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Srivieng Pairojkul, MD.Karunruk Palliative Care Center
Faculty of Medicine, Khon Kaen University
Thai Palliative Care Society
Top 10 causes of death
Thailand 2012Japan
S Korea
ChinaSingapore
ThailandVietnam
MyanmarMalaysia
BruneiIndonesia
PhilippinesLao
âĒ Changes in society â isolated family.
âĒ Patients have limited understanding of their illness
and an inaccurate view of their prognosis.
âĒ The care received is intensive, aggressive, costly.
âĒ Face difficult decisions about EOL treatment.
âĒ More aggressive treatment at EOL.
âĒ High physical symptoms & psychological suffering.
âĒ Increase health care costs.
Beliefs:
âĒ Dead could be avoids using modern technology.
âĒ Science and research could over come dead.
âĒ Death is a failure.
âĒ 23.1% of patients referred to KPC were intubated prior to consultation.
âĒ Diagnosis of these patients: - Advanced cancers 56.8%- Terminal-stage: AIDS, Parkinson, sys sclerosis 7.4% - End-stage organ failure 16.0%- Acute conditions: Hosp-acq infections/stroke 19.8%
Karunruk PC Center 2012 report
âĒ 89 year-old
âĒ Advance dementia,
bed bounded
âĒ Developed massive stroke
âĒ On ventilator, no cognitive
function
Cancer
Organ failure
Frailty/Dementia
âĒ Âū of death from CA occurs in people >65 y.
âĒ HF affects >1/10 people >70 y.
5-y mortality of 80% is worse than many CA
âĒ Dementia 4% in >70 Y, and 13% in >80 Y.
âĒ Length of survival 8 Y.
McCarthy M, J Rol Coll Physicians 1996;30:325Hofman A. Internat J Epidemiology, 1991;20:736.
A large proportion of patients eventually
die in hospitals from recurrent infections
or dementia-related complications
âĒ Advance dementia ApraxiaDysphagiaDecreased mobility
âĒ Sentinel events:Eating difficulties.Recurrent infections.
Increasing risk of infection
Malnutrition
Sachs GA, et al. J Gen Intern Med 2004;19:1057-63.
âĒ Follow up of 323 nursing home residents with AD
âĒ 6-month mortality rate:
- Pneumonia = 46.7%
- Febrile episode 44.5%
- Eating problem 38.6%
âĒ Distressing symptoms: Dyspnea 46.0%, Pain 39.1%
âĒ In the last 3 months of life
- 40% underwent at least one burdensome intervention
(Hospitalization, ER visit, parenteral Rx, tube feeding)
âĒ Proxies who understanding poor prognosis were much
less likely to have burdensome interventions in the last
3 months of life (OR 0.12, 95% CI 0.04-0.37)
Mitchell S. NEJM 2009;361:1529
End of life experiences between cancer and
advanced dementia patients were compared in
US nursing homes
Tube feeding, lab investigations and restraint use were
significantly associated with advanced dementia
CASCADE study: 323 patients in 22 US nursing homes followed for 18 months
Complication Frequency
Pneumonia 41.1%
Febrile Episode 52.6%
Eating Problem 85.8%
Mitchell SL et al. The Clinical course of Advanced Dementia. NEJM 2009
Complication Adjusted 6 month
Mortality
Eating Problem 38.6%
Febrile Episode 44.5%
Pneumonia 46.7%
Survival after the
first episode of
pneumonia, a
febrile episode
and eating
problem
Mitchell SL et al. The Clinical course of Advanced Dementia. NEJM 2009
Dyspnea PainPressure
ulcer Aspiration Agitation
Mitchell SL et al. The Clinical course of Advanced Dementia. NEJM 2009
âĒ Prognostic tools have a modest ability to predict
death Care provided should be guided by their
goal of care rather than estimated life expectancy.
âĒ FAST staging has been used as criteria to assess
hospice eligibility, but insufficient for
prognostication.
FAST stage7 +
- Presence of pneumonia
- Albumin <3.5 mg/dl/presence of a feeding tube
Associated with a reduced survival.
âĒ Aspiration pneumonia indicates a high risk of death
in the next 6-12 months.Brown MA, et al. Palliat Med 2013;27:389-400.
Van der Steen Jt, et al. J Am Med Dir Assoc 2007;8:464-8.
