End of life care an overview
Download
1 / 60

End of Life Care: An Overview - PowerPoint PPT Presentation


  • 262 Views
  • Updated On :

End of Life Care: An Overview. Objectives. Address issues surrounding end-of-life care and vulnerable older adults - definition of palliative care - logistics of end-of life-care - surrogate decision making and advance directives - symptom management ACOVE indicators and EOL care.

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 'End of Life Care: An Overview' - richard_edik


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

Objectives l.jpg
Objectives

  • Address issues surrounding end-of-life care and vulnerable older adults

    - definition of palliative care

    - logistics of end-of life-care

    - surrogate decision making and advance directives

    - symptom management

  • ACOVE indicators and EOL care


What is palliative care l.jpg
WHAT IS PALLIATIVE CARE?

  • Interdisciplinary

  • Goal :

    • to prevent and alleviate suffering

    • assist towards the best possible quality of life

    • optimize function

    • assist with decision making for patients with serious illness and their families.

  • Can be the main focus of care or offered concurrently with all other life - prolonging medical treatment.


  • End of life demographics l.jpg
    END-OF-LIFE DEMOGRAPHICS

    • The majority of deaths occur in elderly adults

    • Very ill patients may spend much of their final time at home, but…

    • Hospitals or nursing homes are actual location of most deaths

    • There is regional/ geographic variability in location of deaths (home vs. institution)

    Adapted from Geriatrics Review Syllabus, Sixth Edition


    End of life eol in the u s l.jpg
    END-OF-LIFE (EOL) IN THE U.S.

    • For elderly, death is typically slow and associated with chronic disease

    • Patients experience increased dependency in their care needs

    • EOL care can be complicated by family stress, poor symptom control, and discontinuity of care

    • In this age of technology, commonly decisions need to be made about the use of these agents

    Adapted from Geriatrics Review Syllabus, Sixth Edition


    Sudden death unexpected cause l.jpg
    SUDDEN DEATH, UNEXPECTED CAUSE

    • < 10%, MI, accident, etc.

    HealthStatus

    Death

    Time


    Steady decline short terminal phase l.jpg
    Steady DeclineShort “Terminal Phase”


    Slow decline periodic crises sudden death l.jpg
    SLOW DECLINEPeriodic Crises, Sudden Death


    Slide9 l.jpg

    Curative / Life Prolonging

    Presentation

    Death

    Sx Control / Palliative Care

    Adapted from Institute of Medicine

    Historical trajectories of care pathways


    Consider an alternative trajectory l.jpg
    Consider an alternative trajectory…

    • Inclusion of palliative concepts from time of diagnosis

    • This piece of the care plan may become more prominent as curative therapies are less available

    • More gradual transitions at the end of life


    Slide11 l.jpg

    Curative / Remissive Therapy

    Death

    Presentation

    Hospice

    Palliative Care

    Adapted from EPEC curriculum, 1999


    What is hospice l.jpg
    WHAT IS “HOSPICE”?

    • Location

      • Place for the care of dying patients

    • Group

      • Organization that provides care for the dying patient

    • Approach to care

      • Philosophy of care for the dying patient

    • A Medicare benefit

    Adapted from Geriatrics Review Syllabus, Sixth Edition


    The hospice medicare benefit l.jpg
    THE HOSPICE MEDICARE BENEFIT

    • For beneficiaries with an expected prognosis of 6 months or less

    • Exchange curative treatments for symptomatic/ palliative treatments

    • Can be revoked at any time

    • Reimbursed per diem for one of four levels of care

    • Can be utilized in the home, nursing home, inpatient hospice units

    See referenced reading, AAHPM Bulletin


    The hospice medicare benefit14 l.jpg
    THE HOSPICE MEDICARE BENEFIT

    • Covered Services

      • physician services, nursing care

      • medical equipment and supplies

      • medications related to the terminal illness designated

      • short-term inpatient care (symptom management & respite)

      • PT or OT based on the goals

      • bereavement services

      • home-health aide services


    Obstacles l.jpg
    OBSTACLES

    • Limited access, i.e. rural areas

    • Logistical support

    • Late referral – median duration time spent with hospice is only 21 days (Hospice Association of America 2006)

