Health Care Guideline: Palliative Care for Adults Text in blue in this Patient presents with new or algorithm indicates a established diagnosis of a serious illness linked corresponding annotation. Sixth Edition January 2020 1 Initiate palliative care discussion 2 Assess patient’s palliative care needs based on the specified domains of palliative care 3 Begin advance care planning process 4 5 6 7 8 9 Psychological and Physical aspects Cultural aspects Social aspects of Spiritual aspects Ethical and legal psychiatric of care of care care of care aspects of care aspects of care 10 Develop or revise Serious Illness: palliative care plan and establish goals of care through the process of shared • Terminal illness decision-making • Chronic, progressive and probably life-shortening 11 illness Does patient meet no • Severe neurodegenerative hospice criteria? diseases yes • Life-threatening illness with a chance of full Hospice care team Does patient yes recovery coordinates palliative care choose hospice, and is plan with primary clinician hospice available? no 12 Care for the dying patient Implement palliative care plan 13 Grief and bereavement Through periodic reassessment, is the care no plan meeting the patient’s needs? yes Continue with current care plan no Remission or yes Patient condition no yes resolution of Out of guideline is worsening? disease? Return to Table of Contents www.icsi.org Copyright © 2020 by Institute for Clinical Systems Improvement 1 Palliative Care for Adults Sixth Edition /January 2020 Table of Contents Work Group Leader Algorithms and Annotations ...............................................................................1–45 Martha McCusker, MD, FACP Algorithm .....................................................................................................................1 Internal Medicine/Geriatrics, Hennepin Healthcare Evidence Grading .........................................................................................................3 Recommendations Table ..........................................................................................4–6 Work Group Members Foreward ......................................................................................................................7 CentraCare Health Introduction .......................................................................................................7–9 Merryn Jolkvosky, MD, CHCQM Palliative Care Scope and Target Population .................................................................................9 HealthPartners Medical Aims ....................................................................................................................10 Group and Clinics Clinical Highlights ..............................................................................................10 Rob Ruff, BCC Chaplaincy Services Implementation Recommendation Highlights ..............................................10–11 Lakewood Health System Related ICSI Scientific Documents .....................................................................11 Julie Benson, MD Definitions ...........................................................................................................11 Family Medicine, Hospice and Palliative Care Annotations ..........................................................................................................12–45 .........................................................................46–56 M Health Quality Improvement Support Drew A. Rosielle, MD, FAAHPM Aims and Measures ..............................................................................................47–48 Palliative Care Implementation Recommendations ............................................................................49 North Memorial Health Implementation Tools and Resources ........................................................................50 Melissa Schmidt, MSW, LICSW Palliative Care Bereavement Implementation Tools and Resources Tables .......................................................51–56 ICSI Assessment Tools ................................................................................................51 Audrey Hansen, MA, BSN, Physician Education Resources (Fast Facts) .................................................51–52 PHN, PMP Team Director General Tools and Resources ........................................................................52–56 Jodie Dvorkin, MD, MPH Supporting Evidence............................................................................................57–76 Associate Medical Director References ............................................................................................................58–63 Senka Hadzic, MPH Appendices ...........................................................................................................64–76 Clinical Systems Improvement Facilitator Appendix A: Literature Search Terms ...........................................................64–65 Appendix B: How to Discuss Serious Illness ...............................................66–68 Appendix C: Signs and Symptoms That Indicate Death .....................................69 Appendix D: Choosing Wisely® Recommendations Regarding Palliative Care.........................................................................70–76 Disclosure of Potential Conflicts of Interest .................................................77–78 Acknowledgements .....................................................................................................79 Document History and Development .............................................................80–82 Document History ......................................................................................................81 ICSI Document Development and Revision Process .................................................82 www.icsi.org Institute for Clinical Systems Improvement 2 Palliative Care for Adults Sixth Edition /January 2020 Evidence Grading Literature Search A consistent and defined literature search process is used in the development and revision of ICSI guidelines. Literature searches for this guideline were done under the following parameters: • Time frame: Jan. 1, 2013, through Dec. 1, 2018. • Types of studies searched for: systematic reviews and meta-analysis, randomized controlled trials, implementation studies and observational studies (case-control, cohort and cross-sectional studies). • Population: adults. • All studies were published in English and included humans. For a detailed list of literature search terms, see Appendix A. In addition to the literature searches, articles were obtained by work group members and ICSI staff. Those vetted by the work group were included in the guideline when appropriate. Methodology ICSI utilizes the Grading of Recommendations Assessment, Development and Evaluation (GRADE) meth- odology system. GRADE involves systematically evaluating the quality of evidence (high, moderate, low, very low) and developing a strength of recommendation (strong, weak). For more detailed information on GRADE, please visit http://www.gradeworkinggroup.org/. In addition, when GRADE methodology could not be applied, the work group developed consensus recommendations. Return to Table of Contents www.icsi.org Institute for Clinical Systems Improvement 3 Palliative Care for Adults Evidence Grading Sixth Edition /January 2020 Recommendations Table The following table is a list of evidence-based recommendations for palliative care. Note: Other recommendation language may appear throughout the document as a result of work group consensus but not included in this evidence-based recommendations table. Topic Quality of Recommendation(s) Strength of Annotation Relevant Resources Evidence Recommendation Number Early Low Palliative care can begin at Strong 1 Temel, 2010 (Randomized Intervention the time of diagnosis of a Control Trial); Kass- serious illness regardless of Bartelmes, 2004 (Summary); treatment plan and continue Morrison, 2004 (Case throughout the course of a Report) Steinhauser, 2000 patient’s illness. (Observational Study) Early Low Palliative care discussion or Strong 1 Kavalieratos, 2016 Intervention referral should be considered (Systematic Review/Meta- whenever a patient develops Analysis); Khandelwal, 2015 or presents with a serious or (Systematic Review); Lamba, life-threatening illness, in all 2014 (Report); Smith, 2014 care settings. (Review); Strand, 2013 (Summary); Weissman, 2011 (Consensus Report) Assess Domains Low Clinicians should use Strong 2 Aslakson, 2017 (Technical of Palliative validated assessment tools, Brief); Bakitas, 2009 Care where available, to assess (Randomized Control Trial); palliative care needs for each Pulchaski, 2009 (Report); of these domains: physical, Smith, 2009 (Case Report); cultural, psychological, Gries, 2008 (Case Report); social, spiritual and ethical/ Chochinov, 2006 (Summary); legal. Moro, 2006 (Observational Study); Kemp, 2005 (Summary); Searight, 2005 (Summary); Morrison, 2004 (Case Report); Curtis, 2002 (Case Report); Werth, 2002 (Summary); Kagawa-Singer, 2001 (Case Report); Block, 2000 (Case Report); Chang, 2000 (Observational Study); Post, 2000 (Summary); Phillip, 1998 (Observational Study); Reed, 1987 (Observational Study) Informed Low Informed consent should be Strong 2 Silveira, 2010 Consent obtained for any treatment (Observational Study); or plan of care from either a Arnold, 2006 (Summary) patient with decision-making capacity or an appropriate