Webinar presented by VITAS Healthcare on October 13, 2016. Presented by B. David Blake, MD, DABFM

1. Introduction to Palliative Care
Developed by:
Barry M. Kinzbrunner, MD, FACP
Chief Medical Officer
VITAS® Healthcare
Miami, Florida
Presented by: Dr. Bryan Blake

2. Goal
To provide an overview of palliative care services and how
they fit into the continuum of care

3. Objectives
At the conclusion of this presentation participants will be
able to:
• Articulate a rationale for palliative care based on barriers to
hospice access
• Compare and contrast palliative care and hospice services
• Describe the different locations where palliative care may be
provided and the indications for palliative care services
• Appreciate the role of palliative care as a key element in the
continuum of care

4. Definitions
Palliative care
• “Palliare,” Latin: to cloak
• “Care provided to treat the symptoms of an illness without
curing or affecting the underlying illness”
• Examples
– Insulin “palliates” diabetes
– Lasix “palliates” congestive heart failure

5. Definitions
Supportive Care
• “Aspects of medical care concerned with the physical,
psychosocial and spiritual issues faced by persons with a
particular illness (i.e.cancer)”
• Includes family and community
• Includes palliation of symptoms of the disease and
management of untoward effects of treatment

6. Definitions
End-of-Life Care
• Care rendered to individuals who are near death or for whom death
is expected in a relatively finite period of time
• Includes supportive care, palliative care, hospice care
• May be provided in virtually any setting where someone may die
– ICU
– Acute care hospital
– LTCF
– ALF
– Private residence

7. Definitions
Hospice Care
• Team-oriented approach to end-of-life care
• Expert in medical care, pain and symptom management and
emotional and spiritual support
• Tailored to the patient’s needs and wishes
• Support to loved ones as well
• Provided in any setting

8. The Case for Palliative Care
What happens to the approximately 56% of patients who do not
die on a hospice program?
• Sudden death
• Accidental death
• Acute illness
• Chronic progressive illness not accessing hospice(why do they not
receive hospice care?)

9. Barriers to Hospice Access
• Six month prognosis requirement
• Communication
- Hospice requires Informed Consent
- Physicians do not want to tell patients
- Patients and families do not want to be told
• Lack of inpatient relationships between hospices and hospitals
• Hospice reluctance to allow “disease-directed” therapy
Wright JB, Kinzbrunner BM: How to assist patients and families in accessing
end-of life care. Chapter 2 in Kinzbrunner BM, Policzer JS (eds): End-of-Life
Care: A Practical Guide. New York: McGraw Hill, 2011, p. 37

10. Theoretical Trajectories of Dying
Lunney, J. R. et al. JAMA 2003;289:2387-2392

11. Six Month Prognosis Requirement
Variable trajectory of death
• Sudden death
• Terminal illness: cancer
– Functional decline several months before death
– Relatively steady decline
• Progressive organ failure
- Waxing and waning course of illness
• Frailty
- Very poor functional status to start with
- Variable decline less perceptible due to poor baseline status

12. Communication
Phase II: Intervention to improve communication
• Patient-specific information given to the physician
– Probability of six month survival
– Risk of patient functional disability
• Nurses were trained to facilitate patient/physician communication:
– Elicit patient family preferences
– Facilitate advance care planning
– Improve family understanding of probable outcomes
– Improve pain control
• Intervention was not successful
SUPPORT Principal Investigators: A controlled trial to improve care for seriously
ill hospitalized patients. The study to understand prognoses and preferences for
outcomes and risks of treatments (SUPPORT). JAMA 274:1591-1598, 1995

13. Lack of inpatient relationships
between hospices and hospitals
SUPPORT Study Phase I
• “Shortcomings” in hospital care
– Physician/patient/family communications
– Physician knowledge of patient preferences regarding CPR
– Number of days spent in the ICU
– Pain control
• Majority of deaths occur in hospital
– 65% in 1990s
– 53% in early 2000s
SUPPORT Principal Investigators: A controlled trial to improve care for seriously
ill hospitalized patients. The study to understand prognoses and preferences
for outcomes and risks of treatments (SUPPORT). JAMA 274:1591-1598, 1995

