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Geriatric Palliative Medicine
Adam Herman, MD
Assistant Professor
Division of Geriatric Medicine and Gerontology
Wesley Woods Health Center
Palliative Medicine Case
Mrs. F. was an 87 year-old widow living in the home of one of her daughters. She required 24-hour supervision because of moderately advanced dementia of the Alzheimer’s type.
Palliative Medicine Case
Her daughter, age 65, herself widowed and medically frail because of congestive heart failure, was struggling physically, emotionally, and financially to provide care for her mother.
A rapid decline in Mrs. F’s mental status and increase in agitation precipitated a hospitalization, during which she was diagnosed with breast cancer that had spread to the spine.
Palliative Medicine Case
After a 3-day stay in the acute hospital, Mrs. F. was transferred to a local nursing home for “terminal care”.
Palliative Medicine Case
It took several days for her daughter to convince the nursing home staff and physician (none of whom had cared for Mrs. F. previously) that her mother’s agitation represented pain.
Opioids were prescribed, but caused Mrs. F. to become sedated, nauseated and severely constipated.
Palliative Medicine Case
Still lethargic and nauseated after one week in the nursing home, Mrs. F. vomited, aspirated, and went into acute respiratory distress.
The staff called 911, and Mrs. F. was transported back to the hospital where she was intubated and admitted to the ICU.
Palliative Medicine Case
Upon arrival at the hospital Mrs. F.’s daughter was extremely distressed to see her mother on a respirator, and requested she be removed from it.
Palliative Medicine Case
After several hours of discussion, Mrs. F. was placed on a morphine drip and removed from the respirator.
She died 6 hours later.
What is Palliative Medicine?
DEATH and DYINGDEATH and DYING(just like hospice)(just like hospice)
PAIN MANAGEMENTPAIN MANAGEMENT
ADVANCE ADVANCE DIRECTIVESDIRECTIVES
DEPRESSIONDEPRESSIONBREATHLESSNESSBREATHLESSNESS
NAUSEA AND NAUSEA AND VOMITTINGVOMITTING
ANOREXIAANOREXIA
FATIGUEFATIGUE
HOME CARE/HOME CARE/HOUSECALLSHOUSECALLS
ETHICSETHICS
CANCERCANCER
ANXIETYANXIETY
WITHDRAWAL WITHDRAWAL OF CAREOF CARE
DIFFICULT DIFFICULT FAMILIESFAMILIES
PHYSICIAN PHYSICIAN BURNOUTBURNOUT
MORPHINEMORPHINE
SUBSTANCE SUBSTANCE ABUSEABUSELIABILITYLIABILITY
HIVHIV
SHARING SHARING INFORMATIONINFORMATION
SPIRITUALITYSPIRITUALITY
GIVING UPGIVING UP
PATIENT PATIENT SATISFACTIONSATISFACTION
DELAYED DELAYED DISCHARGEDISCHARGE
DEADEA CURECURE
QUALITY OF QUALITY OF LIFELIFETUBE FEEDSTUBE FEEDS
What is Palliative Medicine?…an approach that improves the quality of life of patients and their families facing the problems associated with life threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.
http://www.who.int/cancer/palliative/definition/en/
What is Palliative Medicine? provides relief from pain and other distressing symptoms; affirms life and regards dying as a normal process; intends neither to hasten or postpone death; integrates the psychological and spiritual aspects of patient care; offers a support system to help patients live as actively as
possible until death; offers a support system to help the family cope during the
patients illness and in their own bereavement; uses a team approach to address the needs of patients and their
families, including bereavement counselling, if indicated; will enhance quality of life, and may also positively influence the
course of illness; is applicable early in the course of illness, in conjunction with
other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications.
http://www.who.int/cancer/palliative/definition/en/
Model of Modern Palliative Medicine
Life Prolonging TherapyLife Prolonging Therapy
Palliative CarePalliative Care Medicare Hospice Medicare Hospice BenefitBenefit
Diagnosis of Serious Illness
Death
www.capc.org
Disease Progression
The Role of Hospice/EOL Care Hospice: insurance sponsored program
that cares for people at the end of life 1974: Connecticut Hospice opens, funded
by NCI—primarily serves cancer patient 1982: Medicare hospice benefit enacted
Hospice: Necessary but not sufficient (only 25% of potential enrollees)
Why?
