily practice. Posttraumatic stress disorder (PTSD) is a condition characterized by intrusions of traumatic memories, symptoms of avoidance and numbing, and hyperarousal. It has been reported that more than 30% of veterans suffer from PTSD and suggest that this is likely an
267
underestimate of actual prevalence. The volume of veteran deaths is significant (25% of all American deaths in 2006) with most veteran deaths occurring in non-VA facilities or at home. These realities make it important for providers to understand the unique needs of veterans, particularly those with PTSD. A single-site VA study found that 17% of patients reported PTSD-related symptoms in the last month of life. Physical ill health was the most significant risk factor associated with reactivation of PTSD symptoms in late life. PTSD may be exacerbated at the end of life due to re-exposure, pain, and reaction to diagnosis of terminal illness. Often goals of care are constrained by the patient’s psychopathology and clinicians need to accept limitations on their ability to provide optimal medical treatment. Anxiety associated with PTSD may negatively influence the ability for patients to develop a trusting relationship with their medical provider and contribute to ill-feeling in their caregivers or providers. Pharmacological interventions must be considered carefully. Intense PTSD symptoms can mimic ‘‘terminal restlessness’’; however, the antidepressants, anxiolytics, and antipsychotics used to treat terminal restlessness may have a paradoxical reaction in veterans experiencing PTSD agitation. This session will use literature review, case study, and vignette to identify special considerations for veterans with PTSD at the end of life; provide an overview of appropriate and practical pharmacological and psychological interventions; and teach recognition and management skills. By the end of the session, participants will be able to identify/manage constellations of symptoms common in PTSD that could affect quality of end-of-life treatments. Domain All domains
Serving Two Masters: Should One Act as Ethics Consultant and Palliative Care Consultant? (525) Ryan Nash, MD, University of Alabama at Birmingham, Birmingham, AL. Catherine Kelso, MD MS, McGuire VA Medical Center, Richmond, VA. Farr Curlin, MD, University of Chicago, Chicago, IL. (All speakers for this session have disclosed no relevant financial relationships.)
268
Schedule with Abstracts
Objectives 1. Define and distinguish between bias, prejudice, and judgment in the process of ethical discernment, and identify examples of each. 2. Describe a variety of current models for the relationship between palliative care and clinical ethics consultation in the hospital setting. 3. Gain appreciation of varying strategies to control for unjustified moral biases in ethics consultation. These strategies deploy a range of checks and balances. In many clinical settings ethics consultants and palliative medicine consultants overlap significantly in the patients and families they encounter. Though the role of an ethics consultant differs from that of a palliative care consultant, it is common for palliative care team members to be called upon as participants in the resolution of ethical disputes. Given the particularity and limitations of palliative care experience and expertise, it is possible that palliative care consultants are subject to unrecognized moral biases that impact the final resolutions of clinical-ethical conflicts. This session will draw on the experience of a panel of experts who serve both as palliative medicine and clinical ethics consultants to discuss whether palliative care consultants should concomitantly involve themselves in formal mechanisms of addressing clinical ethical disputes. The panel will use clinical cases to address the problem of dealing with moral biases and discerning when they make ethical consultation problematic. The panel will discuss the strengths and weaknesses of a range of models for relating ethics and palliative care mechanisms in the clinical setting with particular focus on how those models accentuate or mitigate unjustified biases. Audience participants will be actively engaged in the discussion. Domain Structure and Processes of Care
No Patient Left Behind: Universal Screening for Palliative Care Needs (526) Mary Hicks, RN ACHPNÒ APN-BC, St. John Hospital and Medical Center, Detroit, MI. Elizabeth Distefano, BSN RN, St. John Providence Health System, Warren, MI. Merry Davis, BA, Durham, NC. Melanie Merriman, PhD MBA, Touchstone Consulting, North Bay Village, FL.
Vol. 41 No. 1 January 2011
Elise McKenna, MPH MSEd RN, New York University, New York, NY. (All speakers for this session have disclosed no relevant financial relationships.) Objectives 1. List three benefits of universal (all patients) screening for palliative care needs. 2. Identify the primary challenges with implementation for universal screening for palliative care needs. 3. Discuss benefits and burdens of universal screening for existing palliative care teams. Are you confident your palliative care service is capturing patients at the appropriate time in their disease trajectory? Many palliative care teams struggle with evaluating patients ‘‘too late’’doften when death is quite near. As part of a 3-year initiative to increase patient access to palliative care, a palliative care screening tool (PCST) was developed and piloted in the MICU and then tested on two medical units and one oncology unit. Patients were screened twice each week during patients care rounds. Findings resulted in refinement of the tool with eventual downsizing to 11 triggers and changes in screening process. We tracked: (1) percentage of patients who had palliative care needs; (2) palliative care team referrals resulting from the PCST; (3) most common criteria leading to palliative care referral; (4) most common palliative needs for patients not referred to the team; and (5) burden reported by users of the tool. All data were analyzed for the MICU and non-MICU, separately. The tool worked well to identify patients in need of palliative care team consultation, but was less successful identifying less urgent palliative care needs. Qualitative data showed that the tool was well received in the MICU, but was a burden to use on other units due to length and complexity, as well as small number of patients it identified. The PCST data revealed ten primary reasons for referral that led to PCST replacement with ‘‘palliative care trigger tool.’’ This tool has been placed on the admission-nursing database and reviewed during dailycare rounds. Use continues to generate high referral rate in the MICU, but has not been found successful on the general inpatient units secondary to user burden and physician reluctance. The use of a screening tool and triggers did help to increase attention to palliative care needs. Domain Structure and Processes of Care