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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

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next month
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
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

Managing Death:Diagnosing Dying,Setting Goals

Jack P. Freer, MD

Professor of Medicine

University at Buffalo

learning objectives
Learning Objectives
  • Be able to recognize the dying patient in institutional settings
learning objectives5
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
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
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
Learning Objectives
  • Be able to recognize the dying patient in institutional settings
diagnosing dying
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
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
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
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
Prognosticating in Cancer Patient
  • Advanced metastatic cancer is fatal
  • Trajectory is predictable
  • Performance predicts survival
prognosticating in chf copd
Prognosticating in CHF/COPD
  • Diseases are potentially fatal
  • Trajectory is less predictable
  • Treatment decisions have significant effect (ventilator)
prognosticating in dementia frailty
Prognosticating in Dementia, Frailty
  • Alzheimer’s is fatal (not widely recognized)
  • Trajectory is very unpredictable
  • Treatment decisions have significant effect (PEG)
learning objectives26
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
Goals of Care?
  • Complete cure
goals of care28
Goals of Care?
  • Complete cure
  • Longevity/survival
goals of care29
Goals of Care?
  • Complete cure
  • Longevity/survival
  • Comfort/avoidsuffering
goals of care30
Goals of Care?
  • Complete cure
  • Longevity/survival
  • Comfort/avoidsuffering
  • Independence
goals of care31
Goals of Care?
  • Complete cure
  • Longevity/survival
  • Comfort/avoidsuffering
  • Independence
  • Remain in familiar environment
goals of care32
Goals of Care?
  • Complete cure
  • Longevity/survival
  • Comfort/avoidsuffering
  • Independence
  • Remain in familiar environment
goals of care33
Goals of Care
  • Goals not explicitly articulated
  • Single goal often presumed
  • Failure to attain that goal devastating
goals of care34
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
Goals of Care?
  • Complete cure
  • Longevity/survival
  • Comfort/avoidsuffering
  • Independence
  • Remain in familiar environment
goals of care36
Goals of Care?
  • Longevity/survival
  • Comfort/avoidsuffering
  • Remain in familiar environment
goals of care37
Goals of Care?
  • Longevity/survival
  • Comfort/avoidsuffering
goals of care38
Goals of Care?
  • Comfort/avoidsuffering
  • Remain in familiar environment
learning objectives39
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
“Futility” vs. Goals of Care
  • Aggressive treatments in dying patients sometimes discounted as “futile”
  • Futility really means totally ineffective
futility vs goals of care41
“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
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
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
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
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
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
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