    • Difficulties in determining prognosis


    Prognosis l.jpg
    PROGNOSIS

    • More straightforward for cancer diagnosis

    • Often unpredictable for chronic disease

      COPD

      Alzheimer’s Disease

      Heart disease

      Failure to Thrive/ Debility


    Prognosis17 l.jpg
    PROGNOSIS

    • In general:

      Patient’s condition is life limiting, and pt/ family are aware

      Pt/ family have elected relief of sx treatment goals rather than curative goals

      Pt has either documented clinical progression of disease or documented recent impaired nutritional status related to the terminal process



    Delivering bad news l.jpg
    DELIVERING BAD NEWS

    • Prepare

      • Plan an agenda

      • Ensure availability of all medical facts

      • Pick an appropriate setting

      • Minimize interruptions

    • What does the patient understand? What does the patient want to know?

    • Deliver the news

      • Be straightforward, avoiding medical jargon

      • Provide a “warning shot”

    • Allow time for discussion

    • Create a plan and organize for follow-up


    Decision making l.jpg
    DECISION MAKING

    • Autonomous choices are voluntary, adequately informed and based on reasoning

      • Does the patient have the ability to choose?

      • Does the patient understand pertinent information?

      • Does the patient appreciate the clinical situation/ choices/ consequences?

      • Can the patient reason through choices?



    Surrogate decision making l.jpg
    SURROGATE DECISION MAKING goal.

    • May be required with both younger and older adults

    • Specific surrogate may be identified via a DPOA (durable power of attorney) for health care

    • Goal of surrogate is to advocate for patient based on what they know of patient’s wishes

      - based on prior discussions, advance directives/ living wills


    Some definitions l.jpg
    SOME DEFINITIONS goal.

    • Durable Power of Attorney for Health Care

      • Appointing someone to make medical decisions for you if you cannot make them yourself

      • Does not require presence of AD or living will

    • Living Will

      • Description of wishes about life sustaining medical treatments if one is terminally ill

    • Advance directives

      • Instructions / guidance for for health care should one become incapacitated

      • Can name an “agent” to make decisions for them

      • Wishes stated must be honored by surrogate unless court orders otherwise

      • Can be revoked at any time

    Adapted from University of New Mexico SoM


    Decision making24 l.jpg
    DECISION MAKING goal.

    • If a patient cannot make their medical decision and has not identified a surrogate decision maker, does not have an advance directive, or has not made their wishes known, a surrogate may have to be identified.

      • Some states have an automatic order of priority for identifying surrogates

      • Kansas and Missouri have no such statues available


    Other palliative care issues l.jpg
    OTHER PALLIATIVE CARE ISSUES goal.

    • Symptom management

    • Cross-cultural issues

    • Spiritual concerns

    • Psychosocial issues

    See recommended readings for further information


    Symptom management l.jpg
    SYMPTOM MANAGEMENT goal.

    • Multiple symptoms of concern near the end of life

      - Pain

      - Dyspnea

      - Constipation

      - Nausea

      - Anxiety

      - Delirium

      - Fatigue

      - Anorexia


    Slide27 l.jpg
    PAIN goal.

    • Treatment based on assessment

      - severity

      - nociceptive vs. neuropathic

      - step-wise approach

    • Potential modalities

      - Non-opioid

      acetominophen

      NSAIDs/ COX-2 –I

      - Opioid

      - Adjunctive

      Anti-convulsants

      Steroids

      TCAs


    And now a little about opioids l.jpg
    And now a little about opioids… goal.

    • Bind to one or more of the opiate receptors (mu, kappa, delta)

    • Mu receptor is 7 transmembrance G protein coupled receptor

      - binding stabilizes the membrane so neuron doesn’t fire

    • Where are the mu receptors?

      - periphery, dorsal root ganglia of spinal cord, periaqueductal grey of brainstem, midbrain, gut


    Opioids l.jpg
    Opioids goal.