1. The surprise question: âWould you be surprised
if this patient were to die in the next 6-12 months?â
2. Choice/ Need - The patient makes a choice for
comfort care only, not âcurativeâ treatment, or is in
special need of supportive / palliative care.
3. Clinical Prognostic Indicators - an attempt to
estimate when patients with advanced disease or
are in the last year or so of life.
Thomas K, et al. Prognostic Indicator Guidance 4th Ed, Oct 2011.
3. Clinical Prognostic Indicators of End Stage Dementia
Unable to walk without assistance, and incontinent, and no consistently meaningful verbal communication, and increasing dependence in ADL
Plus any one of the following: âĒ Multiple comorbidities
âĒ 10% wt loss in previous 6 months without other causes
âĒ Pyelonephritis or UTI
âĒ Serum albumin <25 g/l
âĒ Severe pressure scores
âĒ Recurrent fevers
âĒ Reduced oral intake / weight loss
âĒ Aspiration pneumonia
Thomas K, et al. Prognostic Indicator Guidance 4th Ed, Oct 2011.
âĒ Decisions are almost always made with the
surrogate decision maker.
âĒ Solicit and understanding the patientâs
previously stated goals and values.
âĒ Acknowledge that decisions to withdraw or
withhold life-prolonging therapy might be
stressful for family members.
âĒ Provide compassionate, evidence-based
counseling.
âĒ She was diagnosed with dementia 5 years ago.
âĒ Now not able to walk, speaks few words, difficult
feeding, lost some weight.
âĒ Visit to the GP clinic.
âĒ Daughter concern of her feeding problem, ask if
feeding tube will improve her nutritional status
and her function.
âĒ Admitted to LTC 2 years ago
âĒ Status: Totally dependent, severe dysphagia,
minimal oral intake, almost mute.
âĒ Developed fever with tachypnea.
âĒ Diagnosis â recurrent aspiration pneumonia.
âĒ Treated with AB last month for a similar condition.
âĒ The patientâs daughter asked you:
âWhy my mother sick again?â âIs it poor care?â
âCan you cure her?â
âShould she be sent to the hospital?â
âĒ Feeding tube.
âĒ Transfer to hospital.
âĒ Antibiotics for pneumonia.
âĒ Withholding or withdrawing life-prolonging.
treatment.
âĒ CPR
Cochrane Database of Systematic Reviews, Issue 2, 2009
âĒ No evidence for increased survival.
âĒ None of the studies evaluated tube feeding and
QoL.
âĒ No benefit on nutrition and pressure sores.
âĒ Poor oral intake â Look for
- Altered mental status.
- Excessive drug sedation.
- Painful swallowing.
âĒ Management:
- Good oral care.
- Small volume meals.
- Increased frequency.
- calorie dense.
- Support of caregivers.
âĒ Charts were reviewed for evidence of
pneumonia in US nursing homes
âĒ Aggressiveness of antibiotic use was reviewed
âĒ 133/323 residents had at least 1 episode of pneumonia.
âĒ No statistical difference in survival between the 3 treatment routes
âĒ Patients who were not treated had greater comfort (higher SM-EOLD scores)
In severe dementia:
âĒ Cardiopulmonary resuscitation (CPR) is unlikely
to be successful.
âĒ CPR is three times less likely to be successful in
people with cognitive impairment than in those
who are cognitively intact.
âĒ The success rate is similar to that found in
people with metastatic cancer
Ebell et al, 1998
âĒ Intervention patients received less intravenous
therapy.
âĒ Control patients were less likely to have a
palliative care plan.
âĒ Methodological difficulties with research in
advanced dementia.
âĒ Application of PC to dementia.
âĒ Patient-centered care, communication and
shared decision making.
âĒ Setting care goals and advance planning.
âĒ Continuity of care.
âĒ Prognostication and timely recognition of dying.
âĒ Avoiding overly aggressive, burdensome and
futile treatment.
âĒ Optimal treatment for symptom and providing
comfort.
âĒ Psychosocial and spiritual support.
âĒ Family care and involvement.
âĒ Education of the health-care team.
âĒ Societal and ethical issues.
âĒ For Asian countries, patients and their informal
care givers prefer death to occur at home.
âĒ Dying at home can contribute to a better death
compared with dying in an institution.
