HBM,Dying, Post

7/29/2019 HBM,Dying, Post

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8:30-9:10 Final Exam Review9:10-9:20 Break

9:20-10:00 Trauma Survivor Interview10:00-10:10 Break10:10-11:00 Death & Dying


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Death & Dyingor

Is there such a thing as a good death?Sumer Verma M.D.

Director Alzheimer UnitBriarwood Nursing Care and Rehabilitation

Needham MA

Associate Professor Psychiatry , BUSM


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Though shall not kill;

but needst not strive to officiously keep alive.

The Latest Decalogue

Arthur Hugh Clough 1862


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Change in Life Expectancy

CDC/NCHS Vital Statistics System


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Costs of Dying

Dying can be expensive specially when ICU servicesare involved

1:5 deaths involve ICU services

Average terminal ICU hospitalizations

LOS12 day

Cost $ 24,541

Average Non ICU hospitalizations LOS 8.9 days

Cost $ 8,548

Health US 2010


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Deaths-by Age and Cause of

Death

Health United States 2010

CLRD Chronic lower respiratory diseases


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Place of Death 89,97and 07

CDC/NCHS, National Vital Statistics Division


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Palliative or Hospice Care


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Definitions

Curative medicine Care oriented towards seeking a cure for an existent disease

Preventive Care Aims at preventing the appearance of disease

Palliative Care ( L palliare:to cloak) Alleviation of symptoms whether or not there is hope of a cure

Improve quality of life for persons with a life threatening illness

Hospice Care (L hospes:a guest or host) Palliation of a terminally ill (less than 6m to live) patients symptoms


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Palliative Care

1990: WHO definition: the active total care ofpatients whose disease is not responsive to

curative treatment The disease is terminal

An approach that improves the quality of life of

patients and their families facing the problemsassociated with life threatening illness

Not usually applied to chronic disease


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Palliative Care

Palliative care is provided mostly in acute carehospitals

Services are organized around aninterdisciplinary team

A large focus of the team is to involve the familyin treatment decisions

Palliation can be offered without restriction todisease or prognosis

ABHPM can certify physicians in palliative care


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The Hospice Movement

11th century- Crusaders established places fortreating the incurably ill

1967s Cicely Saunders started contemporaryhospice care

1971 Hospice Inc. founded in the USA byFlorence Wald, Dean of the Yale School ofNursingwith more focus on psychological

preparation for death


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We will do all we can to help you die peacefullybut we will also help you to live till you die

Cicely Saunders


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Growth of Hospice in the USA

1995: 1857 programs

Medicare paid$1.9 billion

1998 3200 programs

2003: First childrens facility in SFO

2008 > 1400 palliative care programs

> 4700 hospice programs

1.4 million persons used hospice

Medicare paid $10 billion (80% of costs)


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Hospice Philosophy

To continue an alert pain free life and tomanage other symptoms so that the remaining

days are spent in dignity

What hospice will provide Comfort

Treatment, if it improves quality of life

What hospice will not provide Diagnostic procedures which aim to diagnose or cure

Hastening death or unduly prolong life


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Hospice Utilization

To qualify for hospice a patient should (not must) have alife expectancy of less than six months

A misconception is that patient should have cancer or

AIDS (60% hospice patients have cancer and many ofthe rest have AIDS)

Many if not most patients referred to hospice at thevery end stage

In 2004 average LOS was 57 days

median LOS 22 days

33% of all patients died within 1 week of admission


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Services Offered to Hospice

Care Patients

CDC/NCHS National Home and Hospice Care Study


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Clinical Management of DyingPatients


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ACTION

How Clinicians Think ??


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Concerns of Dying Patients

Adequate pain and symptom management

Avoid inappropriate prolongation of dying

Achieving a sense of control

Relieve the burden on their loved ones

Strengthen relationships with family

Singer et al: Quality end of life care:patients perspectives. JAMA 1999;281: 163-168


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The SUPPORT Study

38% patients spent >10 days in the ICU 46% of DNR orders were written 2 days before

death

Aggressive care was given to 1:10 patients andignored care and comfort orders 40% had moderate to severe pain 50% experienced dyspnea 25% experienced psychiatric symptoms

Lynn et al: Study to Understand Prognoses and Preferences forOutcomes and Risks ofTreatment

Ann Int Med 1997: 126: 97-106


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The Physicians Task

Primum non nocere

Relief of suffering Pain

Uncertainty

Anxiety and depresion Maintaining dignity

Telling the truth


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The Cs of Management

Control

Composure

Communication Continuity

Compassion

Comfort

Adapted from Cassem and Stewart


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Talking about Death

The veil of ignorance and the denial of

death Saying the unthinkable

Does truth telling remove hope

Detached concern?


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Hospice Care Patients -

Symptoms Before Death



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Drugs Prescribed in the Last

Week of Life



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Managing Pain

Use the least invasive route

When possible, use sustained release

medications

Introduce one agent at a time

Allow time to assess effect

Adjust treatment to prevent adverseevents

Allow patient to self administer if possible


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The WHO Step Ladder

Nonopioid with or without adjuvant

Weak opioid with or without non opiod

adjuvant

Strong opioid with or without nonopiod adjuvant

1

2

3


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Undertreatment of Pain

Patient related factors

Under reporting

Difficulty comprehending assessment tools Polypharmacy induced side effects

Physician related factors

Patient does not look like they are in pain

Mistaking ageing for reversible factors

Fear of causing addiction

Lack of education in pain management


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Titrated Sedation

The practice of inducing unconsciousness in aterminally ill person for the remainder of that

persons life usually by means of a continuousinfusion of morphine or benzodiazepines

This is not equated to euthanasia

Extensive experience and studies that show that

these drugs are not fatal as long as the dose isadjusted to prevent respiratory depression


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Killing or Letting die

Does a person have a right to self

determination Euthanasia

Active

Passive Comfort measures only

The slow code


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Kept Alive by a Machine?

A standard living will can state that treatment bewithheld or withdrawn if it:

serves only to prolong the process of my dying

if I should be in an incurable or irreversible mental

or physical condition with noreasonableexpectationof recovery


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Advanced Directives

Do not resuscitate

Do not treat Antibiotics

CPR

Intubation

Hydration

Feeding / NG tube

Comfort measures only Pain control

How much

How aggressive

Hospice care


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Moral and Legal Dilemmas

Years at the end of life or life at the end of years

The slippery slope-- QUALYs

Killing or letting die? Is physician assisted suicide justifiable


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A Good Death

A good death is defined as one that is:

In general accord with the wishes of patientsand families

Reasonably consistent with clinical, cultural andethical standards

Free of avoidable distress and suffering forpatients, families and caregivers

Field and Cassell: Approaching death:Improving Care at the end of Life

Washington DC: National Academy Press 1997:24


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When you were born, you cried

and the world rejoiced.

Live your life in such a manner

so that when you die,

the world cries and you rejoice.

Kabir 1440-1518


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THE NINE COMMANDMENTS

Thou shalt remember that:

1. Old age is not an illness looking to be cured

2. More drugs does not mean better care

3. Suffering is unnecessary at the end of life

4. It is interdisciplinary NOT multidisciplinary

5. You cannot fix everything by yourself

6. Your task is to protect your patients and not yourself

7. Trust but verify evidence based medicine

8. Death is inevitable -- not an option

9. It is faith that heals!

(With sincere apologies to the original author)

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HBM,Dying, Post