Next month
Download
1 / 48

Next Month Live Conference is on FRIDAY June 5 - PowerPoint PPT Presentation


  • 402 Views
  • Uploaded on

Next Month. Live Conference is on FRIDAY June 5 Millard Fillmore Gates/Suburban will replay session for Monday Grand Rounds Meg Campbell, PhD, RN Recognizing patients who can benefit from palliative care consultation. CME Disclosure. NO commercial relationships of any kind

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Next Month Live Conference is on FRIDAY June 5' - Renfred


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Next month l.jpg
Next Month

  • Live Conference is on FRIDAY June 5

  • Millard Fillmore Gates/Suburban will replay session for Monday Grand Rounds

    Meg Campbell, PhD, RN

    Recognizing patients who can benefit

    from palliative care consultation


Cme disclosure l.jpg
CME Disclosure

  • NO commercial relationships of any kind

  • Some off-label uses may be discussed—they will be identified as such


Managing death diagnosing dying setting goals l.jpg

Managing Death:Diagnosing Dying,Setting Goals

Jack P. Freer, MD

Professor of Medicine

University at Buffalo


Learning objectives l.jpg
Learning Objectives

  • Be able to recognize the dying patient in institutional settings


Learning objectives5 l.jpg
Learning Objectives

  • Be able to recognize the dying patient in institutional settings

    • Help clarify and prioritize the goals of care most relevant to the dying patient


Learning objectives6 l.jpg
Learning Objectives

  • Be able to recognize the dying patient in institutional settings

    • Help clarify and prioritize the goals of care most relevant to the dying patient

    • avoid burdensome diagnostic and therapeutic modalities that are unlikely to further the goals of care


Learning objectives7 l.jpg
Learning Objectives

  • Be able to recognize the dying patient in institutional settings

    • Help clarify and prioritize the goals of care most relevant to the dying patient

    • avoid burdensome diagnostic and therapeutic modalities that are unlikely to further the goals of care

    • Help family and staff understand clinical signs and symptoms that are likely to occur


Learning objectives8 l.jpg
Learning Objectives

  • Be able to recognize the dying patient in institutional settings


Diagnosing dying l.jpg
Diagnosing “Dying”

Some patients are clearly dying

  • They die, no matter how intensely we try to prevent death.

  • They die, no matter how superb the medical care they receive.

  • If we “successfully treat” one potential cause of death, they still “die of something else.”


Diagnosing dying13 l.jpg
Diagnosing “Dying”

Dying patients may be maddeningly difficult to distinguish from those who are simply sick.

  • Frail old people sometimes get pneumonia or an MI.

  • High quality medical care sometimes restores them to baseline.


Diagnosing dying14 l.jpg
Diagnosing “Dying”

More often than not, modern medicine treats dying patients like they are simply sick.

  • Fits with our forensic reductionist medical model (people die of something).

  • In uncertain situations, we avoid the path that will cause us the most chagrin.


Chagrin factor l.jpg
Chagrin Factor

Feinstein AR. The 'chagrin factor' and qualitative decision analysis. Archives of Internal Medicine. 145(7):1257-9, 1985 Jul.

  • Medical decisions produce specific results

  • Each “wrong result” follows from a particular decision

    “...a customary clinical strategy is to choose the option whose wrong result will cause the least chagrin.”


Prognosticating in cancer patient l.jpg
Prognosticating in Cancer Patient

  • Advanced metastatic cancer is fatal

  • Trajectory is predictable

  • Performance predicts survival



Prognosticating in chf copd l.jpg
Prognosticating in CHF/COPD

  • Diseases are potentially fatal

  • Trajectory is less predictable

  • Treatment decisions have significant effect (ventilator)


Prognosticating in dementia frailty l.jpg
Prognosticating in Dementia, Frailty

  • Alzheimer’s is fatal (not widely recognized)

  • Trajectory is very unpredictable

  • Treatment decisions have significant effect (PEG)


Learning objectives26 l.jpg
Learning Objectives

  • Be able to recognize the dying patient in institutional settings

    • Help clarify and prioritize the goals of care most relevant to the dying patient

    • avoid burdensome diagnostic and therapeutic modalities that are unlikely to further the goals of care

    • Help family and staff understand clinical signs and symptoms that are likely to occur


Goals of care l.jpg
Goals of Care?