14. Hospice reluctance to allow
“disease-directed” therapy
• Patients often have an unrealistic outlook regarding the potential
efficacy of disease directed therapy
• Hospice staff is not trained in the proper handling of some of the
more complex disease-directed treatments available today
• Cost of disease directed therapy and related supportive
medications in the face of fixed per diem reimbursement
Wright JB, Kinzbrunner BM: How to assist patients and families in accessing
end-of life care. Chapter 2 in Kinzbrunner BM, Policzer JS (eds): End-of-Life
Care: A Practical Guide. New York: McGraw Hill, 2011, p. 37

15. Institute of Medicine: 1997
Study on End-of-Life Care
• Improve patient education
• Improve education of physicians and other health care providers
• Relax regulatory barriers that impede proper management of pain
and suffering
• Create research initiatives
• Elevate palliative care to a defined specialty area

16. Palliative Care Services
• Extends principles of hospice care to a broader population
• Earlier in disease course than hospice
• Comprehensive and specialized
• Pain and symptom management, advance care planning,
psychosocial and spiritual support, coordination of care
• Definition may be able to be expanded to all aspects of medical
care

17. Palliative Care Programs
Goals:
• Increase patient access to end-of-life care
• Reach patients who are not currently being reached by hospice
• Overcome barriers to hospice access
Wright JB, Kinzbrunner BM: How to assist patients and families in accessing
end-of life care. Chapter 2 in Kinzbrunner BM, Policzer JS (eds): End-of-Life
Care: A Practical Guide. New York: McGraw Hill, 2011, p. 37

18. Hospice
Hospice
Palliative Care
• Palliative Care can
be provided to
patients who are not
terminally ill or
eligible for hospice
• Hospice can be
considered palliative
care for the
terminally ill

19. Comparison of Hospice &
Palliative Care Programs
Wright JB, Kinzbrunner BM: How to assist patients and families in accessing
end-of life care. Chapter 2 in Kinzbrunner BM, Policzer JS (eds): End-of-Life
Care: A Practical Guide. New York: McGraw Hill, 2011, p. 37
Eligibility Prognosis < 6 months None required
Determined by program
Other services
Professional
Services
Interdisciplinary team
Physician
Nurse
Social Worker
Pastoral counselor
Certified nursing assistants
Others as need
Inter or multidisciplinary team
Physician
Nurse
Social Worker
Others as needed
Medications
DME
Bereavement care
Others (see Table 1-2)
No required services.
Determined by program.
Characteristic Hospice Palliative Care
Location of Services
Characteristic Hospice Palliative Care
Comprehensive
Home care
LTCF
Inpatient
Based on program
Some Comprehensive
Some inpatient only
Some LTCF based

20. Comparison of Hospice &
Palliative Care Programs (Cont.)
Wright JB, Kinzbrunner BM: How to assist patients and families in accessing
end-of life care. Chapter 2 in Kinzbrunner BM, Policzer JS (eds): End-of-Life
Care: A Practical Guide. New York: McGraw Hill, 2011, p. 37
Other services
Social Worker
Pastoral counselor
Certified nursing assistants
Others as need
Social Worker
Others as needed
Medications
DME
Bereavement care
Others (see Table 1-2)
No required services.
Determined by program.
Location of Services
Characteristic Hospice Palliative Care
Funding
Comprehensive
Home care
LTCF
Inpatient
Based on program
Some Comprehensive
Some inpatient only
Some LTCF based
Some require networking
between hospital and
hospice or home based
home-health programs
Medicare Hospice Benefit
State Medicaid programs
HMOs and commercial insurers
Charity (not for profit hospices)
Traditional hospital coverage
Traditional home care coverage
Support from hospitals and
hospice partner organizations
Grants
Charity

