1 / 25

End-of-Life Care Perspectives

Historical Perspective. Curative model of medicine disarms us with regards to the dying patientDeath of a patient now means failureOf

giorgio
Download Presentation

End-of-Life Care Perspectives

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. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

    1. End-of-Life Care Perspectives Eric J. Warm M.D. Department of Internal Medicine 4/3/02 ICP-II

    2. Historical Perspective Curative model of medicine disarms us with regards to the dying patient Death of a patient now means failure Of ‘Medicine’ Of the physician Hill TP. Treating the Dying Patient. Arch Intern Med, 1995;155:pp.1263-69

    3. Historical Perspective Changes in Medical Education Subtle and slow Curriculum had to accommodate all the new knowledge Billings JA, Block S. Palliative Care in Undergraduate Education. JAMA. 1997;278:733-738

    4. Historical Perspective “Softer subjects” such as communication skills, ethics, psychological aspects of medicine have been diminished mostly lecture format usually pre-clinical Billings JA, Block S. Palliative Care in Undergraduate Education. JAMA. 1997;278:733-738

    5. Historical Perspective EOL care in medical textbooks Texts shape knowledge and attitudes Caron (1999): reviewed 12 leading causes of death Harrison’s Textbook of Medicine Merck Manual Scientific American CD-ROM Washington Manual Carron AT, et al. End-of-Life Care in Medical Textbooks. Ann Intern Med. 1999:130;pp.82-86

    6. Historical Perspective Textbooks rarely characterize the way in which persons with disease die Frankness about death absent -- often inferred “Supportive Care” mentioned but not spelled out Carron AT, et al. End-of-Life Care in Medical Textbooks. Ann Intern Med. 1999:130;pp.82-86

    7. Current Perspective Exaggerated sense of Medical Power unwarranted confidence in medical expertise and ability to forestall death unprepared for uncertainty and loss Barnard D. Preparing the Ground: Contributions of the Pre-clinical Years To Medical Education Near the End of Life. Acad. Med 1999:74;499-505

    8. Current Perspective Skewed vision of what doctors do underestimate value of palliation has for patients relief of suffering comes from relief of disease Barnard D. Preparing the Ground: Contributions of the Pre-clinical Years To Medical Education Near the End of Life. Acad. Med 1999:74;499-505

    9. Objectives After this presentation the learner should be able to: Describe the double effect vs. unintended consequences Develop proper technique to breaking bad news Formulate different concepts of hope Determine the goals of care

    10. Panel Stanley Troup M.D. Paul Nidich J.D. Mary Gallagher M.D.

    11. Case One An 81 year old female with end stage lung cancer is dying on the hospital ward. She has disseminated metastases and is in constant pain. She had been taking large amounts of per oral morphine at home, but this is no longer effective.

    12. Case One After admission she was placed on an IV infusion of morphine. Despite ever increasing doses her pain is not well controlled. She is asking for more pain medication and an end to her misery.

    13. Case One She has liver dysfunction and is already receiving more morphine than has ever been given to anyone on this hospital floor. The nurses are concerned about overdose and respiratory depression. WHAT SHOULD YOU DO???

    14. Case One A. Increase the patient’s morphine dose until pain relief B. Intubate the patient and increase the morphine until pain relief C. Increase the pain medication only after Psychiatry states that the patient is not suicidal D. Not increase the pain medication because of the risk of respiratory failure E. Not increase the pain medicine until you have discussed the case with the hospital lawyer

    15. Case One Key Points Double effect Vs. Unintended Consequences Pain management at End-of-Life

    16. Case Two A 57 year old man presents with mild abdominal pain and jaundice. After several tests (including biopsy) you diagnose pancreatic cancer. Despite being relatively asymptomatic the patient has late stage disease. His prognosis is on the order of a few months.

    17. Case Two You are called to his bedside to give him the news regarding his cancer. He is anxious. You know this news will be shocking and unexpected.

    18. Case Two How do you tell him the news?

    19. Case Two How do you handle the following questions? “Doc, how long to I have to live?”

    20. Case Two How do you handle the following questions? “Doc, how long to I have to live?” “Doc, is there any hope for cure?”

    21. Case Two How do you handle the following questions? “Doc, how long to I have to live?” “Doc, is there any hope for cure?” “Doc, is there any hope at all?”

    22. Case Two Key Points Breaking Bad News Concept of Hope

    23. Case Three A 66 year old woman presents to your primary care office. She was diagnosed with lymphoma 22 months prior. She underwent extensive chemotherapy and radiation and participated in multiple organized trials.

    24. Case Two Her specialists told her at the last visit that there was no more chemotherapy or radiation that would help her. She is losing weight, and had to be brought to your office in a wheelchair.

    25. Case Three She tells you that the other doctors said “There is nothing more we can do for you” How do you respond?

    26. Case Three Key Points Defining the goals of care Knowing how to give “supportive care”

More Related