Mrs. B, a 97-year-old woman living in a residential care home, was admitted to the hospital after a fall. Her daughter informed staff that Mrs. B had an advance health directive. Mrs. B was treated for aspiration pneumonia and other issues. Despite treatment, Mrs. B remained distressed and her condition deteriorated. She was found dead during an overnight medical team call. Opportunities to improve care included the residential home notifying the hospital of Mrs. B's advance directive and discussing her goals of care when she was confused upon admission.
Carle Palliative Care Journal Club for 7/3/18Mike Aref
Journal club review of "Effect of Lorazepam With Haloperidol vs Haloperidol Alone on Agitated Delirium in Patients With Advanced Cancer Receiving Palliative Care: A Randomized Clinical Trial" by D. Hui et. al. in JAMA. 2017 Sep 19;318(11):1047-1056.
Carle Palliative Care Journal Club for 7/3/18Mike Aref
Journal club review of "Effect of Lorazepam With Haloperidol vs Haloperidol Alone on Agitated Delirium in Patients With Advanced Cancer Receiving Palliative Care: A Randomized Clinical Trial" by D. Hui et. al. in JAMA. 2017 Sep 19;318(11):1047-1056.
Geriatric Population. Geriatric Palliative and End-of-Life Care.Michelle Peck
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.
Developmental Disabilities and Community LifeRoss Finesmith
This manuscript describes the move of the developmentally disabled from institutions into our communities, and the need for doctors to care for this "new" population in the waiting room.
Success Principle 12: End of life care for COPDNHS Improvement
A series of mix and match cards providing practical examples of changes you can make and how to implement them to improve care and quality at every step of the pathway for patients with COPD and asthma.
A presentation made by Dr. Andrew Knight during the free public forum "Continuing the Conversation: a discussion on preparing for end-of-life care" on February 6, 2014 at the United Steelworkers Hall in Sudbury, Ontario.
Dr. Knight is a General Practitioner at the Northeast Cancer Centre and he is the Education Co-chair of the Palliative Care Education Committee and is an Assistant Professor of Family Medicine at the Northern Ontario School of Medicine. He is a Past Chair of the Canadian Association of General Practitioners in Oncology (CAGPO) and is currently the Palliative Care Lead for LHIN 13.
Learn more about the forum at http://www.hsnsudbury.ca/events
Medically unexplained symptoms are ‘persistent bodily complaints for which adequate examination does not reveal sufficient explanatory structural or other specified pathology’.
These patients are challenge to medical professionals
Dr Mark Griffiths - Medically unexplained symptoms: An innovative approach fo...Innovation Agency
Presentation by Dr Mark Griffiths, Consultant Lead Clinical Psychologist, Aintree University NHS Foundation Trust: Medically unexplained symptoms: An innovative approach for a primary care workforce on Wednesday 13 March 2019 at Haydock Park Racecourse.
A presentation made by Dr. Brian Goldman during the free public forum "How to Start the Conversation: a discussion on preparing for end-of-life care" on January 9, 2014 at the United Steelworkers Hall in Sudbury, Ontario.
Dr. Brian Goldman is an Emergency Department physician at Mount Sinai Hospital in Toronto and host of the national CBC radio program “White Coat, Black Art”.
Learn more about the forum at http://www.hsnsudbury.ca/events
Geriatric Population. Geriatric Palliative and End-of-Life Care.Michelle Peck
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.
Developmental Disabilities and Community LifeRoss Finesmith
This manuscript describes the move of the developmentally disabled from institutions into our communities, and the need for doctors to care for this "new" population in the waiting room.
Success Principle 12: End of life care for COPDNHS Improvement
A series of mix and match cards providing practical examples of changes you can make and how to implement them to improve care and quality at every step of the pathway for patients with COPD and asthma.
A presentation made by Dr. Andrew Knight during the free public forum "Continuing the Conversation: a discussion on preparing for end-of-life care" on February 6, 2014 at the United Steelworkers Hall in Sudbury, Ontario.
Dr. Knight is a General Practitioner at the Northeast Cancer Centre and he is the Education Co-chair of the Palliative Care Education Committee and is an Assistant Professor of Family Medicine at the Northern Ontario School of Medicine. He is a Past Chair of the Canadian Association of General Practitioners in Oncology (CAGPO) and is currently the Palliative Care Lead for LHIN 13.
Learn more about the forum at http://www.hsnsudbury.ca/events
Medically unexplained symptoms are ‘persistent bodily complaints for which adequate examination does not reveal sufficient explanatory structural or other specified pathology’.