Higginson IJ, et al. J Pall Med 2000;3:287-300.Barbera I, et al. Palliat Med 2005;19:435-6.
Yao CA, et al. J Pain Symptom Manage 2007;34:497-504.
āļïŋ―āļēāđāļïŋ―āļïŋ―āļēāļĒāļāļĩ āļĩ āļïŋ―āļēāļāļāļĩ āļĩ āļēāļāļ§ïŋ―āļēāļāļĩ āļĩ āđāļĢāļāļāļĒāļēāļāļēāļĨ
āļāļđ ïŋ―āļïŋ―āļ§āļĒāđāļĢāļāļĄāļ°āđāļĢāļđ āļāļ āļēāļĒāđāļïŋ―āđāļāļĢāļāļāļēāļĢ UC āļĄāļđ āļïŋ―āļēāļĢāļđ āļāļĐāļēāļāļĒāļēāļāļēāļĨāđāļāļđ āļāļāļŠāļđ āļāļïŋ―āļēāļĒāļïŋ―āļāļāđāļŠāļđ āļĒāļāļđ āļ§āļđ āļāđāļāļĨāļđ āļđāļĒāđāļïŋ―āļēāļāļđ āļ 44,974 āļāļēāļ āļāļēāļĢāļāļđ āđāļĨāļāļđ ïŋ―āļïŋ―āļ§āļĒāļĢāļ°āļĒāļ°āļŠāļđ āļāļïŋ―āļēāļĒāļāļđ āļđāļïŋ―āļēāļāļĄāļđ āļïŋ―āļēāđāļïŋ―āļïŋ―āļēāļĒāđāļïŋ―āļēāļāļđ āļ 26,821 āļāļēāļ āđāļāļĒāđāļïŋ―āļāđāļïŋ―āļ
18
2,787 āļāļēāļ
7,534 āļāļēāļ
âĒ Expenditure of CA patients under UC coverage (care
in hospital) was 44,974 B in the last month of life.
âĒ Expenditure in the last month of life of care at home
is 26,821 B
Cost consists of:
Medical instrument/supplies
Supplies
Traveling costs
Carer compensation
TDRI. Financing long term care and palliative care, 2016.
Section 12 âThe person has right to make make a statement
of intent not to seek health services that are
only possible. To prolong death in the last of his life. Or to end suffering
from illnessâ
2014 - Health policy of the Ministry of Public
Health.
Every provincial hospital has a full time nurse
(training in PC) coordinates hospital PC Unit by
Dec 2014 and in 300 district hospitals by
September 2015.
2017 - National Health Security provides e-claim
for home care.
Community
Refer
Refer
Provincial Hospitals
District Hospitals
Health Volunteers
PCUsFamily care team
Functional unit with specialist palliative consultation teamâĒ Provide education/training.âĒ Provide consultation.âĒ Networking.
Functional unit with intermediatetraining PC teamâĒ Supervise primary care team.âĒ Provide essential medications.âĒ Provide med equibment.
Home care teamâĒ Basic PC training.âĒ Screening of cases.âĒ Provides home care.
Awareness building
Pilot project in Service Area 7 in
2014 then extended to the whole
Northeast region (including 4
provinces in other part of Thailand)
âĒ 25 provincial hospitals
âĒ 300 district hospitals
Objective: Building strong
network to provide continuity of
care at home in whole NE region
âĒ The NE region now has 17 PC units, which could
act as clinical training sites.
âĒ 80% of district hospitals have at least 1 nurse
training in intermediate-course PC (4-weeks)
âĒ Network extended to primary care units.(3d course)
âĒ The network is strong that dying at home is
manageable with good symptom control and home
care provision.
âĒ This successful model could be replicated.
