Dr. Elizabeth Paulk gives an excellent review of palliative care topics including end of life discussions, hospice, pain management, and family counseling.
Dr. Elizabeth Paulk gives an excellent review of palliative care topics including end of life discussions, hospice, pain management, and family counseling.
Carle General Surgery Grand Rounds presentation on palliative care symptom management, specifically pain, nausea, constipation, and malignant bowel obstruction.
The lecture I gave for the Indiana University Health Joint Transplant Education and Research Lecture Series on palliative care. That's right, palliative care in transplant patients NOT at the end-of-life.
Palliative care is about providing well-being and the highest quality of life to patients with serious, progressive, chronic life-limiting illness, including during the dying process.
Building on the lecture I gave (and uploaded) "Palliative Care: what every primary care doctor should know" I built this talk. It is geared for 1st year medical students who are learning anatomy, physiology, and perhaps some pharmacology and pathophysiology.
In this talk, I do not explicitly address hospice care - as that was provided in an online chapter for students at UMass. I will later upload another slide set on that topic.
I hope you enjoy it.
FYI- the link to the youtube video: http://www.youtube.com/watch?v=XHtHXGhTIC4
Link to PDF of the slide show: https://files.me.com/s.mak/8fzat6
Basics of palliative care including symptom management: pain, dyspnea, nausea and constipation; family meetings, goals-of-care, end-of-life care, and artificial nutrition.
Acute hospitals end of life care best practiceNHSRobBenson
Delivering reliable best practice in an acute hospital setting for patients whose recovery is uncertain. Including details of the AMBER care bundle. Presentation from Anita Hayes and colleagues from England's National End of Life Care Programme as part of the Department of Health's QIPP end of life care workstream seminar series at Healthcare Innovation Expo 2011
Three hour slide deck for basics of palliative care including what is palliative care, symptom management (pain, dyspnea, nausea, constipation), goals-of-care, family meetings, comfort care, and issues around artificial nutrition.
This is a case presentation at g level( FCPS)
It is all about the diagnosis of ALL. practical first hand experienced case at Lady Reading Hospital Peshawar.
Carle General Surgery Grand Rounds presentation on palliative care symptom management, specifically pain, nausea, constipation, and malignant bowel obstruction.
The lecture I gave for the Indiana University Health Joint Transplant Education and Research Lecture Series on palliative care. That's right, palliative care in transplant patients NOT at the end-of-life.
Palliative care is about providing well-being and the highest quality of life to patients with serious, progressive, chronic life-limiting illness, including during the dying process.
Building on the lecture I gave (and uploaded) "Palliative Care: what every primary care doctor should know" I built this talk. It is geared for 1st year medical students who are learning anatomy, physiology, and perhaps some pharmacology and pathophysiology.
In this talk, I do not explicitly address hospice care - as that was provided in an online chapter for students at UMass. I will later upload another slide set on that topic.
I hope you enjoy it.
FYI- the link to the youtube video: http://www.youtube.com/watch?v=XHtHXGhTIC4
Link to PDF of the slide show: https://files.me.com/s.mak/8fzat6
Basics of palliative care including symptom management: pain, dyspnea, nausea and constipation; family meetings, goals-of-care, end-of-life care, and artificial nutrition.
Acute hospitals end of life care best practiceNHSRobBenson
Delivering reliable best practice in an acute hospital setting for patients whose recovery is uncertain. Including details of the AMBER care bundle. Presentation from Anita Hayes and colleagues from England's National End of Life Care Programme as part of the Department of Health's QIPP end of life care workstream seminar series at Healthcare Innovation Expo 2011
Three hour slide deck for basics of palliative care including what is palliative care, symptom management (pain, dyspnea, nausea, constipation), goals-of-care, family meetings, comfort care, and issues around artificial nutrition.
This is a case presentation at g level( FCPS)
It is all about the diagnosis of ALL. practical first hand experienced case at Lady Reading Hospital Peshawar.
Presentation by Dr Sheila Carey - Arrowe Park Hospital at the Regional Emergency Laparotomy Collaborative - Complex decision making collaborative at Arrowe Park Hospital on 24 January 2020.