These patients are challenge to medical professionals
Dr Mark Griffiths - Medically unexplained symptoms: An innovative approach fo...Innovation Agency
Presentation by Dr Mark Griffiths, Consultant Lead Clinical Psychologist, Aintree University NHS Foundation Trust: Medically unexplained symptoms: An innovative approach for a primary care workforce on Wednesday 13 March 2019 at Haydock Park Racecourse.
A presentation made by Dr. Brian Goldman during the free public forum "How to Start the Conversation: a discussion on preparing for end-of-life care" on January 9, 2014 at the United Steelworkers Hall in Sudbury, Ontario.
Dr. Brian Goldman is an Emergency Department physician at Mount Sinai Hospital in Toronto and host of the national CBC radio program “White Coat, Black Art”.
Learn more about the forum at http://www.hsnsudbury.ca/events
The Aging process is a broad topic. This power point hopes to help you understand the process and what can be done to help you age gracefully and positively.
SHARE Presentation: Palliative Care for Womenbkling
Dr. Michael Pearl discusses supportive palliative care for women with cancer, how it differs from hospice care, and the New York Palliative Care Information Act. Dr. Michael Pearl is Professor and Director of the Division of Gynecologic Oncology in the Department of Obstetrics, Gynecology and Reproductive Medicine at Stony Brook University Hospital.
The goal of this webinar was to educate healthcare professionals about the differences between palliative and curative care while exploring the history and philosophy of the hospice movement.
The goal of this webinar was to educate healthcare professionals about the differences between palliative and curative care while exploring the history and philosophy of the hospice movement.
This webinar provides expert guidance and clear answers to common myths about hospice care. Learn about the history and philosophy of hospice care, common hospice prognoses, who pays for hospice, and the difference between hospice and palliative care. Explore the four levels of care and the role of the interdisciplinary hospice team to provide medical, psychosocial and spiritual solutions that support quality of life at the end of life for patients and families. Learn how advance directives can ensure patients are referred to hospice care early in the disease process to enjoy its full benefits.
This PPT is all about Something that we want to lear an discover new things in life which might be very useful and essential to do something so you can figure out and work on it so you will be able to do it simply great and awesome in life. After downlading the ppt please do not forget to reshare it with your friends families and morel
discussion 1 Clinical case scenarioA 39-year-old homeless man pr.docxcharlieppalmer35273
discussion 1 Clinical case scenario
A 39-year-old homeless man presents to the emergency department for cough and fever. He says that his illness has been worsening over the past 2 weeks. He originally had dyspnea on exertion and now is short of breath at rest. On questioning, he tells you that he lives in a homeless shelter when he can, but he frequently sleeps on the streets. He has used IV drugs (primarily heroin) “on and off” for many years. He denies medical history but the only time he gets medical attention is when he comes to the emergency department for an illness or injury. On review of systems, he complains of fatigue, weight loss, and diarrhea. On examination, he is a thin, disheveled man appearing much older than his stated age. His temperature is 100.5°F (38.0°C), his blood pressure is 100/50 mm Hg, his pulse is 105 beats/min, and his respiratory rate is 24 breaths/min. His initial oxygen saturation is 89% on room air, which comes up to 94% on 4 L of oxygen by nasal cannula. Significant findings on examination include dry mucous membranes, a tachycardic but regular cardiac rhythm, a benign abdomen, and generally wastedappearing extremities. His pulmonary examination is significant for tachypnea and fine crackles bilaterally, but no visible signs of cyanosis. His chest x-ray is read by the radiologist as having diffuse, bilateral, interstitial infiltrates that look like “ground glass.”
Answer the following questions:
1. What is the most likely cause of this patient’s current pulmonary complaints?
2. What underlying illness does this patient most likely have?
3. What testing and treatment should be started now?
1 Scholarly Resource in APA format.
Submission Id: 69f3483b-3254-4608-a16e-bb82ab08033e
78% SIMILARITY SCORE 5 CITATION ITEMS 19 GRAMMAR ISSUES
Int ernet Source 0%
Inst it ut ion 78%
Yeni Hernandez
DiabetesinHomeHealth yeni.docx
Summary
1393 Words
Running Head: DIABETES IN HOME HEALTH 1
DIABETES IN HOME HEALTH 2
Yeni Hernandez
GCU
Course: Professional Capst one
Dat e:5/19/2019
Diabet es in Home Healt h
Background
Diabet es is becoming a major problem in t he Unit ed St at es. Current ly, dat a from t he
Cent er for Disease Cont rol and Prevent ion indicat es t hat close t o120 million people in
t he US are suffering from diabet es or prediabet es. This number is very huge and
dealing wit h it is a mat t er of urgency. Wit h t he high number of diabet ic pat ient s and
t he number of t ime pat ient s spend in t he hospit al decreasing; home healt h care has
become a good opt ion for t he care of t hese pat ient s. Home healt h care provides
holist ic care t o pat ient s while improving healt h out comes. Many of t he individuals
suffering from diabet es combined wit h ot her condit ions oft en do not recognize t hat
diabet es should be t he focus of care, according t o t he American Diabet es
Associat ion (2018). This paper will focus on t he t opic .
