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Dartmouth Biomedical Libraries Library Grand Rounds. Palliative and End-of-Life Care Information Resources A Case-Based Presentation December 16, 2004. Ira Byock, M.D. Director, Palliative Care Program Dartmouth-Hitchcock Medical Center Cindy Stewart, M.L.S.
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Dartmouth Biomedical LibrariesLibrary Grand Rounds Palliative and End-of-Life Care Information Resources A Case-Based Presentation December 16, 2004
Ira Byock, M.D. Director, Palliative Care Program Dartmouth-Hitchcock Medical Center Cindy Stewart, M.L.S. Associate Director/Health Sciences Library Dartmouth Biomedical Libraries
Objectives • Introducing participants to readily available web-based information resources for “just-in-time” education and practical management of palliative care issues. • Familiarizing participants with the Palliative Care Program at DHMC. • Providing selected clinical pearls related to therapeutic use of communication in palliative aspects of care.
PCP Hospice Physician & RNs Palliative Medicine specialist Volunteer Coordinator Clinical Pharmacist Patient & Family Hospital Nursing PT/OT/RT Therapists Hospital CRC-Discharge Planner Pastoral Care Social Worker Dietician Palliative Care -- definition Interdisciplinary care for persons with life-threatening illness or injury which addresses physical, emotional, social and spiritual needs and seeks to improve quality of life for the ill person and his or her family.
Hospice and Palliative Care Palliative Care Hospice Care Byock I. Hospice and Palliative Care: A Parting of Ways or a Path to the Future? Journal of Palliative Medicine. 1998;1(2):165-176.
Typical Services of Hospice & Palliative Care • An interdisciplinary team • 24/7 availability • Ongoing communication • Advanced care planning • Formal symptom assessment & treatment • Crisis prevention & early crisis management • Care coordination • Spiritual care • Anticipatory guidance • Bereavement support
Palliative Care at DHMC • Physicians • Ira Byock, M.D. • Frances Brokaw, M.D. • Diane Palac, M.D. • Thomas Prendergast, M.D. • Nurse Practitioners • Lisa Szczepaniak, MSN, ARNP • Marie Bakitas, MSN, ARNP • Peggy Bishop, MS, ARNP • Network and Program Development • Yvonne Corbeil • Administrative Assistant • Geri Barden 650-5402
Palliative Care in the Hospital • Goals of care clarification • Pain & Symptom assessment & treatment • Family support • Counseling & Anticipatory Guidance • Adaptation to illness & prognosis • Issues of life completion & closure • Discharge planning • Planning for home care • Transition to home hospice
Access To Tools Where to go for definitions and basic information • Glossaries • Web-based resources – quick information re palliative treatments and clinical tips • Textbooks • Journals
The case… • Mrs. Smith is a 72 year old Caucasian woman from upstate New York with who is admitted to DHMC with acute dyspnea, altered mental status and low grade fever.
Mrs. Smith – Medical History • She has been treated for Stage IIA (T1N1M0) adenocarcinoma of the right upper lung diagnosed in March 2003. • She completed neo-adjuvant chemotherapy and radiation therapy followed by lobectomy in April 2003. • Post-op course was complicated by R lower extremity deep vein thrombosis. A Greenfield filter was placed.
Mrs. Smith – Social History • Mrs. Smith and her 79 yo husband moved from Rochester, NY 2 years ago to a small home in Milford, NH to be closer to family. Her husband has mild memory loss and confusion and requires her assistance to maintain daily activities. • Their daughter, Ann, who is the durable power of attorney for health care (DPOAHC) for both her parents, lives in Nashua. She apparently was the person who called the ambulance this morning. • The couple’s son lives in Boston. He is an attorney with the an oil company and often travels overseas.
Mrs. Smith – case unfolds • Ann Smith arrives at the hospital 3 hours after the patient is admitted, saying that her mother hadn’t answered the phone that morning and she had arrived at their home and found her mother in bed, confused. She had been incontinent and had no memory of last night.
Mrs. Smith – case unfolds • Her father was sitting at the kitchen table, looking bewildered. He had been trying to make breakfast for Mrs. Smith and himself. The refrigerator door was open and various containers scattered around the counters and kitchen table. • Ann hastily arranged for a neighbor to stay with her father for the day before driving to DHMC.
Mrs. Smith – case unfolds • CBC, electrolytes, calcium, BUN are all wnl • CXR shows a LUL infiltrate and signs of previous RUL surgery. • Cranial MRI reveals a large frontal and smaller parietal cerebral metastases. imagesMD
Mrs. Smith – Diagnoses • NSCLC • Cerebral metastasis • Possible seizure • Probable aspiration pneumonia
Mrs. Smith – case unfolds • Patient’s daughter, Ann, asks your advice. She just spoke with her brother who is in London on business. He is emotionally struggling with their mother’s illness and is not acknowledging the seriousness of her condition. • He is flying home and will be coming to the hospital within 36 hours. • She asks you to meet with her and her brother to discuss her mother’s prognosis and to assist her and her brother in making decisions that are in their parents’ best interests.
Management Resources • Clinical Guidelines • Hospice organizations • Communication resources
Pitfalls in care planning for patients w/o decision-making capacity • Failure to reach shared appreciation of pt’s condition and prognosis • Failure to apply substituted judgment • Offering choice between care and no care, rather than between prolonging life and quality of life • Too literal interpretation of an isolated, out-of- context, earlier statement • Failure to address the full range of decisions & options Lang F, Quill T. Making decisions with families at the end of life. Am Fam Physician. 2004. 70(4):719-723.
Decision-making and Communication eJournals
Decision-making and Communication eJournals Prendergast TJ, Puntillo KA. Withdrawal of life support: intensive caring at the end of life. JAMA Dec 4 2002;288(21):2732-2740.
Decision-making and Communication eJournals Prendergast TJ, Puntillo KA. Withdrawal of life support: intensive caring at the end of life. JAMA Dec 4 2002;288(21):2732-2740.
