End-of-life care - Palliative care

End-of-life care:Palliative care

Abid Iraqi, M.DGeriatric & Palliative MedicineSyracuse VA1The opinions expressed are those of the presenter and do not necessarily represent the opinion/position of Veterans Affairs.

What is End of Life CarePreaching to choir

Managing patients toward the end of their life

Why End of Life Care is importantThe majority of deaths occur in elderly adultsTerminally ill patients spend most of final months at home, but most deaths occur in the hospital or nursing homeMore people are living with chronic illness with typically declining condition before the end of earthly journey of life. For patient who are at end of life, care in acute hospital may have little to offer but may induce unnecessary suffering.

Components of Good end of life care discussiondiagnosis ( of terminal illness)specific treatments (for illness)expected outcome of treatment (of illness)expected outcomes without treatment (of illness)potential untoward effect of treatment (of illness)what to anticipate (in illness) with the passage of time.prognosiselicit treatment preferencesassess psychosocial support & spiritual needs

Why These Discussions are importantIt enables healthcare professionals to recognize their patients values and preferences.How End of Life Care is accomplished Depends on the spectrum of disease processAs disease progresses fromAdvance care planning/directive toPalliative care toHospice discussion & referralComfort careWhat is meant by Advance care planning Palliative care Hospice care Comfort careBefore we proceed, perhaps we should review what is approach by default

Default care is Traditional care Traditional care curative intent focus is in why focus is to fix why full codeWhat is meant by Advance care planning Palliative care Hospice care Comfort care

Advance directive/care planninga communication process between a patient and his/her medical providers, which may involve family or friends, about the goals and desired the direction of care at the end of life in an event when patient loses his/her decision making capacity,1,2

1 Seymour J., Almack K, Kennedy S. implementing advance care planning; a qualitative study of community nurses views and experiences.BMC palliative care 2010;9:4.2. Teno JM. Advance care planning for frail, older persons. In : Morrison RS, Meier DE, eds. geriatric palliative care. New York: Oxford University press, 2003; 307-313.

What is advance care planningliving will health care proxyCode status

A realistic discussion regarding nutrition and hydration in advance directive is also usefulWhy advance directives are importantinitiate the discussion for end of life preference/wishesensure that patients receive care that is consistent with their preferences it may prove improve quality of end-of-life care by achieving control over their care when/if they lose decision making capacityDo Advance directives alone suffice for end of life care? NOIt requires a mechanism/system where patients wishes can be honored

Our job is to clarify focus of care, provide education and then follow the decision of our patients- Role of palliative care may come into place

What is palliative carePalliative care is a specialized medical care that grew out of hospice tradition, and is focused on comfort and quality of life irrespective of the aggressiveness & focus of care regardless of the stage of illness .

What is Hospice care Hospice is a philosophy of care focusing on holistic care of persons with terminal illness rendering life expectancy less than six months, and forgoing curative treatment.

What is comfort careFocus is comfort without any aggressive treatment- depending on facility may be when death is imminent to years, and depending on medical providers ( patients still receiving IVF, antibiotics and lab. work, and other medical providers like me same approach as in hospice with no blood work /antibiotics etc.)

Confusion often arise b/w hospice & palliative care- Not the same though palliative care grew out of hospice traditionDifferences between Hospice and Palliative CareHOSPICEPALLIATIVE CAREAppropriate when one has a terminal disease Life expectancy is less than 6 months Requires Physician certification Patient has agreed to stop active/ curative treatment Payment: per diem payment system

Serious illness regardless of stage of diseaseIrrespective of life expectancy/not time limitedDoes Not require physician certificationCan be provided with active/ curative treatmentPayment: fee for service model

24Similarities between Hospice and Palliative CareHOSPICE PALLIATIVE CAREFocus on symptom management, & quality of life Support to patient, family and caregiverInterdisciplinary in natureCovered under Medicare, Medicaid and private insuranceAddresses goals of care, focus on symptom management, & quality of life Support to patient, family and caregiverInterdisciplinary in natureCovered under Medicare, Medicaid and private insuranceHospice is Palliative Care but Palliative Care is not necessarily Hospice CareRole of Health care providers (MD,NP,PA,CNS) in end of life careNo matter where we work, it is never too early to help patients begin discussion of advance directives including health care proxy, and then as time goes on assist the patients with further end of life care discussion.

Case DescriptionA 76 year old started having abnormal cognitive deficits at the stage of mild cognitive impairment which over the next 8 years progressed to dementia. Then over the next 3 years worsened to advanced stage where he became dependent for all of his IADLs and required supervision for ADLs. Over the next 2 years dementia further worsened to terminal stage.

How to proceedMCI stage: managed at home with support of his family, removed fire-arms, completed health care proxy and financial POA Onset of dementia: family initiated support services and he started exploring assisted living.At advanced stage: moved to assisted living , and over next 9 months to special dementia unit.Terminal stage: DNR by surrogate and no feeding tube.Palliative care, and ongoing discussion with HCP regarding burden & benefits of interventions ConclusionPalliative care is simply a good medical practice to ensure patients comfort and quality of life and keeping in view how patients would like to proceed with their medical careQuestions?