  • Complete cure


Goals of care28 l.jpg
Goals of Care?

  • Complete cure

  • Longevity/survival


Goals of care29 l.jpg
Goals of Care?

  • Complete cure

  • Longevity/survival

  • Comfort/avoidsuffering


Goals of care30 l.jpg
Goals of Care?

  • Complete cure

  • Longevity/survival

  • Comfort/avoidsuffering

  • Independence


Goals of care31 l.jpg
Goals of Care?

  • Complete cure

  • Longevity/survival

  • Comfort/avoidsuffering

  • Independence

  • Remain in familiar environment


Goals of care32 l.jpg
Goals of Care?

  • Complete cure

  • Longevity/survival

  • Comfort/avoidsuffering

  • Independence

  • Remain in familiar environment


Goals of care33 l.jpg
Goals of Care

  • Goals not explicitly articulated

  • Single goal often presumed

  • Failure to attain that goal devastating


Goals of care34 l.jpg
Goals of Care

  • Multiple goals

  • Goals differ in priority

  • Goals differ in attainability

  • Goals conflict with each other

  • Dynamic—changes with time


Goals of care35 l.jpg
Goals of Care?

  • Complete cure

  • Longevity/survival

  • Comfort/avoidsuffering

  • Independence

  • Remain in familiar environment


Goals of care36 l.jpg
Goals of Care?

  • Longevity/survival

  • Comfort/avoidsuffering

  • Remain in familiar environment


Goals of care37 l.jpg
Goals of Care?

  • Longevity/survival

  • Comfort/avoidsuffering


Goals of care38 l.jpg
Goals of Care?

  • Comfort/avoidsuffering

  • Remain in familiar environment


Learning objectives39 l.jpg
Learning Objectives

  • Be able to recognize the dying patient in institutional settings

    • Help clarify and prioritize the goals of care most relevant to the dying patient

    • avoid burdensome diagnostic and therapeutic modalities that are unlikely to further the goals of care

    • Help family and staff understand clinical signs and symptoms that are likely to occur


Futility vs goals of care l.jpg
“Futility” vs. Goals of Care

  • Aggressive treatments in dying patients sometimes discounted as “futile”

  • Futility really means totally ineffective


Futility vs goals of care41 l.jpg
“Futility” vs. Goals of Care

  • Real reason: the treatment is incapable of furthering any realistic goals of care

  • Dialysis, ventilator, PEG tubes etc

  • Diagnostic tests: scans, biopsies, blood tests

  • Vital signs, pulse oximetry


Learning objectives42 l.jpg
Learning Objectives

  • Be able to recognize the dying patient in institutional settings

    • Help clarify and prioritize the goals of care most relevant to the dying patient

    • avoid burdensome diagnostic and therapeutic modalities that are unlikely to further the goals of care

    • Help family and staff understand clinical signs and symptoms that are likely to occur


Death in days weeks l.jpg
Death in Days—Weeks

  • Bedridden

  • Profound weakness

  • Little interest in food / drink

  • Difficulty swallowing

  • Increasingly somnolent

    Palliative Medicine, Declan Walsh, MD, Ed. 2009 by Saunders/Elsevier


Death in hours days l.jpg
Death in Hours—Days

  • Cold skin

  • Clammy skin

  • Cyanosis of extremities / mouth

  • Decreased urine output

  • Diminished level of consciousness

    Palliative Medicine, Declan Walsh, MD, Ed. 2009 by Saunders/Elsevier


Death in hours days45 l.jpg
Death in Hours—Days

  • Breathing may “rattle”

  • Respiration: irregular / shallow / Cheyne-Stokes

  • Waxen face

  • Relaxed facial muscles

  • Prominent nose

    Palliative Medicine, Declan Walsh, MD, Ed. 2009 by Saunders/Elsevier


Summary l.jpg
Summary

  • Diagnose Dying

  • Clarify and Prioritize Goals

    • Start Early

    • Engage Patient & Family

    • Review, Revise, Discuss

    • Trust the Process

  • Communication: Start with Positive Treatments (not “Do Not….”)

  • Location, Location, Location


ad