    • “weak” opioids

      - codeine

      - hydrocodone

      - oxycodone

    • “strong” opioids

      - hydromorphone

      - fentanyl

      - morphine


    Opioids31 l.jpg
    Opioids goal.

    • Distribution

      • Hydrophilic

        * morphine, oxycodone, hydromorphone

      • Lipophilic

        * fentanyl, methadone


    Opioids32 l.jpg
    Opioids goal.

    • IV- morphine, hydromorphone, fentanyl

    • PO- morphine (LA & SA), oxycodone (LA & SA), hydromorphone, methadone, fentanyl, hydrocodone

    • Transdermal- fentanyl

    • Initial decisions based on

      - route of administration

      - need for continuous vs. intermittent dosing

      - severity of pain

      LA= long acting

      SA= short acting


    Opioids pharmacology l.jpg
    Opioids-Pharmacology goal.

    • All water soluble opioids behave similarly:

    • Cmax is 60-90 minutes after PO dose

      30 minutes after SQ or IM

      6-10 minutes after IV dose

    • All are conjugated in liver and 90% excreted via the kidney

    • With normal renal fx, all have ½ life of 3-4 hours, reach steady state in 4-5 ½ lives


    Special notes l.jpg
    Special Notes goal.

    • Morphine

      - low protein binding

      - dialyzes off

      - active metabolite is morphine 6- glucuronide (10%)

      * accumulates in renal failure and causes neuroexcitation

      * prolonged CNS effects


    Special notes35 l.jpg
    Special Notes goal.

    • Fentanyl

      - little or no active metabolites

      - Not dialyzable

      - Elderly more sensitive to effects

      - Unclear how TD route is affected by low subcutaneous fat

    • Hydromorphone

      - Generally considered to have inactive metabolites

      - Drug of choice with renal failure


    Special notes36 l.jpg
    Special Notes goal.

    • Methadone

      • binds mu and blocks NMDA receptors

      • highly protein bound

      • highly variable and prolonged half life

      • Phase I metabolism and may prolong the QT interval

      • caution when changing from another opioid to methadone


    Potential opioid side effects l.jpg
    Potential opioid side effects goal.

    • Nausea

    • CNS depression/ sedation

    • Pruritis

    • Constipation

    • Delirium

    • Endocrine dysfunction with long term use


    Dyspnea l.jpg
    DYSPNEA goal.

    • Subjective symptom

    • Pathophysiology can reflect disorder in regulation or act of breathing

    • Treatment directed at underlying cause

      - Most common reversible causes

      bronchospasm, hypoxia, anemia

      - Both non-pharmacologic and non-pharmacologic treatments can be helpful

      - Opioids used for sx relief when more directed therapy doesn’t reverse the dypsnea


    Nausea l.jpg
    NAUSEA goal.

    • Potentially debilitating symptoms near the end of life

    • Treatment based on source

      - Brain chemoreceptor trigger zone, cerebral cortex, vestibular apparatus

      - GI tract obstruction, motility, mucosal irritation



    Delirium l.jpg
    DELIRIUM goal.

    • Common near the end of life

      - geriatric patients with multiple risk factors for development

    • Large number of cases can be reversible

    • Control of delirium may be important for both patient and family

      - pharmacologic and non-pharmacologic means


    Acove indicators l.jpg
    ACOVE Indicators goal.

    • Assessing Care of Vulnerable Elders

    • Comprehensive set of quality assessment tools for ill older adults

      - Covering domains of prevention, diagnosis, treatment, and follow up

    • Designed to evaluate health care at system level rather than individual level


    Decision making acove l.jpg
    DECISION MAKING (ACOVE) goal.

    • If a vulnerable older adult is admitted directly to the intensive care unit (from the outpatient setting or emergency department) and survives 48 hours, THEN within 48 hours of admission, the medical record should document consideration of the patient’s preferences for care or that these could not be elicited or are unknown


    Decision making acove44 l.jpg
    DECISION MAKING (ACOVE) goal.