Cardiovascular history taking is an important skill that is often assessed in bedside teaching . It’s important to have a systematic approach to ensure you don’t miss any key information. The guide below provides a framework to take a thorough cardiovascular history.
Running Head Homework 2 Homework 2 Homework 2.docxwlynn1
Running Head: Homework 2
Homework 2
Homework 2
Care plan for MI
NUR3125
Fall 2017
This patient is presenting to the emergency with symptoms that indicate a Myocardial Infarction. The patient, who is a 48-year-old man, is stating a 3-day history of sub sternal chest pain that is radiating to his back. The symptoms started up while he was mowing his lawn. He stated the pain has eased up over time. He also reported mild trouble with breathing and some nausea but no vomiting. He exercises daily, but does report that he eats a lot of fast food. His last total cholesterol was 232 mg/dL. He also has a 15-year history of tobacco use and family history of myocardial infarction (MI), specifically his father had an MI at age 54 and his grandfather at age 58. His current blood pressure is elevated at 158/98 and heartrate of 102 bpm, his respiratory rate is currently high at 26 breaths/min and noted mild use of accessory muscles upon examination. Lungs are noted to have slight inspiratory crackles at both lung bases. Jugular venous distention is noted at less than 2cm bilaterally. His lab work reveals an elevated Troponin at 2.9 ng/ml, elevated Creatinine phosphokinase at 141 units/L, and an elevated CK-MB/CK isoenzyme at 2%. Elevated troponin indicates damage to the heart muscle, and the elevated Creatinine phosphokinase and CK-MB/CK isoenzyme along with all these other symptoms and labs indicate a heart attack. ECG is done and shows ST elevation and T wave inversion, also noted with premature ventricular contractions. The lab values and ST elevation point to a Myocardial Infarction and Transmural ischemia that will require immediate attention.
I have chosen three NANDA nursing diagnoses for this patient, with the first one being the priority. The three I choose are:
· Decreased Cardiac Output related to altered heart rate and ischemia as evidenced by ECG showing an ST elevation, elevated Troponin, and patient stating he has had chest pain for three days.
· Acute Pain related to tissue damage in the myocardium from inadequate blood supply as evidenced by elevated troponin labs and patient reporting chest pain that radiates to back for three days.
· Ineffective Health Maintenance related to deficient knowledge about self-care and treatment as evidenced by patient stating he eats fast food often and has had elevated blood pressure and cholesterol at past appointments, and patient admitting to smoking ½ pack of cigarettes daily despite family history of MI.
Care Plan Diagnosis #1 Myocardial Infarction
NANDA Diagnosis 1: Decreased Cardiac Output related to altered heart rate and ischemia as evidenced by ECG showing an ST elevation, elevated Troponin, and patient stating he has had chest pain for three days.
NOC (Nursing Outcome Classification) Label: Tissue Perfusion
Expected Client Outcomes:
1. Patient will demonstrate adequate cardiac output evidenced by blood pressure, heart rate, and heart rhythm within normal pa.
