Northeast Florida Medicine, Spring 2016

Vol. 67, No. 1 2016

Northeast Florida Medicine

DCMS online

. org

Palliative Care

and relief of suffering by means of early identification and

impeccable assessment and treatment of pain and other

problems: physical, psychosocial, and spiritual.

Note that

there is no prognostic limiting factor; for example: a life

expectancy of six months or fewer.The authors’ operational

definition is “to assess, anticipate and alleviate suffering.”

Appropriate candidates for palliative care consultations

include patients with newly diagnosed metastatic cancer,

not merely when all curative modalities fail. Rather, the

early introduction of palliative philosophy and treatment

modalities allows life extending and symptom mitigation

strategies to enhance one’s quality of life and, occasionally,

quantity of life. A sentinel study from the New England

Journal of Medicine demonstrated improved quality of life,

reduced costs and life extension when early palliative care

principles were integrated with standard oncology care.

Moreover, the American Society of Clinical Oncology

has suggested that palliative care be fully integrated in

standard oncology practice in the not too distant future.

Optimally, it should be integrated prior to a crisis in the

emergency room and referred in the outpatient setting.

With time and the practical wisdom of palliative care

physicians guiding the patient and family, in concert with

the primary care physician, all will eventually benefit

from hospice care. Ask yourself the standard “surprise”

question: “Would you be surprised if this patient would

die in the next year?” If not surprised, this is an appro-

priate candidate for hospice referral and most certainly

for a palliative care referral. Palliative care is the “bridge

to hospice.”

Most physicians embrace facets of palliative care; howev-

er, when the patient needs or requests a consultation, the

option of consultative palliative care prevails. Outpatient

and inpatient palliative care consultations are time inten-

sive, patient centered and family inclusive. Regrettably, the

inpatient consultations are often performed in crisis mode

and are often complex, contentious and challenging to

everyone, including the care team. The primary consulta-

tion request for inpatient consultation continues to focus

on variations of “clarification of treatment goals,” and, to

a lesser extent, on symptom evaluation and management.

The family conference typically includes the patient (if

able), the surrogate, all interested family members and

the palliative medicine physicians with other care team

members who are able to participate. The chaplain is

also an important member of the team who is often able

to assist in keeping the focus open and respectful of the

existential aspects of care.

As the referring consultants recognize the value of early

integration of palliative principles, palliative care physicians

are seeing complex symptoms in patients who possess a

higher functional capacity earlier in their disease trajectory,

facilitating advance care planning (ACP). In addition to the

symptom evaluations and treatments, these consultations

are not “reactive” and “crisis-oriented.” Parenthetically, this

is more emotionally tolerable and gratifying. Furthermore,

it recapitulates the inherent notion of living well facing

a non-curable condition. “It is not about dying well! It

really is about living well! We will discern and discover

that which matters the most and develop a plan to meet

your goals.”

The process of the consultations includes evaluation

and documentation of the domains of care as outlined by

the National Consensus Project and other publications.

Briefly, the 8 Domains of Care

include:

Domain 1-

Structure and Process of Care:

This domain includes an interdisciplinary team (IDT)

comprehensively assessing the needs of the patient with

transition to hospice, as appropriate.

Domain 2-

Physical Aspects of Care:

This domain uses best practices to evaluate and ameliorate

pain and other troublesome symptoms in informed-deci-

sion settings effectively communicated to the patient and

care-team.

Domain 3-

Psychological and Psychiatric Aspects of Care:

This domain attempts to assess, analyze and alleviate pain

by pharmacologic, nonpharmacologic and complementary

therapies. Grief and bereavement care is offered.

Table 1:

Functional Assessment Screening Tool for dementia

Stages

• 1. No difficulties

• 2. Subjective forgetfulness

• 3. Decreased job functioning and organizational capacity

• 4. Difficulty with complex tasks, instrumental ADLs

• 5. Requires supervision with ADLs

• 6. Impaired ADLs, with incontinence

• 7. A. Ability to speak limited to six words

B. Ability to speak limited to single word

C. Loss of ambulation

D. Inability to sit

E. Inability to smile

F. Inability to hold head up