Ashley Shreves - How to Diagnose Dying
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A patient's death maybe certain but the timing isn’t. Ashley Shreves discusses the difficult subject of dying and how best to understand and help diagnose when the battle is lost. Shreves explores the correlating patterns present in the functional decline in end of life patients, with particular reference to the type of disease a patient is suffering from. Understanding these patterns is paramount to understanding the care and medical intervention require, at certain points of a patients disease lifecycle.
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Ashley Shreves - How to Diagnose Dying
- 1. How to Diagnose Dying SMACC June 26, 2015 Ashley Shreves, MD Assistant Professor Department of Emergency Medicine Brookdale Department of Geriatrics and Palliative Medicine Icahn School of Medicine at Mt. Sinai
- 2. Atul Gawande “Letting Go”
- 3. Identifying “the dying” • It’s hard • Somewhat subjective • Not always possible • Obvious in retrospect
- 4. Why does it matter? • Patient goals/priorities change • Treatment – Less effective – burdens >> benefits • Resource utilization
- 5. Case • 80 y/o m • Cardiac arrest • EMS: picked up from dialysis • ED: ACLS 10 min – get ROSC • Yay!
- 6. Patterns of Dying Lunney JAMA 2003
- 7. Terminal Illness • Cancer • Lengthy disease, sharp decline • Measure of function? – Time in bed • Associated symptoms – Anorexia, weakness, pain, dyspnea
- 8. Is she dying? • 60 y/o f – Metastatic breast CA – Worsening dyspnea • Need more info – Function? – Dyspnea history – reversible?
- 9. Organ Failure • COPD, CHF • Common • Intermittent crises • Surprising recoveries • Clues – Repeated admits – Higher levels of care
- 10. Is he dying? • 70 y/o m, COPD, 2 L home O2 – 5 admits/past year for COPD exacerbations – Moderate respiratory distress – On BIPAP…may need intubation • Need more info – Function? – Still independent? QOL? • Past experience/GOALS matter bc prognostication tough
- 11. Frailty • Dementia • Slow decline, profound disability • Complications define EOL • Clues – Infections – Eating problems
- 12. Is she dying? • 90 y/o f – Dementia, bedbound, minimal verbal – UTI x 2 in past 3 months – Fever, PNA • Yes – Recurrent infections + AD = months – Can extend but NOT improve life
- 13. Sudden Death • Not chronically ill • 10-15% US population • EM thinks all deaths
- 14. Is he dying? • 40 y/o m, healthy, collapsed on tennis court – Found V fib, CPR/shocked x 3 – Massive STEMI • Maybe – “Dying” when all resuscitative efforts stop • Time to death seconds-minutes
- 15. My case • Cachectic elderly male • NH – Dementia, ESRD, CHF – Not eating or walking lately • Which trajectory? • Palliative extubation/died in ED
- 16. In summary… • Seek trajectories (context) – Ask about function – Look at old chart • Allows qualitative prognostication • More appropriate medical plan
Editor's Notes
- This is a touch one. Why? Dying itself is a moving target. How do you define dying? What does it mean to you to say that a patient is dying? I bet it means something slightly different to everyone in this room
- I thnk Atul Gawande captures this challenge best in his piece Letting Go, which has now been incorporated into his book being mortal. – what does it mean to be dying, at this moment in time, with all our technology. We have to know what this thing is that we’re trying to diagnose. In my opinion, no one describes these issues more eloquently than Atul Gawande. In the single greatest piece of medical journalism ever written, he captures one the dilemmas we currently have…knowing who to even label as dying…
- -and yet,, there are pts I could show you, and you’d all say, yep – that pt is dying. They have the look of someone who is dying. And you’d probably be right. But my hope here is that
- -while I can’t exactly define dying, we all know what it means once we’ve LABELED someone as dying. Once we put them in that category, we think about them differently, we treat them differently
- -so dying is really an event. It’s more of a process. it turns out, there are often rather predictable ways in which pts decline, at the EOL. There are patterns of dying that have been described, depending on the underlying illness. -a patient’s ability to function or take care of himself will change/worsen in the last year of life, but differently depending on the underlying illness These patterns of decline are often characterized by predictable changes in function. When I say function, what do I mean? Right, the ability of someone to perform their ADLs (eating, bathing, dressing, transferring, walking). By paying attention to and asking questions about function, we can identify which of these 4 categories our pt fits into. -being able to place them on one of these trajectories will not only help you treat your patient more effectively, it will also help you understand them and their families better