    • ACOVE indicator for quality care of the older adult:

    • If a vulnerable older adult with dementia, coma, or altered mental status is admitted to the hospital, THEN within 48 hours of admission, the medical record should contain an advance directive indicating the patient’s surrogate decision maker

    • Document a discussion about who would be surrogate decision maker or a search for a surrogate, or

    • Indicate that there is no identified surrogate


    Decision making acove45 l.jpg
    DECISION MAKING (ACOVE) goal.

    • If a vulnerable older adult carries a diagnosis of severe dementia, is admitted to the hospital, and survives 48 hours, THEN within 48 hours of admission, the medical record should document consideration of the patient’s previous preferences for care or that these could not be elicited or are unknown


    Decision making acove46 l.jpg
    DECISION MAKING (ACOVE) goal.

    • All vulnerable older adults should have in their outpatient charts

      1) An advance directive indicating the patient’s surrogate decision maker, or

      2) Documentation of a discussion about who would be a surrogate decision maker or a search for a surrogate, or

      3) Indication that there is no identified surrogate


    Case 1 1 of 3 l.jpg
    CASE 1 goal. (1 of 3)

    • A 79-year-old man with a history of prostate cancer has had worsening back pain for 3 weeks. He recalls no recent accident or injury.

    • The pain limits the patient’s ability to dress and bathe himself. He cannot get comfortable in bed and has been sleeping in a reclining chair for the past few nights. He took acetaminophen with codeine last night with no relief.

    • Physical examination is normal except for tenderness on palpation over the lower spine.

    • Bone scan demonstrates metastatic disease in the lumbar spine and pelvis.


    Case 1 2 of 3 l.jpg
    CASE 1 goal. (2 of 3)

    • Which of the following is the most appropriate initial management strategy for this patient’s pain?

    • (A) Immediate-release oxycodone

    • (B) Sustained-release oxycodone

    • (C) Propoxyphene

    • (D) Transdermal fentanyl

    • (E) Acetaminophen with codeine


    Case 1 3 of 3 l.jpg
    CASE 1 goal. (3 of 3)

    • Which of the following is the most appropriate initial management strategy for this patient’s pain?

    • (A) Immediate-release oxycodone

    • (B) Sustained-release oxycodone

    • (C) Propoxyphene

    • (D) Transdermal fentanyl

    • (E) Acetaminophen with codeine


    Case 2 1 of 3 l.jpg
    CASE 2 goal. (1 of 3)

    • For the third time in 6 months, an 84-year-old man with advanced dementia is admitted to the hospital for aspiration pneumonia.

    • He has lost 9.5 kg (20 lb) over the past 10 months and has a sacral pressure ulcer. He is nonverbal, unable to ambulate, and dependent for all ADLs.His wife cares for him at home. He does not want to go to a nursing home.

    • A swallow study indicates that all food consistencies are unsafe. The hospitalist suggests tube feeding. The advanced care plan states that the patient’s wife is his agent and that he does not want extraordinary measures used to extend his life, including artificial nutrition.


    Case 2 2 of 3 l.jpg
    CASE 2 goal.(2 of 3)

    • What is the most appropriate recommendation for this patient?

    • (A) Long-term placement of a feeding tube and discharge to a skilled nursing facility (SNF)

    • (B) Short-term placement of a feeding tube and discharge to a SNF until the pressure ulcer heals

    • (C) Discharge to a SNF for wound care until the

    • pressure ulcer has healed

    • (D) Discharge home with home-health services

    • (E) Discharge home with home hospice


    Case 2 3 of 3 l.jpg
    CASE 2 goal.(3 of 3)

    • What is the most appropriate recommendation for this patient?

    • (A) Long-term placement of a feeding tube and discharge to a skilled nursing facility (SNF)

    • (B) Short-term placement of a feeding tube and discharge to a SNF until the pressure ulcer heals

    • (C) Discharge to a SNF for wound care until the

    • pressure ulcer has healed

    • (D) Discharge home with home-health services

    • (E) Discharge home with home hospice


    Case 3 1 of 3 l.jpg
    CASE 3 goal. (1 of 3)

    • A 67-year-old woman with terminal metastatic ovarian cancer presents with a 2-day history of nausea and vomiting. She has been unable to tolerate any oral intake and has not had a bowel movement in 4 days.