Opioid Available %
Immediate-released morphine 78.8
Control-released morphine 90.6
Duration of prescription >2weeks 64.4
MO injection used outside hospital 88.6
2018 MOU signed between MOPH and KKU to
replicate the program in the Northern and
Southtern regions of Thailand
Geriatrics
Primary Care
Palliative
Care
The elderly
& Family
Long-term care
Case managerPalliative
Home Care
Family Care Team
âĒ Improve
knowledge
and skills
âĒ Coordination
âĒCert PC Mid-career training (1Y)(2018) âĒ Fellowship - PC for FM (1Y) (2019)
âĒ Basic Cert. Course in Pall Med (8wk)âĒ Basic Cert. Course in Pall Nurs (6wk)âĒ Clinical Attachment for Com Nurs (4wk)âĒ Clinical PC for pharmacists (2 wk)âĒ How to set PC program (1 wk) âĒ TOT for PC education (1 wk)
âĒ Pain and PC for doctors (3d)âĒ Basic PC for Nurses (3d)âĒ PC for pharmacists (2d)
âĒ Symptom managementâĒ PC in critical care settingsâĒ PC in ElderlyâĒ Renal PCâĒ Advance course in PC (2D)
International Course for doctors and nurses
Module 1. Concept & assessment
Module 2. Pain management
Module 3. Non-pain symp Mx
Module 4. Last hours of life
Module 5. Communication skills
Module 6. Psychosocial, spiritual and bereavement care
Module 7. Ethical issues
Module 8. D/C plan & home care
Module 9. Goal setting & ACP
Module contents:
âĒ Objectives, Lessen plan.
âĒ PPT with note page, Case study, Articles, Post test
Composed of:âĒ Work flowsâĒ GuidelinesâĒ Record forms
Implemented by:âĒ Karunruk PC Center
âĒ Srinagarind PCT PC
âĒ PC Units of Northeast
PC Network.
How to Set Hospital Palliative Care Program WS
5-d workshop
âĒ Educational modules:1. Advance dementia2. Prognostication
3. Issues concerned4. Holistic assessment and tools: Functional,
symptom, nutritional, psychosocial& spiritual, care giver needs.
5. Symptom management6. Advance care planning and AD7. Care at the dying phase8. Bereavement care
âĒ Hand book for care giver.