Similar to End of Life Care: Discussions and Medical Decision Making (20)
Katherine Promer Flores, MD (she/her)
Staff Physician
Division of Infectious Diseases and Global Public Health
Department of Medicine
University of California San Diego
Daniel Lee, MD
Clinical Professor of Medicine
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
Leandro Mena, MD, MPH
Chair and Professor of Population Health Science
Department of Population Health Science
University of Mississippi Medical Center
Maile Young Karris, MD
Associate Professor
Co-Director San Diego Center for AIDS Research Clinical Investigations Core
Divisions of Infectious Diseases & Global Public Health and Geriatrics & Gerontology
Department of Medicine
University of California San Diego
Edward Cachay, MD, MAS
Professor of Medicine
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
Gabriel Wagner, MD
Associate Clinical Professor
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
Jocelyn Keehner, MD
Infectious Disease Fellow
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
Richard Garfein, PhD, MPH
Professor
Herbert Wertheim School of Public Health and Human Longevity Science
Adjunct Professor
Division of Infectious Disease and Global Public Health
Department of Medicine
University of California, San Diego
Laura Bamford, MD, MSCE
Associate Professor of Medicine
Medical Director, Owen Clinic
Division of Infectious Diseases and Global Public Health
Department of Medicine
University of California, San Diego
Davey Smith, MD, MAS
Professor of Medicine
Chief, Division of Infectious Diseases and Global Public Health
Co-Director, San Diego Center for AIDS Research (CFAR)
Department of Medicine
University of California, San Diego
Elliot Welford, MD
Infectious Diseases Fellow
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
Darcy Wooten, MD
Assistant Professor of Medicine
Associate Program Director, Infectious Diseases Fellowship
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
Amutha Rajagopal, MD
Associate Physician Diplomate
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
More from UC San Diego AntiViral Research Center (20)
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
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Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
How to Give Better Lectures: Some Tips for Doctors
End of Life Care: Discussions and Medical Decision Making
1. End of Life Care:
Discussions & Medical
Decision Making
Christie Izutsu
Resident Physician, PGY-2
Department of Internal Medicine
University of California, San Diego
2. Case Discussion
23 M born prematurely at 24-28 wks gestation
• Birth complicated by intraventricular hemorrhage
resulting in developmental delay
• Received several blood transfusions resulting in
contraction of HIV at 6 months of age
First visit to Owen adolescent clinic, 1/31/06
• M184V, D67N, & T689D
• K103N, Y188L
• No PI mutations
3. Case Discussion:
Continued
1/17/07 – clinic visit:
• Labs indicate probable development of resistance
(CD4 103, VL 53892) – repeat resistance testing
more consistent with not taking meds
• Meds:
Epzicom/abacavir/3TC
Norvir/ritonavir
Viread/tenofovir
TMP/SMX DS
Reyataz/atazanavir
4. Case Discussion:
Continued
December 2009 – clinic visit:
• Hospitalized for seizures
• Per brother was diagnosed with progressive
multifocal leukoencephalopathy (PML, +JC virus in
CSF)
• Urine tox +amphetamines, +benzodiazepines
• EEG without seizure activity
• Serum CrAg negative
5. Case Discussion:
Continued
2009-2011 – ongoing medication adherence issues:
• Moving back & forth between Northern California
• Intermittent substance abuse (meth, marijuana)
• Insurance problems (ADAP & Ryan White funding
lapsed 3/2010)
• Misplaced prescriptions
• Patient perspective - “did not have a clear
understanding of risks associated with his non-
compliance to meds”
6. Case Discussion:
Continued
2009-2011 – ongoing medication adherence issues:
• Discontinued ARVS 1/2011 due to nonadherence
and increasing resistance pattern
• Resistance testing:
– 12/2008 (on Atripla): Resistant 3TC, FTC, DLV, EFV, NVP
• NRTI: D67N, T69D, M184V; NNRTI: K103N, Y188L; PI:
none
– 2007 (not on meds): pan-sensitive
– 5/23/2002 (on Trizivir): Resistant 3TC, ddC, AZT, DLV, EFV,
NVP
• restarted Atripla 7/2011, realized he had “AIDS”
7. Case Discussion:
Continued
Social history – complicated family dynamics:
• mother passed due to ruptured aneurysm peri-
partum; “misses the mom he never knew”
• Moved to San Diego 2/2010 from Bakersfield;
previously living with uncle who passed (diabetic
