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To Eat or Not to Eat: Managing Dysphagia at End of Life (FR435)
358
Schedule with Abstracts
palliative medicine provider that spans the continuum of serious illness. Each program’s leader will describe its objectives, structure, staffing, workflow, and metrics, as well as sharing program development ‘‘pearls’’ and lessons learned. Participants will then be invited to share opportunities and challenges to palliative care payment change within their own healthcare environments. Our presenters will serve as a panel to respond and stimulate discussion around the key elements of successful innovation and strategies to overcome barriers.
Clinic-Based Palliative Care: Lessons Learned (FR433) Anna Skold, MD MPH, The Southeast Permanente Medical Group Palliative Care, Decatur, GA. Allison Riendeau, PharmD BCACP, Kaiser Permanente, Atlanta, GA. Jane Dausner, MSW, Kaiser Permanente, Atlanta, GA. Cathy Anderson, MDiv BCC, The Southeast Permanente Medical Group, Kennesaw, GA. Ashley Stowers, RN CHPN, Kaiser Permanente, Atlanta, GA. Objectives List two ways of incorporating palliative care into other outpatient multidisciplinary healthcare groups. Describe ‘‘pre-palliative care’’ processes, which may help up-stream patients receive benefits from palliative care clinics. Explain pre-palliative care clinic processes, which increase effectiveness of the palliative care encounter. The Kaiser Permanente (KP) Healthcare system often has been a leader in the movement of palliative care. In this 1-hour session, we would like to present the Georgia KP model for outpatient palliative care clinics, highlighting the interdisciplinary team approach of physician, nurse, chaplain, social worker, and PharmD. We will use a case-based approach to accentuate new areas for improvement in outpatient palliative care. The cases will highlight 1) the incorporation of palliative care team members into interdisciplinary care such as the heart failure clinic, tumor board, and patient education sessions; 2) pre-clinic phone calls by PharmD to complete med recquisitions, check for interactions, discuss how medicines should be taken, perform symptom assessment, and discover amounts of opioid requirements; 3) explanation and review of a program entitled Advanced Illness Care Coordination (AICC), which is six free sessions with a palliative-trained LCSW focusing on adjustment disorder related to a new diagnosis, coping strategies, and
Vol. 51 No. 2 February 2016
resources; and 4) discussion regarding use of direct access to the clinic and scheduled phone call followups for questions, symptom checks, and direct referrals to home hospice, when needed. The purpose of this talk is to feature best practices and discuss new opportunities in how palliative care can be more broadly used and incorporated into a systemic approach to quality care.
Prognostication, Relatedness, and the Hospice Formulary: Where Are We, and Where Are We Going? Part 1 (FR434) Robert Crook, MD FACP, Mount Carmel Health System, Columbus, OH. Joan Harrold, MD MPH FACP HMDC FAAHPM, Hospice & Community Care, Lancaster, PA. Judi Lund Person, MPH, National Hospice & Palliative Care Organization, Alexandria, VA. Rebecca Sears, MSN RN, Mount Carmel Health System, Columbus, OH. Objectives Understand the current hospice regulatory environment. Identify common indicators of decline, regardless of diagnosis, and implications for the CTI. Discuss disease-specific prognostic indicators, commonly-related conditions, and hospice provision of medications. Presentation 1 of 2: New and ever changing regulations for hospices continue to challenge us to improve our documentation, streamline our processes, and determine relatedness and coverage of diagnoses and medications. Join us to review general and disease specific prognostic indicators, enhance CTIs to support hospice eligibility, and explore common issues around determining diagnostic relatedness and hospice provision of medications. This session will include an up-to-date report on current and proposed regulations; development and structure of a persuasive CTI; and tools to help your program to determine relatedness of diagnoses and coverage of medications.
To Eat or Not to Eat: Managing Dysphagia at End of Life (FR435) Lauren Buning, MS CCC-SLP, University of Kansas Hospital, Kansas City, KS. Kylie Bullock, MA L/CCCSLP, University of Kansas Hospital Authority, Kansas City, KS. Objectives Understand how the anatomy and physiology of the swallow mechanism is impacted by compensatory swallow techniques.
