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How to Diagnose Dying
SMACC
June 26, 2015
Ashley Shreves, MD
Assistant Professor
Department of Emergency Medicine
Brookdal...
Atul Gawande “Letting Go”
Identifying “the dying”
• It’s hard
• Somewhat subjective
• Not always possible
• Obvious in retrospect
Why does it matter?
• Patient goals/priorities change
• Treatment
– Less effective
– burdens >> benefits
• Resource utiliz...
Case
• 80 y/o m
• Cardiac arrest
• EMS: picked up from dialysis
• ED: ACLS 10 min – get ROSC
• Yay!
Patterns of Dying
Lunney JAMA 2003
Terminal Illness
• Cancer
• Lengthy disease, sharp decline
• Measure of function?
– Time in bed
• Associated symptoms
– An...
Is she dying?
• 60 y/o f
– Metastatic breast CA
– Worsening dyspnea
• Need more info
– Function?
– Dyspnea history – rever...
Organ Failure
• COPD, CHF
• Common
• Intermittent crises
• Surprising recoveries
• Clues
– Repeated admits
– Higher levels...
Is he dying?
• 70 y/o m, COPD, 2 L home O2
– 5 admits/past year for COPD exacerbations
– Moderate respiratory distress
– O...
Frailty
• Dementia
• Slow decline, profound disability
• Complications define EOL
• Clues
– Infections
– Eating problems
Is she dying?
• 90 y/o f
– Dementia, bedbound, minimal verbal
– UTI x 2 in past 3 months
– Fever, PNA
• Yes
– Recurrent in...
Sudden Death
• Not chronically ill
• 10-15% US population
• EM thinks all deaths
Is he dying?
• 40 y/o m, healthy, collapsed on tennis court
– Found V fib, CPR/shocked x 3
– Massive STEMI
• Maybe
– “Dyin...
My case
• Cachectic elderly male
• NH
– Dementia, ESRD, CHF
– Not eating or walking lately
• Which trajectory?
• Palliativ...
In summary…
• Seek trajectories (context)
– Ask about function
– Look at old chart
• Allows qualitative prognostication
• ...
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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.

Published in: Health & Medicine
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Ashley Shreves - How to Diagnose Dying

  1. 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. 2. Atul Gawande “Letting Go”
  3. 3. Identifying “the dying” • It’s hard • Somewhat subjective • Not always possible • Obvious in retrospect
  4. 4. Why does it matter? • Patient goals/priorities change • Treatment – Less effective – burdens >> benefits • Resource utilization
  5. 5. Case • 80 y/o m • Cardiac arrest • EMS: picked up from dialysis • ED: ACLS 10 min – get ROSC • Yay!
  6. 6. Patterns of Dying Lunney JAMA 2003
  7. 7. Terminal Illness • Cancer • Lengthy disease, sharp decline • Measure of function? – Time in bed • Associated symptoms – Anorexia, weakness, pain, dyspnea
  8. 8. Is she dying? • 60 y/o f – Metastatic breast CA – Worsening dyspnea • Need more info – Function? – Dyspnea history – reversible?
  9. 9. Organ Failure • COPD, CHF • Common • Intermittent crises • Surprising recoveries • Clues – Repeated admits – Higher levels of care
  10. 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. 11. Frailty • Dementia • Slow decline, profound disability • Complications define EOL • Clues – Infections – Eating problems
  12. 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. 13. Sudden Death • Not chronically ill • 10-15% US population • EM thinks all deaths
  14. 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. 15. My case • Cachectic elderly male • NH – Dementia, ESRD, CHF – Not eating or walking lately • Which trajectory? • Palliative extubation/died in ED
  16. 16. In summary… • Seek trajectories (context) – Ask about function – Look at old chart • Allows qualitative prognostication • More appropriate medical plan

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