on dialysis)
• Moved in with GM, father, two uncles (Guillermo &
Juan), one of whom assisted with meds
• Father s/p CVA and recent coma, now “like a baby”
• Education up to 11th grade, wanting to get GED
8. Case Discussion:
Continued
Progression through 2012:
• Started on new ARV regimen
• Developed anemia of chronic disease & worsening
of thrush
• Hospitalized for pneumonia at end of 2011
• Hospitalized 7/2012 for GI bleed, coagulopathy
and duodenal obstruction; persistent vomiting –
started on MAC therapy
• Admitted to Hillcrest next week, 7/23-7/25, for
emesis, dehydration; thought to be due to MAC
9. Case Discussion:
Continued
8/2-8/11/12 – clinic to hospitalization:
• Readmitted for tachycardia, bloody diarrhea;
ARVs discontinued
• Stool AFB positive, likely disseminated MAC
• Also diagnosed with:
– severe malnutrition (188 87 lb over 2 yrs)
– hypogonadism
– peridontitis
10. Case Discussion:
Continued
Progression through 1/2013 – clinic visits:
• Worsening diarrhea, now in diapers
• More weight loss – now 83 lb
• requiring assistance to shower
• new abdominal distention & lower
extremity/scrotal edema
• uncles note worsening functional decline
– using walker for ambulation due to leg weakness
– R>L UE tremor which makes feeding himself difficult
11. Case Discussion:
Continued
ARV Clinic, 1/5/12 – ARV history:
• 7/11-present: Atripla
• 2/09-4/10: EPZ+RAL+ETR
(continued viremia, questionable adherence)
• 10/07-2/09: Off ARVs
• 3/05-10/07: EPZ+TDF+ATV/r
(persistent viremia, likely non-compliant)
• 3/04-1/05: FTC+TDF+ABC+ATV/r
• 10/01-1/04: Trizivir
(undetectable, then rebound viremia)
• 11/98-3/99: D4T+NFV+EFV (continued viremia)
• 5/96-7/98: 3TC+d4T
• 12/94-1/96: Ddi+AZT+NVP
• 8/93-3/94: AZT
12. Case Discussion:
Continued
2/1/12 – ARV Clinic:
• “understands why he can no longer use Atripla and understands
he has developed resistance to certain medications due to non-
compliance”
• “based on his genotype, Complera, Prezista/Norvir appears to be
a reasonable option for this patient which will help with
adherence and this regimen should have full antiretroviral activity
based on the past genotype resistance test.”
• “MedAction plan should help the patient stay adherent with his
regimen”
• “Expect a 1-2 log reduction in VL after 2-4 weeks on this new
regimen, and should provide an excellent long-term virologic
response, as long as patient continues to be adherent to the
regimen.”
16. Case Discussion:
Continued
1/15-1/28/13 – hospitalization:
• Admitted following posturing of arms and nonresponsiveness
• Emesis during LP, intubated for airway protection
• 1/17: bronchoscopy revealed exophytic lesion of right main
stem bronchus; galactomannan (+), cytology (-)
• 1/19: evaluated by neuro, thought to have HAND (HIV
associated neurocognitive disorder)
• Started on empiric meningitis coverage; all cultures (-)
• CT abdomen/pelvis with new and enlarging hypoattenutating
lesions in the liver & spleen, diffuse colitis and
lymphadenopathy; broadened to vancomycin & pip/tazo
• continued on ARVs, MAC coverage and OI prophylaxis
• 1/21: amphotericin added, discontinued 1/23
17. Case Discussion:
Continued
1/15-1/28/13 – hospitalization:
• Developed new thrombocytopenia
• Noted to have ongoing aspiration events – per speech
eval, unsuitable for oral intake; NG placed temporarily
• 1/23: family meeting to discuss goals of care
– Discussed severity of condition
– Liver lesions suspicious for malignancy, unable to biopsy
– Believe it is time to consider other options to minimize
“suffering”
– Current options included prolongation of life v providing
quality of life measures to improve comfort and enjoyment in
last phase of life
18. Case Discussion:
Continued
1/15-1/28/13 – hospitalization:
• 1/24/13 – DNR/DNI order placed
• Over the next few days, Howell consulted; priest
present
• 1/28/13 – noted to have agonal breathing, passed at
3am
• Autopsy declined by father – previously permitted by
sister who “wanted to help advance medicine for her
children”
19. Dealing with End-of-Life: Pre-ARV era
• Number 1 cause of death of Americans aged 25-
44 in 1997
CDC “Mortality Slide Series”
20. Dealing with End-of-Life: Pre-ARV era
• Number 1 cause of death of Americans aged 25-
44 in 1997
• Death often before knowing diagnosis
• Focus on quality, rather than quantity of life
• Eventually shifted to emphasis on the quality of
one’s death
– Due to increased acceptance of death in young
healthy individuals
– “Sharing a common fate”
– Desire to control how one dies
Kobayashi JS. Bulletin of the Menninger Clinic. 1997;61(2):146-188.