Vol. 51 No. 2 February 2016
Schedule with Abstracts
Identify evidence-based considerations for patients choosing PO intake despite risk for aspiration pneumonia. Understand the role of the speech-language pathologist in management of patients with dysphagia receiving palliative services across the lifespan. Dysphagia is a common diagnosis for many of our patients nearing end of life. Our goal within the session is to empower physicians along with other helping professionals to improve management of patients with swallow disorders receiving palliative services. We will help to develop a better understanding of the anatomy and physiology of the swallow mechanism to improve use of bedside compensatory swallow techniques as well as outline the patient populations that are appropriate for PO intake at end of life. As speech-language pathologists, we will outline our role to assist and develop an evidence-based toolkit with strategies to improve comfort with eating/drinking, reduce aspiration risk, and further prevent pulmonary disease.
Not Just Another Pretty Face: Botulinum Toxin Gives Symptom Control in Palliative Care a Facelift (FR436) April Zehm, MD, Massachusetts General Hospital, Boston, MA. Mihir Kamdar, MD, Massachusetts General Hospital, Boston, MA. Objectives Describe how botulinum toxin exerts its therapeutic effects. Summarize current literature regarding palliative uses of botulinum toxin. Recognize practical aspects of therapeutic botulinum toxin use in the palliative care setting. To the public and most clinicians, the use of botulinum toxin is commonly associated solely with cosmetic indications. Surprisingly, the use of botulinum toxin is a novel yet underutilized therapeutic that can improve the quality of life for patients with refractory musculoskeletal and neuropathic pain syndromes, sialorrhea, and even depression. We will present the case of a woman with recurrent oral squamous cell carcinoma status after extensive head-andneck surgery followed by concurrent chemoradiation whose course was complicated by debilitating muscle spasms and neck pain that was refractory to a multimodal therapeutic approach, and for which botulinum toxin was considered. Botulinum neurotoxin is a potent toxin that can be used as an analgesic and muscle relaxant; it has emerged as both a primary and adjunctive treatment for musculoskeletal and neuropathic pain, spasticity and dystonia, migraines, sialorrhea, and many other
359
disorders. We will review its mechanisms of action, potential benefits, risks, and barriers to its use, and our patient’s response to treatment. We will then review common cancer- and treatment-related pain syndromes for which botulinum toxin may be helpful, including oromandibular dystonia, spasticity, postmastectomy and post-thoracotomy pain, sialorrhea related to ALS and Parkinson’s disease, and depression. We will analyze the current literature involving palliative uses of botulinum toxin, including results of recent randomized controlled trials of this therapy. We will also provide guidance regarding which patients will benefit most from this advanced symptom management strategy. Transcutaneous botulinum toxin injection is becoming more readily available for patients suffering from disease- and treatment-related pain and other symptoms. Palliative care clinicians should understand its role, be aware of existing barriers to its use, and identify patients likely to respond.
Pediatric VAD: A Bridge to NowheredLessons Learned as a Result of One Child’s Suffering (FR437) Carly Levy, MD, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE. Shylah Haldeman, MSN NP-C, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE. Laurel Stanley Glynn, MSW ACHP-SW LCSW OSW-C, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE. Ryan Davies, MD, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE. Michael McCulloch, MD, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE. Objectives Describe via case report a pediatric ventricular assist device (VAD) implantation and review complications that arose when transplantation was no longer an option. Identify psychosocial factors that hindered care of patient and family. Discuss barriers to re-goaling and approaches to partnering with families in extreme circumstances. Background. In 2013, 64 pediatric patients underwent ventricular assist device (VAD) implantation in the United States. To date, no preparedness planning guidelines exist for this population. We will present a case of VAD placement as a bridge-to-transplantation and discuss the lessons learned and practice change following the complications that arose when transplant was no longer an option. Case Description. A 10-year-old male with an extracorporeal VAD suffered a debilitating stroke while awaiting cardiac re-transplantation. He was inactivated
Schedule with Abstracts
palliative medicine provider that spans the continuum of serious illness. Each program’s leader will describe its objectives, structure, staffing, workflow, and metrics, as well as sharing program development ‘‘pearls’’ and lessons learned. Participants will then be invited to share opportunities and challenges to palliative care payment change within their own healthcare environments. Our presenters will serve as a panel to respond and stimulate discussion around the key elements of successful innovation and strategies to overcome barriers.