The goal of this webinar is to educate healthcare professionals about the differences between palliative and curative care while exploring the history and philosophy of the hospice movement.
The who, what, where, why and how of end-of-life care. A continuing education webinar presented by VITAS Healthcare on March 15, 2018. For more information or future webinars, please visit: https://www.vitas.com/partners/continuing-education
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
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
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Best Ayurvedic medicine for Gas and IndigestionSwastikAyurveda
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
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SURGICAL ANATOMY OF THE RETROPERITONEUM, ADRENALS, KIDNEYS AND URETERS.pptx
End of life discussions
1. "Limits of Care / DNR
discussions".
In Acute Care Setting
LAKMAL NANDADEWA
2. What is an advanced health directive?
A document that contains your/patients decisions about future treatments including medical,surgical,dental treatment
and other health care
Who can make an advanced health directive ??
If you/patient is at least 18yrs of age and have full legal capacity
If the patient does not have the capacity who else can do it ??
Patient may lack full capacity I if your decision making is impaired by illness, disease or injury or the effects of
medications ,drugs or alcohol
An Enduring Guardian ,a Guardian, Health care professional
3. Dying in acute care
• Dying in Australia is more institutionalised than in the rest of the world
• 50 % of Australians dying in hospital, despite 68 % indicating a preference to die at
home
• Home deaths, which include people who die in residential care facilities, are half as
prevalent in Australia as they are in New Zealand, the United States of America,
Ireland and France.
• Hospitalisations in Australia have increased significantly for older age groups, with
the hospitalisation rate for those aged over 85 increasing by 35 % for women and 48
% for men in the decade to 2011-2012
4. • A high number of hospital admissions and emergency department
presentations occur in the last 12 months of life.
• Frequently these acute care presentations and admissions are inappropriate
and they can be distressing for patients. They also place increased stress on
an already pressured health system
5. The cost of dying in acute care
• Research shows that 59 % of health care expenditure is incurred during a
person’s last three years before death, regardless of their age at death
• This cost increases substantially during a person’s last year of life and, in
particular, increases substantially during their last three months of life
• Each year more than $2 billion is spent on older people who die in hospital,
with an estimated 9 % of all inpatient costs being allocated to patients aged
65 years and over in their last year of life.
6. • Approximately 1/3 of all people who die in hospital will have only one
admission – the one in which they die – at an estimated cost of $19,000 for
those aged 50 and over.
• With more people dying each year due to Australia’s ageing population, the
real costs of dying will increase accordingly. Policies to address this
anticipated increase in costs are essential in order to manage the health
budget
7. Recognising and responding to clinical
deterioration
• The acute care setting is designed to provide short-term, episodic care for mainly
acute illnesses. Patients are often intensively managed and the default position
is to continue to treat symptoms
• Recognition of dying is frequently inadequate, resulting in missed
opportunities to consider appropriate referral to specialist palliative care and to
initiate end-of-life care plans.
• Clinicians have a responsibility to initiate and facilitate honest discussions
with patients earlier in their illness trajectory and to assist them to make
decisions about how they want to live for the rest of their lives.
8. Supporting clinicians in their practice
• There is also a need to ensure that clinicians across all health settings are
adequately trained and supported to provide this level of care.
• The quality of care at end-of-life is often dependent on a clinician’s
experience and the resources available, leading to a wide variation in practices
within and across health services.
9. “It’s hard for experts (health professionals) to listen to non-experts (carers),
when they are the experts of their loved one”
“...the idea that cure is improbable or impossible, or that continued life
support is inappropriate or unkind, is unacceptable to many families.