21. A Different Death Experience
• Multiple losses – friends, partners,
employment, future, independence, self-
esteem, meaningfulness in life
• Often results in complicated grief
• High rates of depression
• “Hidden grievers”
22. Death in the era of Treatment
Advancements
CDC “Mortality Slide Series”
23. Death in the era of Treatment
Advancements
CDC “Mortality Slide Series”
24. Death in the era of Treatment
Advancements
CDC “Mortality Slide Series”
25. Death in the era of Treatment
Advancements
CDC “Mortality Slide Series”
26. Death in the era of Treatment
Advancements
Death still exists
• Treatment failures
– Declining benefits of treatment with time
– Intolerable side effects
– Inability to adhere due to demands & complexity
(significant portion of patients not 100% adherent)
• 75% adherence rates in 2011 (UCSF study)
• 46-88% in 2001
• Inaccessible treatments (economic, social –
providers may not prescribe due to concern for
adherence)
27. Death in the era of Treatment
Advancements
Feelings surrounding death:
• Seems “more unusual” – avoidance and disbelief
when death occurs
– AIDS now a “chronic illness”
• Death anxiety
– “longer period of uncertainty and anticipatory grief”
(Demmer)
– Greater variability in course of illness
– Treatment can fail at any time
• Caregivers – more emotional & physical exhaustion
28. What do you feel is the largest barrier
to discussions about end-of-life care?
a) Timing – not sure when to bring this up
b) Patient discomfort
c) Clinic appointment constraints
d) Lack of training
29. Difficulties Discussing Death
Clinician perspectives:
• Unsure when to discuss end-of-life issues
• Not ready for patients to die (Curtis et al) due to
treatment advancements
• Still with feelings of helplessness, frustration
– Close relationships with long-term pts so more intense
feelings of loss
– Advancements = new challenges, don’t know how to deal
with them
• Lack of training for paraprofessionals
30. Difficulties Discussing Death
Patient perspectives:
• Physician and patient not on same “page”
– Not wanting to face reality
– Complicated process
– Family opinion
• Lack of knowledge
– Understanding what actually happens
– Statistics surrounding resuscitation
31. “Barriers to communication”
Curtis et al, 1996:
• Focus groups of 47 AIDS patients and 19 physicians
• Physician issues – discomfort, time pressures
during appt, fear of undermine hope, role to make
patients feel better, young age of patients
• Patient issues –having AD meant no further
discussions were needed, didn’t want preferences
“set in stone”, felt discriminated against
Curtis et al. J Gen Intern Med. 1997;12:736-41.
32. “Barriers to communication”
Curtis et al, 1996:
One major concern was that “discussing end-of-life care may be
harmful to the patient and may even hasten death”
Curtis et al. J Gen Intern Med. 1997;12:736-41.
33. SUPPORT Study
• “timely provision of prognostic information
by trained nurse”
• Less than 50% of physicians knew when
patients changed their code status to DNR
• Caveat – did not include HIV positive
patients
34. What percentage of your patients have
advance planning documents written up
prior to actually needing end-of-life care?
a) More than 95%
b) 75-95%
c) 50-75%
d) 25-50%
e) Less than 25%
35. Improving Communication:
HIV-Specific Advance Directive
Singer et al. at University of Toronto, 1995
•203 individuals randomized to generic v HIV-specific
living will (50 v 52)
•101 received both
•77.2% v 22.8% preferred the HIV-specific document,
(p<0.001)
•ADAQ (Adv Directive Assessment Questionnaire)
compared the two –mean ADAQ score slightly higher for
HIV document (68.5% v 66.2%, p=0.051
•May not be document itself, but translates to point that
advanced planning should be tailored to patient
36. Creating an Advance Directive:
HIV-specific documents
Singer et al. J Gen Intern Med 1997;12:729-735
37. Creating an Advance Directive:
HIV-specific documents
Singer et al. J Gen Intern Med 1997;12:729-735
38. Advance directive:
disease-specific study
Figure 1: Treatment preferences based on Centre for Bioethics Living Will (Singer et al)
39. Advance directive:
disease-specific study
Figure 2: Treatment preferences based on the HIV Living Will (Singer et al)
40. Advance directive:
disease-specific study
• Generally, prefer less aggressive treatment if
illness more advanced
• Within specific illness scenarios, little
variation in preferences for different
therapies
• Advanced directives are NOT meant to be a
substitute for end-of-life discussions
41. Improving Discussions
What clinicians can do:
• Act as “fellow travelers who can help grievers
make sense of issues that may impact their grief”
– Information and warnings about what to expect
• Open communication
• Active coping strategies
• Structured deliberation – (Emanuel LL) small
choices rather than large ones all at once
42. Improving Discussions
Ongoing discussions:
• “Learn why patients express certain preferences
rather than what those preferences are” (Forrow
L.)
