Palliative Service

Legacy Content

This page is about the pre-ICD10 diagnosis coding schema. See the ICD10 Diagnosis List, or the following for similar diagnoses in ICD10:Palliative care

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Category/Organ System:	Category: Other Medical (old)
Type:	Medical Problem
Main Diagnosis:	Palliative Care
Sub Diagnosis:	PALLIATIVE CARE
Diagnosis Code:	904-00
Comorbid Diagnosis:	Critical Care and/or Medicine
Charlson Comorbid coding (pre ICD10):	Currently Collected
Program:
Status:

Category/Organ System update pending

How is code used by database program?

Definition for data collector for the Regional ICU/Medicine database

• The focus of care is geared to the treatment of those conditions & symptoms that are "reversible" to maintain comfort and quality of life for a long as possible for those patients who have been diagnosed with an underlying terminal disease condition that cannot be cured and who's death is apparent but not immediately imminent.
• Terminal disease (Cancer, end stage heart disease, end stage lung disease). http://en.wikipedia.org/wiki/Terminal_illness

• there is documentation in the chart (history, orders or consult forms) that patient is "palliative care".
• ACP status(1 to 4) is not relevant and should not be used as the guide to decide if patient is palliative care or not.

• Palliative care is always provided even if treatment has been discontinued in an ICU patient. Patients' who's treatment has been DC'd, don't need to be also coded as palliative. Commons sense dictates that care is still provided to maintain patient comfort following a DC TX whether death is immidiate or prolonged.

• For those patient who have come in as "palliative care" and had this status reversed during encounter to Hospital, keep status as palliative.

• For more information on Palliative care see (Health Canada website)

TOstryzniuk 14:21, 6 August 2008 (CDT) FINAL

Possible new definition for Medicine - NOT AN INSTRUCTION YET

Dr Garland discussed the misunderstandings re. Paliative care with Dr Roberts. As a result, the following new definition has been proposed:

Code Palliative if, on admission, either the Resident's or the Attending's note specify comfort care or palliation.

collectability

The question to collectors is: If this were the new definition, would you be able to collect this? The question is not whether this new definition sounds better or worse, just whether it is collectable. The other question would be in the next section. Template:Discussion

• yes it is collectable & clear (Judy, 17 oct 2013)

appropriateness of new definition

Before any change we need to confirm with Julie if anyone is currently asking us for this information who would not be able to work with this new definition. If not, then any concerns about who might think that this should be collected differently are moot. In considering that, please keep in mind that this new definition would replace one that has been recognized to lead to inconsistent coding practices, so even if this definition may be less fitting for someone's purpose the increase in consistency might make up for that. Trish, Julie, Thoughts? Template:Discussion

• so if someone who is already PALLIATIVE CARE in the community due to terminal condition, is admitted to hospital with pneumonia, which is going to be treated, then palliative care DX is not to be coded unless Dr notes in chart that patient in palliative care or comfort care this admission. So is it being suggested that, we longer code patients that are already deemed to be palliative care while they are coming in and going out of hospital for treatable conditions, such as pneumonia, pain etc., while they are already know to have an untreatable terminal underlying condition? Collectors do any of you have any better understanding on this?-Trish Ostryzniuk 17:38, 2013 October 10 (CDT)
  • There are database requests for palliative patient counts in both Med and ICU but people requesting are not saying what are their definition so I cannot say either. But looking at the new definition, I don't see any difference from the old definition we had since 2007. JMojica 13:51, 2013 October 15 (CDT)
    • Me neither really.Trish Ostryzniuk 14:23, 2013 October 15 (CDT)
    • I think there are two issues here being looked at & it can be confusing. Group 1)those who are already palliative in the community or are newly referred to the palliative care program this admission. Both are expected to be treated for a treatable condition and both are expected to be released from hospital. Group 2)those who are are admitted to hospital & are already in the palliative program from the community & those who are admitted to hospital and are newly referred to the palliative care program but are not expected to survive. They are not usually given aggressive treatment. The above new proposed definition will capture both groups. (Judy K oct. 16, 2013)

survival not expected

Template:Discussion Discussion at June 2013 collector meeting to add a subcode to indicate that survival is not expected. I suspect what we really need is to get rid of the no-subcode option and give two or more subcode that together exhaustively address all palliative options. That should also take care of the mess that is in this article and in DC_Treatment#DC_Treatment_vs._Palliative_Care. I think this would best be addressed in a meeting. Trish, who needs to be there? Ttenbergen 11:25, 2013 June 24 (EDT)

• not sure why adding a subcode to palliative to say in collectors judgement, patient is not going to survive this admission. Why do you need a code to justify why overstay screening form was not filled out for OverstayProject? If you have a patient with a terminal illness that is under "palliative care" and pt does not survive current hospitalization, the medicne program with the statistican can determine what is the cut point to exclude from overstay prediction stats. Anyways, if collector ends up screening someone who is red, but once reviewed by transition coordinator, it is very apparent to them that the patient dying, then they would not proceed with the coordination of discharge planning.

Current obstacles to consistent coding practices for Pallitive Care

Current collection problems with Palliative care code:TOstryzniuk 16:06, 25 June 2008 (CDT)

• Some collectors code palliative care when status is coded as ACP1.(VIC).Others are saying that ACP (Advanced Care Plan) information at their site is not in the chart, others coding palliative when they see ACP 1 or 2 is documented in the chart, others are coding palliative care only when physician writes to word palliative care in notes/orders or fills out a form for palliative care consult. The debate is that it is not a Dr’s decision but the patient and families..........

