Geriatric Population. Geriatric Palliative and End-of-Life Care.
During your journey through this slide deck Geriatric Population. Geriatric Palliative and End-of-Life Care you will experience what it means to die badly. After practicing as a Geriatric Clinician for over a decade what I know for sure is: Life is a tremendous gift. 100% of us are going to die. If you don't communicate your end-of-life plan, then you should plan on dying badly. In The Cost of Dying: End-of-Life Care on CBS 60 minutes Steve Kroft interviews Doctor Ira R. Byock. “Families cannot imagine that there could be anything worse than their loved one dying, but in fact there are things worse, generally it’s having someone you love die badly.” ~Doctor Ira Byock “Dr. Byock what do you mean dying badly?” ~Mr. Kroft “Dying suffering, dying connected to machines, denial of death at some point becomes a delusion and we start acting in ways that make no sense whatsoever.” ~Doctor Ira Byock A majority of Americans say they want to die at home. Why is this not happening? Place of death should be regarded as an essential goal in end-of-life care. Let’s explore how the end-of-life decision occurs? For Doctors Bernacki & Block (2014) found in their review and synthesis of best practices that physician attitudes, training, and perceptions of feeling inadequate in managing the emotional and behavioral reactions of patients all play a role. A majority of trainees were not taught how to communicate and they express strong desires to learn more. Physician barriers also include not addressing psychosocial concerns, placing focus on diagnoses, treatments, and procedures during discussions about the medical care at the end-of-life. For Patients Bernacki & Block (2014) found that patients who do bring up dying concerns with their physicians often meet barriers and often are not aware that they are at the end-of-life. Patients that have not set goals based on meaningful conversations about their desires may overuse life-prolonging treatment and underuse services that support quality of life. Conclusion Bernacki & Block (2014) found that there is a large body of evidence demonstrating that early discussions of serious illness care goals are associated with: ♛ beneficial outcomes for patients, ♛ no harmful adverse effects, and ♛ potential cost savings. Apply & Do To prevent dying badly start early conversations, enhance your knowledge and establish goals. Dreams are only dreams until you write them down. When you write dreams down then they become goals. Do ♛ The Conversation Project a collaboration with the Institute for Healthcare Improvement. http://theconversationproject.org/starter-kit/intro/ Do your conversation kit now and make your loved ones aware of your wishes. Wishing you the very best, Michelle Bernacki RE, Block SD, for the American College of Physicians High Value Care Task Force. Communication About Serious Illness Care Goals: A Review and Synthesis of Best Practices. JAMA Intern Med. 2014;174(12):1994-2003.
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Geriatric Population. Geriatric Palliative and End-of-Life Care.
- 2. Place of death Preference: Majority want to die at home Reality: Minority will die at home Most institutional deaths could occur at home Societal and clinician lack of familiarity with dying
- 3. Large Gap Reality vs. Desire Fears Die on machine Die in discomfort Be a burden Die in institution Desires Die NOT on ventilator Die IN comfort Die WITH family Die at HOME
- 4. Place of death Our health care system is oriented toward providing life-sustaining treatment, unless a patient actively chooses against it. More interventions and life-sustaining treatments are associated with poorer patient quality of life and higher family distress. Bernacki RE, Block SD, for the American College of Physicians High Value Care Task Force. Communication About Serious Illness Care Goals: A Review and Synthesis of Best Practices. JAMA Intern Med. 2014;174(12):1994-2003.
- 5. Place of death In the absence of conversations about prognosis, goals, and outcomes of treatment, patients do not have the opportunity to express their values and preferences. Leading clinicians to assume that patients want additional interventions, even late in the illness. Bernacki RE, Block SD, for the American College of Physicians High Value Care Task Force. Communication About Serious Illness Care Goals: A Review and Synthesis of Best Practices. JAMA Intern Med. 2014;174(12):1994-2003.