Life Threatening Illness in Young Adults Often a single disease process (trauma,
cancer) Few or no comorbidities Tolerate therapy well Spouse/partner likely to be healthy, and
provide care Fairly rapid (and predictable) decline
before death
Life Threatening Illness in Older Adults Difficult to recognize 80% of deaths occur
in those >65 Illness and death in
the older population is different
Comorbidities increase complexity
Emergence of Geriatrics
Geriatrics is different Geriatrics addresses the care of those
who have had multiple chronic diseases, often for many decades, and require multiple medications to remain functional and well
All clinicians will be caring for these patients
Demographic Changes
2003 Chartbook on Trends in the Health of Americans, http://www.cdc.gov/nchs/data/hus/hus03cht.pdf
Demographic Changes
2003 Chartbook on Trends in the Health of Americans, http://www.cdc.gov/nchs/data/hus/hus03cht.pdf
The Cure-Care Dichotomy: The Traditional Model
Life Prolonging Care
“Dying”
Palliative/
Hospice
Care
Disease Progression
D
E
A
T
H
www.capc.org
Diagnosis of Serious Illness
Defining “Dying”
Is there a clear distinction between two states?
Four different trajectories of illness prior to death among older adults have been identified by clinicians, and supported by data.
Trajectories of Dying
Lunney et al. reviewed physician Medicare claims in the year before death.
They divided 7,258 decedents into 4 previously described conceptual categories
Do these groupings classify decedents?
Lunney JR, et al. JAGS. 2002;50:1108-1112
Trajectories of Dying
Lunney JR, et al. JAGS. 2002;50:1108-1112
Acute illness
CHF, COPD
Cancer
Alz, CVA, PD, hip fx,
incont, PNA,
dehydration, syncope
Trajectories of Dying
Sudden Death
Terminal Illness
Organ Failure
Frailty
Percent 7 22 16 47
Mean Age 73 77 80 83
% Nursing Home
12 24 42 52
% Hospice Care
2 46 8 8
% Died in Hospital
1 27 47 39
Lunney JR, et al. JAGS. 2002;50:1108-1112
Opportunities for Improvement: Hospital-Based CareSUPPORT Trial: 4-year study in 5 major teaching
hospitals; 9105 patients with life-threatening illness
The SUPPORT Principal Investigators. JAMA. 1995;274:1591-1598
47% of MDs knew their patients wanted DNR 46% were ventilated within 3d of death 38% of those who died spent ≥ 10d in ICU 50% of those who died were in moderate-
severe pain ≥ half time within 3d of death
Opportunities for Improvement: Long-Term CareSites of Death US Georgia
Hospital 49.2 55.2
NH 23.7 15.9
Home 23.2 20.5
Site of terminal care is projected to change NH population projected growth from 2.5 to
3.4 million by 2020 1 in 2 adults is likely to die in NH in 2020
Brock DB, Foley DJ. Hospice J. 1998;13:49–60.http://www.chcr.brown.edu/dying/FACTSONDYING.HTM
Opportunities for Improvement: Long-Term Care
http://www.chcr.brown.edu/dying/FACTSONDYING.HTM
Cancer: 52.8%
Terminally ill: 39.3%
Nationally: 41.6%
Opportunities for Improvement: Long-Term Care
http://www.chcr.brown.edu/dying/FACTSONDYING.HTM
Nationally: 45.4% Terminally ill: 23.4%
Report Card: Access to Palliative careHospital Group GA Region National
Mid/large 38%(28/74) 41% 53%
For Profit 0%(0/15) 18% 20%
Non-Profit 47%(16/34) 54% 61%
Public 42%(8/19) 35% 41%
Community provider
14%(1/7) 17% 29%
Large 80%(16/20 65% 75%
Mid 22%(12/54) 32% 45%
Small 17%(5/29) 13% 20%
www.CAPC.org
How Georgia Compares…
Nationally: C grade Georgia: D grade
Percentage of mid-size and large hospitals with a palliative care program (50+ beds)
www.CAPC.org
Questions?
Special thanks to Laurent Adler, MD the original creator of these slides. (updates and edit have been added)