The wider problem here is that acknowledgement of the inevitability of death,
and preparation for it, have largely lost their place in our culture. For many, an
almost child-like faith in medicine and science has taken its place”
10. Changing the culture of dying and planning
for death
• Research indicates that real benefits for individuals and communities can
result from strengthening society’s awareness and understanding of death,
dying, loss and palliative and end-of-life care
11. fear, denial and unrealistic expectations
• Talking about death and dying is emotive and difficult for many people
• Western societies, including Australia, have been characterised as ‘death
denying’ and curative medical treatments are commonly prioritised ahead of
palliative care and quality of life
• Clinicians’ individual values, beliefs and experiences can also affect their
behaviours and influence the way that they provide care to dying patients. eg:
one study found that the religious beliefs of doctors influenced the way they reported managing ethically
controversial decisions such as providing continuous deep sedation until the point of death
12. • Fear and denial about facing issues around death and dying is common amongst
clinicians as well as patients and families
• fear as being a major barrier to talking about dying and planning for the end of life.
• A number of papers describe how television programs hugely inflate the
success rates of interventions such as cardiopulmonary resuscitation
• Television may contribute to patients and families developing unrealistic
expectations of the outcomes of such treatments
13. trajectories of decline
• Dying is no longer the relatively rapid process that it once was
• Most people will die with ‘unpredictable timing from predictably fatal
chronic disease
• Glaser and Strauss first described the concept of a ‘trajectory of dying’ in
the 1960s. This term describes how an eventually fatal condition will change
a person’s health and functional status over the period of time leading up to
their death
14. The four trajectories of decline that are commonly described relate to groups
of conditions that are eventually fatal
1. Sudden death
2. Terminal illness
3. Organ failure
4. Frailty
15.
16.
17. Patient-1
Six months prior to death- Mr A a 68-year-old man diagnosed with cancer
Mr A is a 68-year-old-man who lives at home with his wife, daughter and son-in-law. He is
referred by his GP to hospital for admission as he has been experiencing increasing nausea,
vomiting and lethargy. He has a history of lung cancer (diagnosed one year ago) for which he
has been having chemotherapy. During his admission the doctors discover his cancer has
spread throughout his lungs and also to his liver. Mrs A is upset about this as he believed his
cancer was being treated by the chemotherapy. Mr A’s treating team consider a different type of
chemotherapy to help ease his symptoms. While in hospital Mr A regularly tells nursing staff he
wants to go home and that he dislikes spending time in hospitals away from his wife. Mr A
starts the new chemotherapy in hospital and with his symptoms treated he is sent home. His
GP is sent a discharge letter and he has a planned outpatient appointment in four weeks.
18. Areas for discussion
Opportunities to improve quality of care prior to this admission
Cancer diagnosis- There may have been an opportunity to introduce the concept of Advance Care Planning (ACP) to Mr and Mrs A
once this diagnosis was made .Mr A may have used this time to discuss his goals of care with his family, treating team and/or his GP
Opportunities to improve quality of care prior to this admission
Opportunities and key stages this admission
Disease progression (triggers/surprise question)-
The treating medical staff could discuss prognosis and goals of care with Mr A and his family as his condition has worsened and he is
likely to need increasing care in the next 6 months.
Dislikes hospital (patient-centred care)
There is an opportunity for the team and the family to consider the different options for care at home for Mr A in the future as his
condition worsens. This may also include discussions about where he may wish to be cared for when he dies.
Options for care (specialist palliative care)
This may be an opportunity to introduce palliative care services as an option in future care if needed or wanted at the time.
19. Patient 2:
Last days of life Mrs B – a 97-year-old lady from a residential care home
Mrs B is a 97-year-old lady who lives in a residential care home. Mrs B is admitted to hospital after a fall. She
appears confused on admission. The staff from Mrs B’s home say that she has been increasingly unable to care
for herself or move about the home. She has fallen several times in the last few months and has lost weight. Her
daughter is with her on admission and she informs one of the junior doctors that her mother has an Advance
Health Directive (AHD) she completed at the care home. Mrs B has no other specific medical problems. She is
found to have aspiration pneumonia. Treatment includes antibiotics and fluids with a full assessment by social
workers, physiotherapists, speech pathologists and other health care professionals. The goal is to find a
residential care home for Mrs B to move to which suits her needs. Three days after admission there is an
emergency medical team call for Mrs B when staff find her very distressed and she appears to have problems
with her breathing. She receives intravenous medication to help her breathing and is referred for further
investigations. She remains agitated overnight and during a night shift round the nurse finds her dead.
20. Opportunities and key stages prior to this admission
Residential care home-
The residential care home could have notified the hospital (and GP or treating doctors) that Mrs B had an AHD. A copy of the AHD
could have gone with Mrs B to hospital. Mrs B’s daughter could have kept a certified copy of it too. This may have assisted in
determining Mrs B’s goals of care while she was in a confused state.