Clinic-Based Palliative Care: Lessons Learned (FR433) Anna Skold, MD MPH, The Southeast Permanente Medical Group Palliative Care, Decatur, GA. Allison Riendeau, PharmD BCACP, Kaiser Permanente, Atlanta, GA. Jane Dausner, MSW, Kaiser Permanente, Atlanta, GA. Cathy Anderson, MDiv BCC, The Southeast Permanente Medical Group, Kennesaw, GA. Ashley Stowers, RN CHPN, Kaiser Permanente, Atlanta, GA. Objectives List two ways of incorporating palliative care into other outpatient multidisciplinary healthcare groups. Describe ‘‘pre-palliative care’’ processes, which may help up-stream patients receive benefits from palliative care clinics. Explain pre-palliative care clinic processes, which increase effectiveness of the palliative care encounter. The Kaiser Permanente (KP) Healthcare system often has been a leader in the movement of palliative care. In this 1-hour session, we would like to present the Georgia KP model for outpatient palliative care clinics, highlighting the interdisciplinary team approach of physician, nurse, chaplain, social worker, and PharmD. We will use a case-based approach to accentuate new areas for improvement in outpatient palliative care. The cases will highlight 1) the incorporation of palliative care team members into interdisciplinary care such as the heart failure clinic, tumor board, and patient education sessions; 2) pre-clinic phone calls by PharmD to complete med recquisitions, check for interactions, discuss how medicines should be taken, perform symptom assessment, and discover amounts of opioid requirements; 3) explanation and review of a program entitled Advanced Illness Care Coordination (AICC), which is six free sessions with a palliative-trained LCSW focusing on adjustment disorder related to a new diagnosis, coping strategies, and
Vol. 51 No. 2 February 2016
resources; and 4) discussion regarding use of direct access to the clinic and scheduled phone call followups for questions, symptom checks, and direct referrals to home hospice, when needed. The purpose of this talk is to feature best practices and discuss new opportunities in how palliative care can be more broadly used and incorporated into a systemic approach to quality care.
Prognostication, Relatedness, and the Hospice Formulary: Where Are We, and Where Are We Going? Part 1 (FR434) Robert Crook, MD FACP, Mount Carmel Health System, Columbus, OH. Joan Harrold, MD MPH FACP HMDC FAAHPM, Hospice & Community Care, Lancaster, PA. Judi Lund Person, MPH, National Hospice & Palliative Care Organization, Alexandria, VA. Rebecca Sears, MSN RN, Mount Carmel Health System, Columbus, OH. Objectives Understand the current hospice regulatory environment. Identify common indicators of decline, regardless of diagnosis, and implications for the CTI. Discuss disease-specific prognostic indicators, commonly-related conditions, and hospice provision of medications. Presentation 1 of 2: New and ever changing regulations for hospices continue to challenge us to improve our documentation, streamline our processes, and determine relatedness and coverage of diagnoses and medications. Join us to review general and disease specific prognostic indicators, enhance CTIs to support hospice eligibility, and explore common issues around determining diagnostic relatedness and hospice provision of medications. This session will include an up-to-date report on current and proposed regulations; development and structure of a persuasive CTI; and tools to help your program to determine relatedness of diagnoses and coverage of medications.
To Eat or Not to Eat: Managing Dysphagia at End of Life (FR435) Lauren Buning, MS CCC-SLP, University of Kansas Hospital, Kansas City, KS. Kylie Bullock, MA L/CCCSLP, University of Kansas Hospital Authority, Kansas City, KS. Objectives Understand how the anatomy and physiology of the swallow mechanism is impacted by compensatory swallow techniques.
