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A Natural Death - Alex Psirides

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Alex is an Intensive Care specialist working in Wellington, having trained in London, Melbourne and New Zealand. He has been involved in the design and implementation of Rapid Response Systems in several different hospitals. Because of this, he is clinical lead for the New Zealand Health Quality & Safety Commission’s national ‘Deteriorating Patient’ programme. In his spare time, when not walking his dog or his children, he builds websites & designs logos for Wellington ICU’s prodigious research department. He has nearly written a lot more research papers & as such needs to spend less time on Twitter. He also once ventilated a chimpanzee but it didn’t end well (for the chimp).

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A Natural Death - Alex Psirides

  1. 1. alex psirides A NATURAL DEATH @psirides IN AN UNNATURAL WORLD 11th december 2018
  2. 2. “ First I will define what I conceive medicine to be. In general terms, it is to do away with the sufferings of the sick, to lessen the violence of their diseases, and to refuse to treat those who are overmastered by their disease, realising that in such cases medicine is powerless. Hippocrates 400 BC
  3. 3. 6
  4. 4. Q: why do oncologists do CPR? A: to circulate the chemo
  5. 5. MUCH OF WHAT I LEARNED ABOUT DYING WELL, I LEARNED FROM A CHIMPANZEE
  6. 6. ευθανασία
  7. 7. World Mortality % Dead *data extrapolated from current trends
  8. 8. High Low FUNCTION T I M E
  9. 9. High Low FUNCTION T I M E APPROPRIATE MEDICAL INTERVENTION BADNESS MEDICAL INTERVENTION
  10. 10. High Low FUNCTION T I M E INAPPROPRIATE MEDICAL INTERVENTION BADNESS MEDICAL INTERVENTION
  11. 11. Old Medical Model Current Medical Practice Single acute pathology Multiple chronic pathologies Short term conditions predominate Long term conditions predominate Diagnose, treat, cure Ameliorate, listen, explain, advise, console Survival dependent upon skills of paramedical, medical & nursing staff Survival dependent upon patient’s lifestyle choices Smith, BMJ 2015
  12. 12. 2.1. 3.hold meetings and discuss end-of-life care with a patient’s family turn a frail 90-year-old into a fit 25 year-old increase blood pressure in refractory shock and multi organ failure 3 THINGS ANTIBIOTICS WON’T DO: DON’T USE ANTIBIOTICS INSTEAD OF WORDS Dr. Fernando Zampieri
  13. 13. 2weeksinICUcan saveyou1hourof difficult conversationDr.Will Cairns
  14. 14. 6 SUPPORT THEM, THEIR FAMILY & YOUR COLLEAGUES WHILE THEY DIE YES Are you sure? NO DO MEDICAL STUFF YES NO YES TELL THEM then ask them what they would like Go you! High fives all round & go to Pub NO YES NO ‘Everything’ ‘Comfort’ Review patient Are they dying? ICU REFERRAL Are you sure they’re not just actually dying? Did you make them better?
  15. 15. DO MEDICAL STUFF •DIAGNOSE •TREAT •CURE MAKE A DECISION
  16. 16. 9 dying doesn’t have a biomarker
  17. 17. sick person with a reversible process who would benefit most from intensive care dying person with an irreversible process who would benefit most from palliative care
  18. 18. 4 the bad death •Occurs on bedroom floor or in an acute hospital bed •Paramedics, nurses or doctors present, not family or friends •Occurs during or immediately after a treatment or procedure that doesn’t change outcome •Patient may have been unaware they were dying •Monitors & alarms •Lack of dignity •Ignorance of cultural/ spiritual needs •THE DEFAULT
  19. 19. CRITICAL CARE CONVEYOR BELT
  20. 20. THE PALLIATIVE PARAMEDIC Kirk, Journal Paramedic Practice 2017 70% concerned about validity of document 46% were afraid of litigation 50% concerned about conflict with families 182 UK paramedics End of life care is ‘central to role’ BUT…
  21. 21. AND-ICU
  22. 22. 70% 80% WANT TO DIE AT HOME WILL DIE IN A HOSPITAL OR NURSING HOME YOU CAN’T ALWAYS GET WHAT YOU WANT
  23. 23. Nursing in Critical Care 2005; 10(3):116-121
  24. 24. The good death is now the death that we choose. Not by the dogmas of religion nor the institutional routines of medicine, but by the dying, dead or bereaved individuals themselves. Tony Walter The Revival of Death1994
  25. 25. 3 how can we change things? •encourage palliative care exposure for ICU trainees •talk to patients about not doing stuff & why •ask your patients what they want •invite palliative care clinicians to attend multidisciplinary meetings •always consider ‘is this patient actually dying?’
  26. 26. “Iwanttodiepeacefullyinmy sleeplikemyfather,not screaming&yellinglikethe passengersonhisbus.” BobMonkhouse
  27. 27. @psirides AlliconsfromTheNounProject Thank you wellingtonicu.com

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