21. Opportunities and key stages this admission
Confused:
Staffs duty-Should have discussed about advance care plans, designated decision maker and/or has expressed any wishes for her future
care.
AHD: the junior doctor could have contacted the care home to ask for a copy of the document. This could then be reviewed with the
daughter and Mrs B (Ensuring that information about advance care plans and treatment-limiting orders is in the patient clinical record,
where appropriate).
Full assessment
the multidisciplinary team could have discussed Mrs B’s end of life care needs and wishes with her as well as any resuscitation plan at
any stage during the assessments in consultation with her family.
22. After the emergency medical team call
the staff could discuss prognosis and end of life care with Mrs A and her family as her condition worsened.
Education and training for end-of-life care
support staff to assess, monitor and evaluate end-of-life care including symptom relief, psychosocial and spiritual needs of patients and
their families
23. Patient 3:
Last months of life Mrs C – a 71-year-old lady with comorbidities
Mrs C is a 71 year old lady who lives at home with her son. She is admitted to hospital via the
Emergency Department after a fall. She is found to have pneumonia. She has a history of
alcohol dependence, type 2 diabetes, high blood pressure and AF. She has been in hospital five
times in the past 12 months with increasing problems and difficulty coping with her diabetes at
home. After several days in hospital she finds it more difficult to breathe and becomes agitated
and aggressive. Her pneumonia worsens and she has bacteraemia. She is sent to the Intensive
Care Unit (ICU) where her care continues for five days. Her condition improves somewhat and
she is transferred back to a ward. After 14 days in hospital she is discharged home with some
equipment to support her. There is a plan for community support services to assess her needs
and assist her to manage at home.
24. Opportunities and key stages prior to this admission
Multiple admissions (triggers)
There may have been an opportunity (triggered by multiple unplanned admissions) to start Advance Care Planning
(ACP) discussions during at least one of these admissions. Mrs C may have used this time to discuss her wishes for her
future care with her son, her treating doctors and her general practitioner.
Opportunities and key stages this admission
Admission
Admitting nurses and doctors could ask Mrs C if she has any form of ACP documented
25. Worsening condition
the treating medical staff could discuss prognosis and goals of care with Mrs C and her family as her condition
worsened. The practicality of an ICU admission could be discussed
Post ICU
Treating medical staff could discuss the future likelihood of ICU admissions and determine what Mrs C and her family
would like to do if ICU admission became likely again.
Plan for recurrent admission
Mrs C may require more community-based support and health services to manage her care at home and avoid
unplanned hospital admissions
26. policies, strategies and programs
• National Palliative Care Strategy
• National Palliative Care Program
• Guidelines for end-of-life care and decision-making
• In Western Australia, the Palliative Care Network Advisory Committee
oversees a range of activities aimed at developing an integrated model of
palliative care across the state. These include the development of Rural
Palliative Care Networks, Metropolitan Palliative Care Teams and the
Paediatric Palliative Care Program
27. Community awareness
1. National DonateLife Communications Framework
2. Healthy Dying Initiative -www.dhhs.tas.gov.au/palliativecare/advance_
care_planning_for_healthy_dying
3. Planning Ahead Tools - www.planningaheadtools.com.au
28. References:
• 1. Western Australia. Department of Health. WA Cancer & Palliative Care Network. Consumer Carer Focus Group Report: Communication at end-of-life in hospital.
Perth: Department of Health; 2015.
• 2. Leadership Alliance for the Care of Dying People. One chance to get it right: Improving people’s experience of care in the last few days and hours of life. United
Kingdom; 2014.
• 3. Smith, R. A good death. British Medical Journal 2000;320.
• 4. Swerissen H, Duckett S. Dying well: Grattan Institute Report No. 2014-10 [cited 2015 Nov 16]. Available from: http://grattan.edu.au/wp-
content/uploads/2014/09/815-dying-well.pdf
• 5. Clinical Excellence Commission. Care for the dying in NSW: a review of the data from the 2012 Quality Systems Assessment. Sydney South; 2013.
• 6. Australian Bureau of Statistics. Australian Demographic Statistics. Feature article: population by age and sex, Australia, States and Territories. Canberra: Australian
Bureau of Statistics; 2014.
• 7. The University of Sydney. Clinical Practice Guidelines for Dementia in Australia. Public Consultation Draft 2015. Sydney: Cognitive Decline Partnership Centre;
2015.
• 8. Rosenwax LK, McNamara BA, Murray K, McCabe RJ, Aoun SM, Currow DC. Hospital and emergency department use in the last year of life: a baseline for future
modifications to end-of-life care. Med J Aust 2011;194(11):570-3