– Outcomes may drive preferences (Rosenfeld, et al)
– Similar concept as Singer study
• Realize that some patients will continue to resist
despite our best efforts
43. President’s Emergency Plan for
AIDS relief
HIV Palliative Care:
• Palliative care begins at time of diagnosis
• Clinical, psychological, social and spiritual
care
45. What do you feel is the most important
aspect of HIV care in children/youth?
a) Medication adherence
b) Understanding the disease & its progression
c) How the child feels about the disease
d) How the disease impacts their relationships
with others
46. Children/Youth and HIV
• How could we explain children/youth that they
are different, and unless they take multiple
pills every day they would die?
• Common terminology among clinicians
treating for growing and youth living with HIV
are: treatment experienced, HIV resistance
• Not very often stated or address are: stigma
and isolation felt by these patients
47. Children/Youth & HIV: Statistics
Children/youth living with HIV:
• WHO – 3.4 million as of 2011
• UNAIDS – as of 12/2003, children < 15 yrs of age:
– 700,000 newly diagnosed = 13% of all new cases
– 500,000 died that year alone
• Older stats: through 2002, 9300 Americans < 13
– 92 new cases of pediatric AIDS in 2002
– 3x as many HIV cases
• Death rates declined 68% from 1998-2002 in
number of children/youth who died from AIDS
48. Children/Youth & HIV: Progression
Two general patterns:
• 20% - serious disease in first 12 months
– Death usually by age 4
• 80% - slow rate of progression
– May not see serious symptoms until adolescence
– Often with delayed growth & milestones
– Opportunistic infections:
• PCP is the leading cause of death in children
• CMV – primary infection rather than reactivation
• LIP (lymphocytic interstitial pneumonia)
• Severe candidiasis
49. Children/Youth and HIV: Discussions
Talking to children/youth about their disease:
• Tailor to age & development
• May not be a “right” age
51. Children/Youth and HIV: Concerns
Issues that affect children/youth with HIV:
• Medications – who to tell at school
• Friends
– Psychosocial variables & immune response
• Increase in CD4% by ~5.55% with recent disclosure
(Sherman et al, 2000)
• Being “different”
– Anger, withdrawal, rebelliousness
– Refusal to take medications
• Socially isolated & restricted in activities
52. Children/Youth and HIV:
Medication Adherence
Barriers to medication use:
• Insurance and financial
concerns less prominent
• Otherwise similar to
adults
• Results in complications
and resistance
Table 2. Barriers to Medication Adherence for full Study Sample & By Route of Infection (MacDonell et al.)
53. Spirituality
• Spirituality is part of comprehensive palliative
care
• Associated with health outcomes
– McClain C et al (2003) Lancet 361:1603 – spiritual
well-being correlated with less depression,
hopelessness, SI; higher social support
– Existential well-being and HIV symptoms correlate
with psychological well-being
54. What percentage of your patients have
discussed spirituality with you and the
role this plays in their healthcare?