Vol. 51 No. 2 February 2016
Schedule with Abstracts
Identify evidence-based considerations for patients choosing PO intake despite risk for aspiration pneumonia. Understand the role of the speech-language pathologist in management of patients with dysphagia receiving palliative services across the lifespan. Dysphagia is a common diagnosis for many of our patients nearing end of life. Our goal within the session is to empower physicians along with other helping professionals to improve management of patients with swallow disorders receiving palliative services. We will help to develop a better understanding of the anatomy and physiology of the swallow mechanism to improve use of bedside compensatory swallow techniques as well as outline the patient populations that are appropriate for PO intake at end of life. As speech-language pathologists, we will outline our role to assist and develop an evidence-based toolkit with strategies to improve comfort with eating/drinking, reduce aspiration risk, and further prevent pulmonary disease.
Not Just Another Pretty Face: Botulinum Toxin Gives Symptom Control in Palliative Care a Facelift (FR436) April Zehm, MD, Massachusetts General Hospital, Boston, MA. Mihir Kamdar, MD, Massachusetts General Hospital, Boston, MA. Objectives Describe how botulinum toxin exerts its therapeutic effects. Summarize current literature regarding palliative uses of botulinum toxin. Recognize practical aspects of therapeutic botulinum toxin use in the palliative care setting. To the public and most clinicians, the use of botulinum toxin is commonly associated solely with cosmetic indications. Surprisingly, the use of botulinum toxin is a novel yet underutilized therapeutic that can improve the quality of life for patients with refractory musculoskeletal and neuropathic pain syndromes, sialorrhea, and even depression. We will present the case of a woman with recurrent oral squamous cell carcinoma status after extensive head-andneck surgery followed by concurrent chemoradiation whose course was complicated by debilitating muscle spasms and neck pain that was refractory to a multimodal therapeutic approach, and for which botulinum toxin was considered. Botulinum neurotoxin is a potent toxin that can be used as an analgesic and muscle relaxant; it has emerged as both a primary and adjunctive treatment for musculoskeletal and neuropathic pain, spasticity and dystonia, migraines, sialorrhea, and many other
359
disorders. We will review its mechanisms of action, potential benefits, risks, and barriers to its use, and our patient’s response to treatment. We will then review common cancer- and treatment-related pain syndromes for which botulinum toxin may be helpful, including oromandibular dystonia, spasticity, postmastectomy and post-thoracotomy pain, sialorrhea related to ALS and Parkinson’s disease, and depression. We will analyze the current literature involving palliative uses of botulinum toxin, including results of recent randomized controlled trials of this therapy. We will also provide guidance regarding which patients will benefit most from this advanced symptom management strategy. Transcutaneous botulinum toxin injection is becoming more readily available for patients suffering from disease- and treatment-related pain and other symptoms. Palliative care clinicians should understand its role, be aware of existing barriers to its use, and identify patients likely to respond.
Pediatric VAD: A Bridge to NowheredLessons Learned as a Result of One Child’s Suffering (FR437) Carly Levy, MD, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE. Shylah Haldeman, MSN NP-C, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE. Laurel Stanley Glynn, MSW ACHP-SW LCSW OSW-C, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE. Ryan Davies, MD, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE. Michael McCulloch, MD, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE. Objectives Describe via case report a pediatric ventricular assist device (VAD) implantation and review complications that arose when transplantation was no longer an option. Identify psychosocial factors that hindered care of patient and family. Discuss barriers to re-goaling and approaches to partnering with families in extreme circumstances. Background. In 2013, 64 pediatric patients underwent ventricular assist device (VAD) implantation in the United States. To date, no preparedness planning guidelines exist for this population. We will present a case of VAD placement as a bridge-to-transplantation and discuss the lessons learned and practice change following the complications that arose when transplant was no longer an option. Case Description. A 10-year-old male with an extracorporeal VAD suffered a debilitating stroke while awaiting cardiac re-transplantation. He was inactivated