• Hospitals in the city, not all sites seem to document Advance Care Plan (ACP)status on admission? Is this correct? (thought this was a regional requirement for every admission?)

• Collectors suggest it would be better collect the ACP status instead, though I am told this could change with every new admission to hospital ?

• collectors want to know the purpose of collecting that status of “palliative care” and how this information is being used.

• Issue of same patient with multiple admissions back to hospital once being deemed "palliative care". Subsequent admission not alway documenting that patient has been deemed palliative care previously. Example pt with end stage heart disease, palliative care 2003, frequent admission (14 repeated admits) for CHF, CP and other reversible problems, but no mention of palliative care in Dx codes until 2007.

• What is a reasonable time line for "immediately imminent" vs. not immediately imminent? (example; patients DC TX in ICU, did not die immediately, not until 3 or 3 days or even 1-2 weeks after ward admission. Should ward call this DC TX or palliative or both?

When to code Palliative Care (update pendingTOstryzniuk 15:59, 25 June 2008 (CDT))

The diagnosis Palliative care should be coded for patients where all of the following are true:

• Patient either on Medicine ward or in ICU
• active care of reversible conditions is given to a person with progressive, advanced underlying disease with little or no prospect of cure. Underlying disease condition is terminal.
• death is apparent however is not immediately imminent

NOTE: Trish is looking at this definition. I will add more detail and will review with Roberts. Need to include a purpose as to why we are tagging these patients. TOstryzniuk 17:27, 24 June 2008 (CDT)TOstryzniuk 19:16, 21 July 2008 (CDT)still working on it. Contributions welcome.

When not to code Palliative Care (update pendingTOstryzniuk 17:49, 25 June 2008 (CDT)

For our purposes and the way we analyze the data, a patient whose death is immediately imminent should not be coded as Palliative care, but might be coded as DC Treatment if appropriate.

Discussion

Trish, in your definition, I think you should remove the word "reversible" when discussing this as it is confusing. Also, I think that when a patient's care has been DC and if they don't die immediately, they should also be coded as palliative as this is the focus of care for a period of time. I don't normally code a pt as both DC tx and palliative but occasionally death is delayed for quite awhile even a day or more, and in this case I think palliative is appropriate.--LKolesar 14:29, 6 August 2008 (CDT)

• I have a ? about pall care vs dc treatment Pts are transfered to D5 from the icus to die I put in my 1st admit pall care and I add d/c treatment, does icu put pall care in acquired as well as d/c treatment or do I put in my 1st admit the cause of their demise with d/c treatment. How do you wish these cases to be coded. (Pat Stein)
• We’ re only after part of the data within the ACP documents as they affect whether or not a patient would be a candidate for a higher level of care which would be ICU.
  • From Dan Roberts- further discussions: (July 2008)
• All this relates only to determinations made at the time of admission.We need to know 2 things.
• If a patient is terminal and it is decided not to continue active treatment, that is palliative.
• The next issue we need to capture is whether or not a patient has a DNAR order at the time of admission.What is in the ACP IS NOT RELAVENT.
• Therefore we need to capture palliative vs non palliative .If non palliative is there a DNAR? (For palliative patients there must always be a DNAR.).
• This information helps us to determine who can be excluded from randomization to a higher level of care at the time of admission.The palliative patients would never go to high obs and the non palliative patients with DNARs would require further screening to determine their candidacy for ICU.However that subsequent screening information would not be required for the database.
• Status on a previous admission is relevant for the care team determining level of care for the present admission but only the determination for this admission is relevant.
  • FINAL DEFINTION PENDINGTOstryzniuk 14:58, 4 July 2008 (CDT)

Further to unstub

• Incorporated Laura's definition from Health Canada. However, will we code if only some of the aspects of palliative care (e.g. pain mgmt, but not emotional support) are provided? In the end, this is a coding guide, and the above makes is less clear when to code. The "when to code..." section should be updated to clarify which parts of definition are mandatory, or how to gather from chart. I suppose the main information is that the focus of care is for comfort rather than active treatment. LKolesar

Trish Here....

• • the focus of care is the active treatment of "reversible" conditions for those patients whose underlying disease condition cannot be cured.
  • Ok we need to continue work on this definition further. It is a given that emotional, spiritual, treatment of pain etc is part of any type of patient care...........TOstryzniuk 19:09, 21 July 2008 (CDT)
  • My version of definition is: Palliative care is when a pt is dying of an underlying terminal disease/condition and palliative care/comfort care is documented in chart either by palliative care form/doctor, pt may come in and out of hospital for treatment of symtoms of underlying disease/secondary issues. ACP2 and up is truly not relevant to whether or not a pt is palliative care.--PStein 08:57, 28 July 2008 (CDT)

April 3, 2009

• This code was discussed at ICU database task group meeting today. The suggestions will be taken to the database steering committee. Update will be posted here when final. --TOstryzniuk 14:35, 3 April 2009 (CDT)

DC Treatment vs. Palliative Care

see DC_Treatment#DC_Treatment_vs._Palliative_Care