âĒ Caregiver Burden
Medical
review
Nursing care
Managing anticipated
complications
Caring for the carers
âĒ Medical history reconciliation
âĒ Physical examination
âĒ Dementia specific assessment tools
âĒ Nursing care
âĒ Nutritional advice
âĒ Anticipatory planning
âĒ Preferred Plans of care
âĒ āļŦāļāļīāļāđāļāļĒāļāļēāļĒāļļ 84 āļāļĩ
âĒ 4 M āļāđāļāļāđāļāļĨāļĩāļĒ āļāļ·āļāļāđāļāļ āđāļāļ·āđāļāļāļēāļŦāļēāļĢ
âĒ 2 M āļŦāļēāļĒāđāļāđāļĄāđāļāļīāđāļĄ āļāđāļāļāđāļāļāļķāđāļ āļāļāļ
āļĢāļēāļāđāļĄāđāđāļāđ āđāļāđāļŦāđāļāđ āļāļ.āļĨāļ
âĒ Pleural effusion, ascities.
Pleural Bx: Metastatic
adenocarcinoma
āđāļāļāļĒāđāļŠāļ·āđāļāļŠāļēāļĢāđāļĢāļ·āđāļāļāđāļĢāļ āļāļĒāļēāļāļĢāļāđāđāļĢāļāļāļĢāļ°āļĄāļēāļ 6 āđāļāļ·āļāļ
Suggest Palliative CMT
āļāļāļīāđāļŠāļāļāļēāļĢāļāļĢāļ§āļāļāļīāđāļĻāļĐāđāļĨāļ°āļāļēāļĢāđāļŦāđ palliative CMT
āļāļāļĢāļąāļāļĐāļēāļāļēāļĄāļāļēāļāļēāļĢ āđāļĄāđāđāļŦāđāđāļāđāļāļāļ§āļ āđāļĨāļ°āļāļĢāļĄāļēāļ āļāļđāđāļĨāļāļĩāđāļāđāļēāļ
1. āļŦāļāļāđāļŦāļāļ·āđāļāļĒ
2. āđāļ
3. āļāđāļāļāļĨāđāļē
4. āđāļāļ·āđāļāļāļēāļŦāļēāļĢ
Symptom Palliation
âĒ Morphine syrup āđāļāļ·āđāļāļāļąāļāļāļēāļĢāļāļēāļāļēāļĢāļŦāļāļ
âĒ āļĒāļēāļĢāļ°āļāļēāļĒ
âĒ āļŠāļāļāļ§āļīāļāļĩāļāļąāļāļāļēāļĢāļāļēāļāļēāļĢāļŦāļāļāđāļāļĒāđāļĄāđāđāļāđāļĒāļē āļāļķāļāļŦāļēāļĒāđāļ āļŠāļāļ§āļ
āļāļĨāļąāļāļāļēāļ āđāļāđāļĒāļēāđāļ§āļĨāļēāļĄāļĩāļŦāļāļāļāļļāļāđāļāļīāļ
âĒ Paracetesis āđāļāđāļāļāļĢāļąāđāļāļāļĢāļēāļ§
Good discharge plan
âĒ Effective symptom control - āļāļēāļāļŦāļĄāļēāļĒāļāļēāļāļēāļĢāļāļĩāđ
āļāļēāļāļāļ°āđāļāļīāļ āđāļāđāļēāļāļķāļāļĒāļēāļĢāļ°āļāļąāļāļāļ§āļ
âĒ Advance care plan - āđāļāđāļēāđāļāđāļāđāļēāļŦāļĄāļēāļĒāļāļđāđāļĨ āļŦāļĨāļĩāļāđāļĨāļĩāđāļĒāļ
readmission āļāļēāļĢāļāļĒāļļāļāļāļĩāļāļāļĩāđāđāļĄāđāđāļāļīāļāļāļĢāļ°āđāļĒāļāļāđ
âĒ āļŠāļāļāļāļđāđāļāļđāđāļĨāļŦāļĨāļąāļ/āļĢāļāļ - nursing care āļāļēāļĢāđāļŦāđāļĒāļē āđāļŦāđ
āļāđāļāļĄāļđāļĨāļāļēāļāļēāļĢāļāļĩāđāļāļēāļāļāļāđāļāđāđāļāļĢāļ°āļĒāļ°āļāļĩāđ āđāļĨāļ°āļĢāļ°āļĒāļ°āđāļāļĨāđ