- 7. The relief you need when you are experiencing serious medical illness PALLIATIVE CARE
- 9. Patient & Family Centered Care Patient Population Comprehensive Care Inter- disciplinary Team Attention to relief of suffering Timing Quality Improve- ment Communi- cation Continuity of care across settings Equitable Access Addressing regulatory barriers Palliative Components
- 10. Palliative Care Team Clinical Team: Physician Nurse Practitioner Physician Assistant Nurse Therapists, Dietician Pharmacist Psychosocial Team: Social Worker Case Manager Psychologist Chaplain Grief Counselor Child Life Specialist
- 11. Who Uses Palliative Care? People of all ages… Life threatening illness Limiting injuries from accidents or other trauma Congenital injuries Dependent on life- sustaining treatments Serious, life- threatening illness Progressive chronic conditions
- 12. Palliative Care Indications Uncontrolled symptoms Goals of care Cardiac arrest Advanced cancer Multi-organ failure Ventilation support Hospice eligibility Prolonged hospitalization Multiple hospitalizations Family distress
- 13. Reduce physical/emotional symptoms Improve function and reduce disability Integrating complimentary therapies Coordinate with specialists, resources Assist in making informed decisions Palliation of suffering along with continued treatment (no requirement to give up curative) What are the goals of Palliative Care?
- 14. Pain and symptom control Avoid inappropriate prolongation of the dying process Achieve a sense of control Relieve burdens on family Strengthen relationships with loved ones Singer, et al. JAMA 1999;281(2):163-168. The Patient’s Perspective What Do Palliative Care patients want?
- 15. Who is eligible for hospice? Advanced disease with life expectancy of “six months or less” given natural course of disease (may be longer if patient meets criteria)
- 16. Who is eligible for hospice? Poor functional/nutritional status High morbidity/mortality markers Patient/surrogate decision maker consent Payment sources
- 17. Hospice Care Physician services Nursing services Health aide, homemaker services, volunteers Spiritual support and social work
- 18. Hospice Care Medical equipment, supplies Medications PT/OT, speech therapy, dietary counseling Bereavement counseling, support services
- 19. Where is Hospice? Home: primary or family residence, nursing home, group home, assisted living facility; mandated to be >80% of delivered care of any hospice’s services
- 20. Where is Hospice? Inpatient facility: Short term, 3-5 days Continuous care at home: Highly regulated, typically 24 hours Respite care
- 21. Hospice Access Issues Culture, Race Religious Diversity Insurance Issues Geography Healthcare Staff Median survival in Hospice care is 2- 3 weeks, primarily due to late physician referrals
- 22. Last Hours of Life Semicomatose State Impaired Heart & Renal Function Respiratory Dysfunction Neurologic Dysfunction
- 23. Semicomatose State Eyes become sunken and glazed Senses are generally dulled Hearing may not be lost, light sensitivity Ability to move decreases Beginning in the legs and then the arms Body becomes stiff, joints painful if moved Medicate symptoms
- 24. Impaired Heart, Renal Decrease cardiac output peripheral and renal perfusion blood pressure Pulse rate first increases, then weakens, irregular Peripheral cooling, bluish, skin mottling May perspire, may have peripheral swelling Body temperature may increase
- 25. Respiratory Dysfunction Breathing may become shallow or labored Respiration rate fluctuations Secretions may increase Breathlessness feeling may increase Death “rattle” Terminal congestion occurs due to changes in respiratory rate and inability to clear secretions Is distressing to family
- 26. Neurologic Dysfunction Multiple nonreversible factors: Metabolic imbalances Acidosis Kidney failure Infection Reduce blood flow to brain
- 27. THE “USUAL ROAD” Decreasing level of consciousness Sleepy Lethargic Semicomatose Comatose Death
- 28. THE “DIFFICULT ROAD” Nervous system agitation prior to semicomatose state Restlessness, Confusion, Tremors Hallucinations, Mumbling Delirium Muscle jerking, Seizures Semicomatose Comatose Death
- 29. Large amount of research evidence shows…. Early discussions of serious illness care goals are associated with: ♛ beneficial outcomes for patients, ♛ no harmful adverse effects, and ♛ potential cost savings. Bernacki RE, Block SD, for the American College of Physicians High Value Care Task Force. Communication About Serious Illness Care Goals: A Review and Synthesis of Best Practices. JAMA Intern Med. 2014;174(12):1994-2003.
- 30. To die differently you must prevent dying badly… Bet on Luck or Take Control
- 31. Take Control… Dreams are only dreams until you write them down. When you write them down then dreams become goals. How do YOU take control? Do ♛ The Conversation Project a collaboration with the Institute for Healthcare Improvement. http://theconversationproject.org/starter-kit/intro/ Do your conversation kit now and make your loved ones aware of your wishes.