21. Eligibility
• Hospice
– Prognosis of < = six months
• Palliative care
– No specific eligibility requirement
– Determined by provider
Comparison of Hospice &
Palliative Care Programs (Cont.)
Wright JB, Kinzbrunner BM: How to assist patients and families in accessing
end-of life care. Chapter 2 in Kinzbrunner BM, Policzer JS (eds): End-of-Life
Care: A Practical Guide. New York: McGraw Hill, 2011, p. 37

22. Comparison of Hospice &
Palliative Care Programs (Cont.)
Professional Services
• Hospice: defined interdisciplinary team
– Physician
– Social Worker
– Certified Nursing Ass’t
– Nurse
– Pastoral Counselor
– Others
Wright JB, Kinzbrunner BM: How to assist patients and families in accessing
end-of life care. Chapter 2 in Kinzbrunner BM, Policzer JS (eds): End-of-Life
Care: A Practical Guide. New York: McGraw Hill, 2011, p. 37

23. Comparison of Hospice &
Palliative Care Programs (Cont.)
Professional Services
• Palliative Care: inter-or multi-disciplinary team consisting of one or
more of the following:
– Physician
– Nurse Practitioner
– Others as needed
• May be less of an issue as standards are introduced defining
minimum professional requirements for Palliative Care Teams
Wright JB, Kinzbrunner BM: How to assist patients and families in accessing
end-of life care. Chapter 2 in Kinzbrunner BM, Policzer JS (eds): End-of-Life
Care: A Practical Guide. New York: McGraw Hill, 2011, p. 37
– Nurse
– Social Worker

24. Other Covered Services
• Hospice
– Medications
– DME
– Bereavement Care
• Palliative care
– No required services
– Most non-professional services are provided by existing
insurance coverage if available
Comparison of Hospice &
Palliative Care Programs (Cont.)
Wright JB, Kinzbrunner BM: How to assist patients and families in accessing
end-of life care. Chapter 2 in Kinzbrunner BM, Policzer JS (eds): End-of-Life
Care: A Practical Guide. New York: McGraw Hill, 2011, p. 37

25. Location of services
• Hospice: Availability of services required in all locations
– Private Residence
– Nursing Home
– Adult Living
– Inpatient Care
Comparison of Hospice &
Palliative Care Programs (Cont.)
Wright JB, Kinzbrunner BM: How to assist patients and families in accessing
end-of life care. Chapter 2 in Kinzbrunner BM, Policzer JS (eds): End-of-Life
Care: A Practical Guide. New York: McGraw Hill, 2011, p. 37

26. Location of services
• Palliative Care: Varies based on program
– Home care only
– Inpatient only
– Nursing home only
– Combination
– Networking between hospital and hospice or home-based
home-health program
Comparison of Hospice &
Palliative Care Programs (Cont.)
Wright JB, Kinzbrunner BM: How to assist patients and families in accessing
end-of life care. Chapter 2 in Kinzbrunner BM, Policzer JS (eds): End-of-Life
Care: A Practical Guide. New York: McGraw Hill, 2011, p. 37

27. Current funding sources
• Hospice
– Medicare Hospice Benefit
– Most state Medicaid programs
– MCOs and commercial carriers
– Charitable funding to supplement cost of care can be raised by
non-profit hospices
• Palliative care
– Traditional hospital insurance coverage
– Traditional home health care coverage
– Support from hospital and hospice partner organizations
– Charitable funding
Comparison of Hospice &
Palliative Care Programs (Cont.)
Wright JB, Kinzbrunner BM: How to assist patients and families in accessing
end-of life care. Chapter 2 in Kinzbrunner BM, Policzer JS (eds): End-of-Life
Care: A Practical Guide. New York: McGraw Hill, 2011, p. 37

28. Palliative Medicine Recognition
• Hospice & Palliative Medicine
– 2006 - recognized by American Board of Medical
Specialties (ABMS)
– 2007 - recognized by American Osteopathic Association
(AOA)
– 2008 - first board exam offered by ABIM, >1400 examinees
• Certification also available for:
– Nurse Practitioners
– Registered Nurses
– Licensed Clinical Social Workers