āđāļŠāļĩāļĒāļāļĩāļ§āļīāļāđāļĨāļ°āļ§āļīāļāļĩāļāļēāļĢāļāļđāđāļĨ
âĒ āđāļŦāđāļāļ§āļēāļĄāļĄāļąāđāļāđāļāļ§āđāļēāļāļ°āđāļāđāļĢāļąāļāļāļēāļĢāļāļđāđāļĨāļāđāļāđāļāļ·āđāļāļ āđāļāđāļēāļāļķāļāļāļēāļĢ
āđāļŦāđāļ āļēāļāļĢāļķāļāļĐāļēāļāļĩāļĄ PC āđāļāđāļāļĨāļāļ 24 āļāļĄ. āļāļĨāļąāļāļĄāļē admit
āđāļāđāđāļĄāđāļ·āļāđāļāļīāļāļ āļēāļ§āļ° emergency āļŦāļĢāļ·āļāļ āļēāļŦāļąāļāļāļāļēāļĢāļāđāļēāļāđ
âĒ āļāļąāļāļŦāļēāļāļļāļāļāļĢāļāđāđāļāļēāļĢāđāļāļāļĒāđāļāļĩāđāļ āļēāđāļāđāļāđāļŦāđāđāļāđāļāļĩāđāļāđāļēāļ
âĒ āļĄāļĩāđāļāļĢāļ·āļāļāđāļēāļĒāļāļāļĄāļ āļđāļĄāļīāļĢāļāļāļĢāļąāļāļāļēāļĢāļŠāđāļāļāđāļāđāļĨāļ°āđāļĒāļĩāđāļĒāļĄāļāđāļēāļ
âĒ āļāļĩāļĄāđāļāļāļļāļĄāļāļāđāļāđāļēāļāļķāļāļāļēāļĢāļāļĢāļķāļāļĐāļē PC specialist āđāļĄāđāļāđāļēāļĒāđāļāđ
âĒ āļĄāļĩāļĒāļē opioids āļāļĩāđāđāļāđāļēāļāļķāļāđāļāđāļāđāļēāļĒ
âĒ āļĄāļĩāļĢāļ°āļāļāļāļēāļĢāļāļđāđāļĨāļĢāļ°āļĒāļ°āļāđāļāļāđāļŠāļĩāļĒāļāļĩāļ§āļīāļ āļāļđāđāļāđāļ§āļĒāļĄāļąāļāđāļĄāđāļŠāļēāļĄāļēāļĢāļ
āļāļĨāļ·āļāļĒāļēāđāļāđ āļŠāļēāļĄāļēāļĢāļāđāļāļēāļĒāļēāļāļĩāļāļĄāļāļĢāđāļāļĩāļāđāļĨāļ°āļĒāļēāļāļ·āđāļāđāļāļĩāđāļ āļēāđāļāđāļ
āđāļāļāļēāļĢāļāļąāļāļāļēāļĢāļāļēāļāļēāļĢāđāļĄāđāļŠāļļāļāļŠāļāļēāļĒāļāļāļāđāļāđāļŦāđāļāđāļĩāļāđāļēāļāđāļāđ
âĒ āđāļĒāļĩāđāļĒāļĄāļŦāļĨāļąāļāļ āļēāļŦāļāđāļēāļĒ 7 āļ§āļąāļ
âĒ āļāļĢāļ°āđāļĄāļīāļāļāđāļēāļ āļāļđāđāļāļđāđāļĨ āđāļŦāļĨāđāļ
āļāđāļ§āļĒāđāļŦāļĨāļ·āļ āļāļēāļĢāđāļāļāļīāļāļāļąāļāļŦāļē
āļāļāļāļāļĢāļāļāļāļĢāļąāļ§ āļŠāļĢāļļāļāļāļąāļāļŦāļēāđāļĨāļ°
āđāļŦāđāļāļ§āļēāļĄāļāđāļ§āļĒāđāļŦāļĨāļ·āļ
âĒ āļāļīāļāļāļēāļĄāđāļĢāļ·āđāļāļ ACP: family
meeting āļāļĩāđāļāđāļēāļ
âĒ āļāļđāđāļāđāļ§āļĒāđāļĢāļīāđāļĄāļĄāļĩāļāļēāļāļēāļĢāļŦāļāļāļĄāļēāļāļāļķāđāļ
âĒ āļāļĢāļąāļāļāļāļēāļāļĒāļē MO
âĒ 2 āļ§āļąāļāļāđāļāļĄāļēāđāļĢāļīāđāļĄāļāļķāļĄāļĨāļ āļāļĨāļ·āļāļĒāļēāđāļĄāđāđāļāđ
āļŦāļēāļĒāđāļāļāļąāļāļāļĢāļ·āļāļāļĢāļēāļ āļĨāļāđāļĒāļĩāđāļĒāļĄāļāđāļēāļ
âĒ āļĄāļĩāđāļāđāļēāļŦāļĄāļēāļĒāđāļĨāļ°āđāļāļāļāļēāļĢāļāļēāļĢāļāļđāđāļĨāļāļĩāđāļāļąāļāđāļāļāļĢāđāļ§āļĄāļāļąāļāļĢāļ°āļŦāļ§āđāļēāļ
āļāļđāđāļāđāļ§āļĒ āļāļĢāļāļāļāļĢāļąāļ§ āđāļĨāļ°āļāļĩāļĄāļŠāļļāļāļ āļēāļ