    • The patient is reluctant to undergo further invasive procedures or hospitalization.

    • Medications are acetaminophen with codeine as needed and docusate sodium stool softener every morning.

    • The patient appears uncomfortable. No fever, BP 98/60, pulse 105, tachycardia. Abdomen is markedly distended with decreased bowel sounds, tympany on percussion, diffuse tenderness on palpation. Rectal exam is normal.


    Case 3 2 of 3 l.jpg
    CASE 3 goal.(2 of 3)

    • In addition to providing the patient with morphine, which of the following is the most appropriate management strategy?

    • (A) Diverting colostomy

    • (B) Nasogastric suctioning

    • (C) Octreotide

    • (D) Atropine

    • (E) Ondansetron


    Case 3 3 of 3 l.jpg
    CASE 3 goal.(3 of 3)

    • In addition to providing the patient with morphine, which of the following is the most appropriate management strategy?

    • (A) Diverting colostomy

    • (B) Nasogastric suctioning

    • (C) Octreotide

    • (D) Atropine

    • (E) Ondansetron


    Summary l.jpg
    SUMMARY goal.

    • The goal of palliative care is to relieve suffering and assist patients with serious illness and their families with medical decision making

    • Advance directives are an important way to facilitate this and are viewed as an important quality indicator

    • Learning to communicate these issues in key

    • Palliative care also encompasses a wide realm of symptom management, as well as support surrounding psychosocial and spiritual issues


    References l.jpg
    REFERENCES goal.

    • AGS Panel on Persistent Pain in Older Persons, “ The Management of Persistent Pain in Older Persons,” Journal of the American Geriatrics Society, June 2002, Vol. 50, No.6 supplement

    • Finucane, Christmas, and Travis, “Tube Feeding in Patients with Advanced Dementia: A Review of the Evidence,” JAMA, Oct. 13, 1999, Vol. 282, No. 14

    • Ganzini et al, “Ten Myths about Decision-Making Capacity,” Journal of the American Medical Directors Association, May/ June 2005

    • Tulsky, “Beyond Advance Directives: Importance of Communications Skills at the End of Life,” JAMA, July 20,2005, Vol. 294, No. 3

    • Ross and Alexander, “Management of Common Symptoms of Terminally Ill Patients: Part I,” American Family Physician, Sept. 1, 2001, Vol. 64, No. 5

    • Ross and Alexander, “Management of Common Symptoms of Terminally Ill Patients: Part II,” American Family Physician, Sept. 15, 2001, Vol. 64, No. 6

    • http://aspe.hhs.gov/daltcp/reports/impquesa.htm(Click to Appendix C for prognosis guidelines)


    Additional references l.jpg
    ADDITIONAL REFERENCES goal.

    • “Health Care Decision Making Web Module for Medical Students.” Developed by Dr. Christine Hayward, Carla Herman. University of New Mexico School of Medicine. Funded by Donald W. Reynolds Foundation, John A Hartford Foundation. Web-based, self directed learning module

    • EPEC Participant’s Handbook 1999

    • Geriatric Review Syllabus 6 teaching slides

    • Kinzbrunner, “The Medicare Hospice Benefit,” AAHPM Bulletin Spring 2001,Vol. 1, No. 3


    Acknowledgements l.jpg
    Acknowledgements goal.

    • Dr. Karin Porter-Williamson, Medical Director of the Palliative Care team at the University of Kansas Medical Center

    • For GRS sixth edition teaching slides:

      Co-Editors: Karen Blackstone, MD & Elizabeth L. Cobbs, MD

      GRS6 Chapter Authors: Stacie T. Pinderhughes, MD & R. Sean Morrison, MD

      GRS6 Question Writers: Susan Charette, MD

      Medical Writer: Barbara B. Reitt, PhD, ELS (D)

      Managing Editor: Andrea N. Sherman, MS

      © American Geriatrics Society


    ad