29. Palliative Care Programs
Hospital-based Palliative Care
• Interdisciplinary or multi-disciplinary
• Typically physician led
• Physician consults with supplementation by other
disciplines
• Some academic centers and hospitals have discreet
inpatient units
• ICU consults to facilitate end of life decision making
• Reduces ICU utilization
Wright JB, Kinzbrunner BM: How to assist patients and families in accessing
end-of life care. Chapter 2 in Kinzbrunner BM, Policzer JS (eds): End-of-Life
Care: A Practical Guide. New York: McGraw Hill, 2011, p. 37

30. Palliative Care Programs (Cont.)
Hospital-based Palliative Care
• Reimbursement through traditional system
– No specific reimbursement stream for “palliative care”
– Physician consults
– DRGs for hospital care
• Savings by reducing ICU and inpatient days
• Improved quality of inpatient care
• May partner with a hospice to provide more
comprehensive services
Wright JB, Kinzbrunner BM: How to assist patients and families in accessing
end-of life care. Chapter 2 in Kinzbrunner BM, Policzer JS (eds): End-of-Life
Care: A Practical Guide. New York: McGraw Hill, 2011, p. 37

31. Palliative Care Programs (Cont.)
Long-term care palliative care
• Need for palliative care for patients accessing Medicare Part A
for nursing home care
• Physician consult services
• Partnerships with hospices
Wright JB, Kinzbrunner BM: How to assist patients and families in accessing
end-of life care. Chapter 2 in Kinzbrunner BM, Policzer JS (eds): End-of-Life
Care: A Practical Guide. New York: McGraw Hill, 2011, p. 37

32. Palliative Care Programs (Cont.)
Home-based palliative care
• Home health agency services
• May be independent or affiliated with a hospice program
• Patients need to be home-care eligible
• Pre-hospice “bridge” programs
– Affiliated with hospice
– Reimbursed as home health agencies
– Hospice or hospice trained staff
Wright JB, Kinzbrunner BM: How to assist patients and families in accessing
end-of life care. Chapter 2 in Kinzbrunner BM, Policzer JS (eds): End-of-Life
Care: A Practical Guide. New York: McGraw Hill, 2011, p. 37

33. Home-based palliative care
• Pre-hospice “bridge” programs
– Affiliated with hospice and reimbursed as HHA
– Hospice or hospice trained staff
– Longer median survival (52 vs. 20 days)
– Supplementary funding for non-covered services
– Patients living > six months doubled from 6-13%
– Patients were hospice eligible
– No data on why patients did not elect hospice
– May have desired treatment hospice was unwilling
to provide
Effectiveness of Palliative Care
Casarett D, Abrahm JL: Patients with cancer referred to a hospice versus
a bridge program: Patient characteristics, needs for care, and survival. J
Clin Oncol 19:2057, 2001.

34. Disease-based palliative care
• Focused on special needs of patients with specific chronic and
potentially terminal Illnesses
– Cancer
– HIV
– Pediatrics
– Dementia
Palliative Care Programs (Cont.)
Wright JB, Kinzbrunner BM: How to assist patients and families in accessing
end-of life care. Chapter 2 in Kinzbrunner BM, Policzer JS (eds): End-of-Life
Care: A Practical Guide. New York: McGraw Hill, 2011, p. 37.

35. Common Reasons for Palliative
Care Consults
• Goals of care identification/advance care planning
• Coordination of care across settings
• Complex pain and symptom management
• Counseling and emotional support
• Spiritual support
• Physician support w/complex decision making
– (e.g. tube feeding, withdrawal of dialysis)

36. Effectiveness of Palliative Care
Hospital-based palliative care consultation
Results of retrospective analysis at two VA centers:
• Total inpatient direct costs
– PC: $ 1000
• Ancillary costs
– PC: $ 123
• PC patients were 42% less likely to use ICU
• No difference in inpatient pharmacy costs
– Non-PC: $ 1239 Diff: $ 239
– Non-PC: $ 221 Diff: $ 98
Penrod JD, et al. Cost and utilization outcomes of patients receiving
hospital-based palliative care consultation. J Pall Med 9(4):855-860, 2006.