âĒ āļāļđāđāļāđāļ§āļĒāđāļĨāļ°āļāļĢāļāļāļāļĢāļąāļ§āđāļāđāļĢāļąāļāļāļēāļĢāļāļāļāļŠāļāļāļāļāļēāļĄāļāļ§āļēāļĄ
āļāđāļāļāļāļēāļĢ āļāļķāļāļāļāđāļāļāļēāļĢāļāļĢāļīāļāļēāļĢāļāļĩāđāđāļāđāļĢāļąāļ
âĒ āļĨāļāļāļēāļĢ admission āđāļĨāļ°āļāļēāļĢāļĄāļēāļĢāļąāļāļāļĢāļīāļāļēāļĢāļāđāļĩāļŦāđāļāļāļāļļāļāđāļāļīāļ
âĒ āļāļđāđāļāđāļ§āļĒāļĄāļĩāļāļļāļāļ āļēāļāļāļĩāļ§āļīāļāļāļĩāđāļāļĩāļāđāļĩāļāđāļēāļ āļŠāļēāļĄāļēāļĢāļāļāļēāļĒāļāļĩāļāļĩāđāļāđāļēāļ
āļŠāļĢāļļāļāđāļāļĢāļ°āļĒāļ°āđāļ§āļĨāļē 6 āđāļāļ·āļāļāļāļĩāđāļāļđāđāļĨ
âĒ āļĨāļāđāļĒāļĩāđāļĒāļĄāļāđāļēāļāļāđāļąāļāļŦāļĄāļ 5 āļāļĢāļąāđāļ āļāļīāļāļāļēāļĄāļāļĩāđ OPD PC 8 āļāļĢāļąāđāļ
âĒ āļāļīāļāļāļēāļĄāļāļēāļāđāļāļĢāļĻāļąāļāļ/āđLine 20 āļāļĢāļąāđāļ
âĒ āđāļŦāđāļ āļēāļāļĢāļķāļāļĐāļēāđāļāđāļāļĨāļāļ 24 āļāļąāđāļ§āđāļĄāļ 28 āļāļĢāļąāđāļ
âĒ āļāļ§āļēāļĄāļāđāļāļāļāļēāļĢāļāļāļāļāļđāđāļāđāļ§āļĒāđāļĨāļ°āļāļĢāļāļāļāļĢāļąāļ§
âĒ āļāļ§āļēāļĄāļŠāļēāļĄāļēāļĢāļāļāļāļāļāļđāđāļāļđāđāļĨāđāļāļāļēāļĢāļāļđāđāļĨāļāļđāđāļāđāļ§āļĒ
âĒ āļāļēāļĢāļĢāļąāļāļĐāļēāđāļĨāļ°āļāļēāļĢāļāļ§āļāļāļļāļĄāļāļēāļāļēāļĢ
âĒ āļāļąāļāļŦāļēāđāļĻāļĢāļĐāļāļāļīāļ āļāļēāļĢāļāļāļāļŠāļāļāļāļāļ§āļēāļĄ
āļāđāļāļāļāļēāļĢāļāđāļēāļāļāļēāļĢāļĄāļāđ āļŠāļąāļāļāļĄāđāļĨāļ°āļāļīāļāļ§āļīāļāļāļēāļ
1.āļāļđāļāđāļ§āđāļĒāđāļĨāļ°
āļāļĢāļāļāļāļĢāļ§āļą
âĒ āļĢāļ°āļāļāļāļĢāļīāļāļēāļĢāļāļđāđāļĨāļāļĩāđāļāđāļēāļ
âĒ āļĒāļēāđāļĨāļ°āļāļļāļāļāļĢāļāđāļāļēāļĢāđāļāļāļĒāđāļāļĩāđāļ āļēāđāļāđāļ
âĒ āļĄāļĩāļāļđāđāļāļĢāļ°āļŠāļēāļ/āļŠāđāļāļāđāļ/āļāļđāđāļĨāļāđāļāđāļāļ·āđāļāļ āđāļŦāđāļ āļēāļāļĢāļķāļāļĐāļē
āđāļĨāļ°āđāļāđāļēāļāļķāļāđāļāđāđāļĄāļ·āđāļāļāđāļāļāļāļēāļĢ
âĒ āļāļĨāļąāļāļĄāļēāļĢāļąāļāļĐāļēāđāļ āļĢāļ. āđāļāļ·āđāļāļ āļēāļŦāļąāļāļāļāļēāļĢ āļāļąāļāļāļēāļĢ
āļ āļēāļ§āļ°āļāļļāļāđāļāļīāļāļāđāļēāļāđāđāļāđāļāļēāļĄāļāļ§āļēāļĄāđāļŦāļĄāļēāļ°āļŠāļĄ
2.āđāļŦāļĨāđāļ
āļāļĢāļ°āđāļĒāļāļāđ
âĒ CC: āļāļķāļĄāļĨāļāļĄāļē 5 āļ§āļąāļ āđāļĄāđāļĢāļđāđāļāļąāļ§ 1 āļ§āļąāļāļāđāļāļāļĄāļēāļĢāļ. āļāļāļ°āļāļĒāļđāđāļāļĩāđāļŦāđāļāļāļāļļāļāđāļāļīāļāđāļāļāļĒāđāļāļāļŦāļēāļĒāđāļāđāļĄāđāļŠāļĄāđ āļēāđāļŠāļĄāļ āđāļāđāđāļŠāđāļāđāļāļāđāļ§āļĒāļŦāļēāļĒāđāļāđāļĨāļ°āļŠāđāļ CT brain
