Palliative care of advanced dementia a patient centered approach
Download
1 / 18

Palliative care of advanced dementia A patient centered approach - PowerPoint PPT Presentation


  • 658 Views
  • Uploaded on

Palliative care of advanced dementia A patient centered approach. VJ Periyakoil, MD Director, Palliative Care Fellowship Program Stanford University General Internal Medicine & VA Palo Alto Health Care System Email: [email protected] Main Message.

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 'Palliative care of advanced dementia A patient centered approach' - 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
Palliative care of advanced dementia a patient centered approach l.jpg

Palliative care of advanced dementia A patient centered approach

VJ Periyakoil, MD

Director, Palliative Care Fellowship Program

Stanford University General Internal Medicine &

VA Palo Alto Health Care System

Email: [email protected]


Main message l.jpg
Main Message approach

  • Currently, patients with dementia do not get access to quality palliative care

  • Access to quality palliative care can be facilitated only if we take an inter-disciplinary approach to care


Talk agenda l.jpg
Talk Agenda approach

  • Current state of palliative care for dementia

  • Key challenges in providing palliative care for dementia patients

    • Prognostication

    • Decision making

    • Advance care plan

    • Symptom management

    • Caregiver stress


Prognostication questions in dementia l.jpg
Prognostication questions in dementia approach

  • Patient’s question: “How long do I have before my mind is shot?”

  • Health professional’s question: “ Is s/he eligible for palliative care?”

  • Family’s question: “How long does s/he have to live ?”

  • Caregiver’s question: “ I am exhausted. How much longer can I do this?”

    Is dementia a terminal illness? If so, when do they start dying?


Dementia hospice eligibility l.jpg
Dementia hospice eligibility approach

  • Stage 7 or beyond according to the FAST scale

  • Unable to ambulate without assistance

  • Unable to dress without assistance

  • Unable to bathe without assistance

  • Urinary or fecal incontinence, intermittent or constant

  • No meaningful verbal communication, stereotypical phrases only, or ability to speak limited to six or fewer intelligible words

  • Plus one of the following within the past 12 months:

    • Aspiration pneumonia

    • Pyelonephritis or other upper UTI

    • Septicemia

    • Multiple stage 3 or 4 decubitus ulcers

    • Fever that recurs after antibiotic therapy

    • Inability to maintain sufficient fluid and calorie intake, with 10 percent weight loss during the previous six months or serum albumin level less than 2.5 g per dL (25 g per L)

Schonwetter RS, Han B, Small BJ, Martin B, Tope K, Haley WE. Predictors of six-month survival among patients with dementia: an evaluation of hospice Medicare guidelines. Am J Hosp Palliat Care 2003;20:105-13.


Decision making in dementia l.jpg
Decision making in dementia approach

  • Hierarchy of decision making

    • Pt with capacity

    • Advance directive

      • Health care proxy

      • Living will

    • Substituted judgment

    • Best interests

  • Competence v. capacity

  • Special circumstances


  • Special circumstances l.jpg
    Special circumstances approach

    Case 1: Incapacitated pt with no proxy and unknown preferences

    Case 2: Chronically mentally ill pts with no capacity

    Case 3: Chronically mentally ill pts with fluctuating capacity


    Intact decision making prior to death in the elderly l.jpg
    Intact decision making prior to death in the elderly approach

    Lentzer HR et al “ The quality of life in the year before death”. Am J Public Health 82: 1093-1098, 1992


    Interface between palliative care and dementia l.jpg
    Interface between palliative care and dementia approach

    • Clarity of decision making

      • Soft balls ( relatively speaking):

        • Advanced dementia with advanced other terminal illness

        • Early dementia with early stages of other chronic illness

    • Hard balls

      • Moderate dementia with other terminal illness

      • Dementia, terminal illness, infection and delirium

      • Dementia and PTSD or depression

      • Dementia and recreational ETOH/ drug use

    The decisions themselves are never easy.


    Advance care planning shades of gray l.jpg
    Advance care planning approachShades of Gray

    Possible levels of care:

    • Full court press

    • Hospitalize with DNR

    • Hospitalize for reversible illness

    • Do not hospitalize (DNH): treat to the extent possible

    • DNH with comfort care


    Heroic life prolonging measures l.jpg
    Heroic life prolonging measures approach

    • CPR

    • “Whopper no veggie*”

    • Artificial nutrition

    • Artificial hydration

    • Antibiotics

      What are the goals of care?

    * James Hallenbeck, personal communication


    Tube feed or not tube feed that s the question l.jpg
    Tube feed or not tube feed? approachThat’s the question

    • The facts:

      • Effect on life span is an open question

      • Increases suffering

  • Need for better pt/family education

    • Discussing benefits and burdens of therapy

    • Use neutral language

    • Separate facts from your opinion

    • Please offer your opinion

    • Make allowances for special circumstances.


  • Palliative care symptoms and cognitive impairment l.jpg

    Symptoms approach

    Bio

    Pain

    Non-pain symptoms

    Psychological issues

    Social issues

    Spiritual issues

    Presentation of these symptoms is skewed

    Palliative care symptoms and cognitive impairment


    What does dying look like l.jpg
    What does dying look like? approach

    • Decline in functional status

    • Lack of desire to eat or drink

    • Withdrawn

    • Sleep- wake state

    • Mottling of limbs

    • Jaw movement

    • Death rattle

    • Co-morbid symptoms


    Slide15 l.jpg
    ??? approach

    • Unpaid

    • Overworked

    • On-call 24/7

    • Sleep deprived

    • No social life

    • Poor support system


    Notes l.jpg
    Notes approach

    Questions / feedback:

    Please contact VJ Periyakoil

    [email protected]

    [email protected]

    ___________________________________

    ___________________________________

    ___________________________________

    ___________________________________

    ___________________________________

    ___________________________________


    Notes17 l.jpg
    Notes approach

    ___________________________________

    ___________________________________

    ___________________________________

    ___________________________________

    ___________________________________

    ___________________________________

    ___________________________________

    ___________________________________

    ___________________________________


    Notes18 l.jpg
    Notes approach

    ___________________________________

    ___________________________________

    ___________________________________

    ___________________________________

    ___________________________________

    ___________________________________

    ___________________________________

    ___________________________________

    ___________________________________


    ad