a) Greater than 95%
b) 75-95%
c) 50-75%
d) 25-50%
e) Less than 25%
55. Spiritual Distress
• Distress comes from fear of dying, conflict of
beliefs and same reasons make addressing
death difficult
57. Suggestions for Discussing
Spirituality
Lo et al:
• Clarifying religious statements
• Responding to statements that may indicate
spiritual concerns
• Responding to religious reasons for rejecting
medical recommendations
• Listening – nonjudgmentally
• Recognizing rituals, symbols, icons
58. Addressing Spiritual Needs
Puchalski et al – FICA format:
• F – faith (belief, meaning)
• I – importance (influence on life)
• C – community (who they belong to)
• A – address/action in care (how we
address)
60. Books on Life & Death:
Recommended by Rev Kovach, MD
61. At the end:
Medical Decision Making
Decisions at end-of-life:
• Can be difficult if poor communication ahead of
time
• Most times left to family (Kelly B et al)
– Involved 60-80% of the time
– Unfortunately family often unsure of patient wants
• Difficult to decide when to stop pursuing active
measures in hospitalized patients
– Stepwise process (Stroud)
64. Closing Thoughts & Reflections
• Medicine is a balance of science & art
• Our compassion and caring connections with
patients can have an immense impact on patient
perceptions & influence the ultimate outcome of
one of the biggest events in life
65. Resources
Demmer, C. “Dealing with AIDS-related loss and grief in a time of treatment advances.” Am J of Hospice & Palliative Care. Vol 18, No
1, Jan/Feb 2001.
Singer et al “The HIV-Specific Advance Directive.” J Gen Intern Med 1997;12:729-735
http://www.slideshare.net/ucsdavrc/addressing-the-spiritual-and-emotional-needs-of-hiv-patients
Wilson, I. “End of Life Care in HIV Disease.” JGIM. Vol 12, Dec 1997.
Forrow L. “The green eggs and ham phenomena. Hastings Cent Rep. 1997;24:S29-32.
Rosenfeld, et al. “End-of-Life Decision Making. A Qualitative Study of Elderly Individuals.” J Gen Intern Med. 2000; 15:620-625.
http://www.state.gov/documents/organization/64416.pdf
“Spiritual Issues in HIV/AIDS Palliative Care.” The Center for Palliative Care Education.
Curtis JR, Patrick DL. “Barriers to Communication About End-of-Life Care in AIDS Patients.” J Gen Intern Med. 1997;12:736-741.
Lo et al. JAMA. 2002;287:749-754.
Puchalski CM, Romer AL. Taking a spiritual history allows clinicians to understand patients more fully. J Pall Med 2000;3:129-37.
CDC Mortality Slide Series. “HIV Mortality Slides.”
WHO. “Antiretroviral therapy for HIV infection in infants and children: Towards universal access. Recommendations for a public
health approach: 2010 revision”
Vaz et al. “Telling Children They Have HIV: Lessons Learned from Findings of a Qualitative Study in Sub-Saharan Africa.” AIDS
Patient Care and STDs. Vol 24, Num 4. 2010.
MacDonell et al. “Barriers to Medication Adherence in Behaviorally and Perinatally Infected Youth Living with HIV.” AIDS Behav.
(2013) 17:86-93.
Kovach, DA. “Caring for the whole person with HIV: Mind, Body and Spirit.” The Permanente Journal. Spring 2008. Volume 12,
Number 2.
Sherman et al. “When Children Tell Their Friends They Have AIDS: Possible Consequences for Psychological Well-Being and Disease
“Please Talk to Kids About AIDS”. Hennessey et al. (documentary, vineeta.org)
Womenshealth.gov “AIDS”
66. Resources
“Talking with Children about Sex & AIDS: At What Age to Start?” New York Times. Feb 26, 2008.
Childrennow.org “Talking with Kids About Tough Issues: HIV/AIDS”
Kelly B, et al. “Systematic Review: Individuals’ Goals for Surrogate Decision Making.” JAGS. 60: 884–895
National Institute of Allergy and Infectious Disease (NIAID) website. “HIV/AIDS: HIV infection in infants and children”
http://www.niaid.nih.gov/topics/HIVAIDS/Understanding/Population%20Specific%20Information/Pages/children.aspx
Okonsky, J. “Problems taking pills: understanding HIV medication adherence from a new perspective.” AIDS Care. Vol 23, Issue 12.
2011.
Univ of Toronto Joint Centre for Bioethics. “HIV Living Will.”
http://www.jointcentreforbioethics.ca/tools/documents/jcb_livingwill_hiv.pdf
“The SUPPORT Principal Investigators. A Controlled trial to improve care for seriously ill hospitalized patients: The Study to
Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT).” JAMA. 1996;274:1591-8.
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