âĒ PH: āļ§āļīāļāļīāļāļāļąāļĒāđāļāđāļ dementia 5 āļāļĩāļāđāļāļāļāđāļ§āļĒāđāļŦāļĨāļ·āļāļāļąāļ§āđāļāļāđāļāđ āļŠāļąāļāļŠāļāļāļēāļāļāļĢāļąāđāļ āđāļĢāļīāđāļĄāļāļāļāļāļīāļāđāļāļĩāļĒāļāļĄāļē 3 āļāļĩāļāđāļ§āļĒāđāļŦāļĨāļ·āļāļāļąāļ§āđāļāļāđāļĄāđāđāļāđ āļ āļēāđāļāļĢāđāļĄāđāđāļāđ āđāļŦāđāļāļēāļŦāļēāļĢāļāļēāļāļŠāļēāļĒāļĒāļēāļ āđāļĄāđāļĄāļĩāđāļĢāļāļāļĢāļ°āļ āļēāļāļąāļ§āļāļ·āđāļāđ
âĒ FH: āļāļēāļāļĩāļāļāļĢāļđ āļŠāļēāļĄāļĩāđāļŠāļĩāļĒāļāļĩāļ§āļīāļ 10 āļāļĩāļāđāļāļ āļĄāļĩāļāļļāļāļĢāļŠāļāļāļāļ
āļāđāļ§āļāđāļĢāļāļāļēāļĻāļąāļĒāļāļąāļāļāļļāļāļĢāļāļēāļĒāļāļĩāļāđāļ.āļāđāļāļĄāļēāļāļđāđāļĨāļĨ āļēāļāļēāļ āļāļķāļāļĄāļē
āļāļēāļĻāļąāļĒāļāļąāļāļāļļāļāļĢāļŠāļēāļ§āļāļĩāđāđāļāđāļāļāļēāļāļēāļĢāļĒāđāļāļĒāļđāđāļāļāļāđāļāđāļ
âĒ āļāļąāļāļāļ·āļāļĻāļēāļŠāļāļēāļāļļāļāļ
âĒ CT brain: Brain metastasis
with hemorrhage at Rt frontal
& left parietal lobe is most
likely, aging brain atrophy.
âĒ CXR: Right upper lobe mass.
âĒ Blood Chem - alb 2.1
DX: Adv dementia with lung CA with brain mets
PE: No cognitive function on MV
Cachexia, pressure sores at sacrum grade 4
âĒ āđāļŦāđāļāđāļāļĄāļđāļĨāđāļĢāļ āļāļĒāļēāļāļĢāļāđāđāļĢāļ āđāļāļ§āļāļēāļāļāļēāļĢāļāļđāđāļĨ
āļāļāļāļēāļĢāļĢāļąāļāļĐāļēāđāļĨāļ°āđāļŦāđāļāļēāļĢāļāļđāđāļĨāļāļēāļĄāļāļēāļāļēāļĢ
Comfort care āļĒāļļāļāļīāļāļēāļĢāļĢāļąāļāļĐāļēāļāļĩāđāđāļĄāđāļāđāļāđāļāļīāļāļāļĢāļ°āđāļĒāļāļāđ
āđāļāđāļ āđāļāļĢāļ·āđāļāļāļāļĒāļļāļāļāļĩāļ
âĒ āļāļĢāļāļāļāļĢāļąāļ§āđāļŦāđāļāļāđāļāļāļāđāļāļāļāļąāļāđāļĨāļ·āļāļ comfort care āļĒāļļāļāļīāļāļēāļĢ
āļāļĒāļļāļāļāļĩāļ
âĒ āļāļĩāđāļāļ·āļāļāļēāļĢāļāļēāļĒāļāļĩāļŦāļĢāļ·āļāđāļĄāđ ?
âĒ āļāļļāļāļĄāļĩāđāļāļ§āļāļēāļāļāļēāļĢāļ āļēāđāļāļīāļāļāļēāļĢāļāļĒāđāļēāļāļāļ·āđāļāļŦāļĢāļ·āļāđāļĄ?āđ
âĒ āļāđāļēāļāđāļēāļāđāļāđāļĄāļĩāđāļāļāļēāļŠāļāļđāđāļĨāļāļđāđāļāđāļ§āļĒāļĢāļēāļĒāļāļĩāđāđāļĄāļ·āđāļ 3 āļāļĩāļāđāļāļ āļāđāļēāļ
āļāļ°āļ āļēāļāļ°āđāļĢāļāđāļēāļ ?