37. Effectiveness of Palliative
Care (Cont.)
Inpatient palliative care team: RCT
• Multi-center randomized trial
• Inpatient palliative care service (IPCS) vs. usual care (UC)
Results
• Hospice utilization: median LOS
– IPCS: 24 days – UC: 12 days (p = 0.04)
• Advance directives at hospital discharge
– IPCS: 91.1% – UC: 77.8% (p = 0.001)
– No difference in % of patients with ADs prior to study
• Mean satisfaction with hospital care and providers
– Place: IPCS: 6.8 – UC: 6.4 (p = < 0.001)
– Providers: IPCS: 8.3 – UC: 7.2 (p = < 0.001)
• No differences in survival or symptom control
Gade G, et al. Impact of an inpatient palliative care team: A
randomized control trial. J Pall Med 11(2):180-190, 2008.

38. Effectiveness of Palliative
Care (Cont.)
Results
Total healthcare expenditures for six months following index hospitalization:
• Total mean costs
– IPCS: $14,486 – UC: $21,252 Diff: $6,766 (p = 0.001)
• Net savings after subtracting consult staff costs
– Net savings: $4,855 – Staffing cost: $1,911
• Number of hospital readmissions was not different between the two groups
during the six months following index hospitalization
• Cost of hospital readmission during the six months
– IPCS: $6,241 – UC: $13,275 (p = 0.009)
• Number of ICU stays on readmission
– IPCS: 12 – UC: 21 (p = 0.04)
Gade G, et al. Impact of an inpatient palliative care team: A
randomized control trial. J Pall Med 11(2):180-190, 2008.

39. Effectiveness of Palliative
Care (Cont.)
Zhang B, et al. Health care costs in the last week of life. Associations with end of
life conversations. Arch Int Med 169(5):480-488, 2009
Health care costs and EOL conversations
• 603 patients with advanced cancer
• Interviewed at baseline and followed to death
• All costs in the last week of life—ICU, hospital, hospice and life-sustaining
procedures including resuscitation and ventilation—were aggregated
Results
• 188 (31.2%) reported EOL discussion at baseline
• Costs of care in last week
– w/EOL: $1876 – wo/EOL: $2917 Diff: $1041 (p = 0.002)
• Patients with higher costs had worse quality of death in their final week
(p = 0.006)

40. Early Palliative Care in Cancer
Patients
• Significant improvement of quality of life of life at 12 weeks as
measured by three validated instruments
• Significantly lower percentage of patients with depression and
anxiety
• Significant improvement in patient survival up to two years
following diagnosis
Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with
metastatic non-small-cell lung cancer. N Engl J Med 363:733-742, 2010

41. Survival of patients with metastatic non-small cell lung cancer
patients receiving early palliative care interventions alongside
chemotherapy
Early Palliative Care in Cancer
Patients (Cont.)
Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with
metastatic non-small-cell lung cancer. N Engl J Med 363:733-742, 2010

42. Hospice/Palliative Care Interface
Traditional Model of Health Care
Emanuel, von Gunten, Ferris. Plenary 3: EPEC series and reproduced in
Kinzbrunner. Palliative Care Perspectives, Chapter 1 in Kuebler, Davis,Moore
Palliative Practices, An Interdisciplinary Approach, 2005, p. 21

43. Hospice/Palliative Care Interface
(Cont.)
Integrated Palliative Care Model
Modified From Emanuel, von Gunten, Ferris. Plenary 3:EPEC series and reproduced in
Kinzbrunner. Palliative Care Perspectives, Chapter 1 inKuebler, Davis, Moore Palliative
Practices, An Interdisciplinary Approach, 2005, p. 22.

44. For those eligible to obtain CE credit:
1. Enter the following website information in your web
browser:
www.VIT.CmeCertificateOnline.com
2. Click on the link:
Introduction to Palliative Care– 10.13.16
3. You will be asked to complete a brief questionnaire,
and your certificate will be available to print immediately
afterward. A copy of the certificate will also be sent to
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