End of Life Care Flashcards
Curing
The alleviation of symptoms or the termination or suppression of a disease process through surgical, chemical, or mechanical intervention
Healing
May be spontaneous, but more of it is a gradual awakening to a deeper sense of self (and of the self in relationship to others) in a way that effects profound change. Healing comes from within and is consistent with a person’s OWN readiness to grow and to change
What percentage of Americans die in in a hospital or nursing home?
70% (39% in hospital; 31% in nursing home)
Half of conscious patients had moderate to severe pain at least ___ before death
1/2 the time
__% of patients did not wish to have CPR… BUT physicians of more than half were NOT aware of DNR order preference
31
Nearly ___ of DNR orders were written within 2 days of patient death
half
__% of the patients spent at least 10 days in the ICU
40%
TENO Study: 1/4 of people who died did not receive enough pain medication and sometimes received none at all. Inadequate pain management was 1.6 times more likely to be a concern where vs where?
In a nursing home vs a home with hospice care
TENO Study: 1/2 of patients did not receive enough emotional support. This was 1.3 times more likely to be the case where?
In an institution
What is the biggest concern when considering yesterday’s solutions as today’s problems?
- Cost*
e. g. Mechanical ventilation, Renal dialysis, Pacemakers/defibrillators, Organ transplantation
What are the major medical issues at the end of life?
- Withholding and Withdrawing Care (e.g. Invasive Nutrition, Resuscitation (DNR), Antibiotics)
- Medical Futility
- Assistance in Dying
What is the first question that should be answered when dealing with end of life care?
What is/are the PATIENT’S goal(s)?
***Ask this before “what else can we do here?” or “What else can we offer this patient?”
What is the object of all clinical decision-making?
First, to secure the health, well-being, or good dying of the patient and to do this in a manner that respects the integrity of all participants in the decision-making process.
What is the moral valance of technology?
Technology is NEUTRAL. How it is used gives it its moral valance.
In what context is there a huge difference between withholding and withdrawing treatment?
Emotionally
There is no difference morally, ethically, medically, legally, or religiously
What is the goal of withholding and withdrawing artificial nutrition and hydration?
Restoration/cure, stabilization, preparation for death
What is the process for withholding and withdrawing artificial nutrition and hydration?
After listening carefully to patient/surrogate decision-maker, MAKE A MEDICAL RECOMMENDATION (NOT a question) consistent with patient’s goals of care
Recommendations: Feeding Tubes in Advanced [End Stage] Dementia
Percutaneous feeding tubes are not recommended in patients with advanced dementia; rather, oral-assisted feeding is recommended
What are the 3 signals that indicate desire to refuse food?
Pursing lips, blocking with hand, and saying “No”
What is 6-6-6-6?
What was your mother like 6 months ago, 6 weeks ago, 6 days ago, 6 hours ago?
Helps family members see that patient has been changing
What does this mean to you?
What is involved in a “Goals of Care” conversation?
- Review the clinical situation
- Assess the decision maker’s understanding (6-6-6-6; what does this mean to you?)
- Establish patient’s Goals of Care
- Present options to manage clinical issues
- Weigh risks and benefits with values and preferences
- Measure effects the decision has on family and loved ones
- Offer additional sources of decisional support
- Provide ongoing support and recognize the need to revisit the decision
Euthanasia
Clinician performs lethal intervention
Note: includes the intention that death is the result
Not legal anywhere in the US
Physician Assisted Suicide
Clinician provides the means; patient acts
Legal in Oregon, Washington, and Montana; Vermont and New Jersey with restrictions
Voluntary Euthanasia
Requested; Killed
Involuntary Euthanasia
Expressed with wish to the contrary; Killed
Nonvoluntary Euthanasia
Made no request/Gave no consent; Killed
“Passive” Euthanasia
Erroneous term; Intent is lacking
What are some Established Practices for Terminally Ill Patients?
- Voluntary/Informed refusal of treatment by patient
- Withholding and withdrawing treatment on behalf of incapacitated patients on the basis of substituted judgment or best interests
- Palliative and Hospice Care
What are some Controversial Issues for Terminally Ill Patients?
- Voluntarily stopping eating and drinking
- Palliative sedation (aka “Terminal Sedation”)
- Physician Assistance in Dying
- Patient/surrogate demands for futile therapies –> Troubled Concept of Medical Futility
What is the OVERUSED (and inappropriate) Clinical Argument for using analgesics that may hasten death?
“Better to give enough medication to control the patient’s symptoms than to have the patient suffer EVEN if this means the patient will die sooner”
Principle of Double Effect: “Foreseen but not intended consequence”: Four Elements
- Nature of the act (good, at least morally neutral)
- Agent’s intentions (agent must intend only good; bad effects can be foreseen, tolerated, permitted, but not intended)
- Distinction between means and effect (bad effect must not be a means to the good effect)
- Proportionality between the good effect and the bad effect (good must outweigh the bad)
Medical Futility
Unacceptable likelihood of achieving a therapeutic benefit for the patient
Quantitative vs Qualitative Components of Medical Futility
Quantitative: how many times and to what degree do we have to fail before we agree to call a Rx futile?
Qualitative: PATIENT must have capacity to appreciate benefit of the Rx and the Rx should release pt from preoccupation with illness/render him or her capable of achieving other life goals
Medical Futility: Effectiveness
Assessment of the capacity of the tx to alter the natural hx of the disease… objective determination by the CLINICIAN
Medical Futility: Benefit Assessment of value, desirability of effect
Determination by the PATIENT
Burden
Assessment of costs, discomfort, pain, inconvenience, both subjective and objective
Determined by PATIENT and CLINICIAN
Considered medical futility when the proposed intervention… (4 things)
- Won’t achieve the patient’s goal
- Serves no legitimate goal of medical practice
- Is ineffective more than 99% of the time
- Does not conform to accepted community standards
What is more common than unequivocal cases of medical futility?
Miscommunication, value differences
Medical Futility: Due Process
- Earnest Attempts
- Joint decision making
- Negotiation of disagreements
- Involvement of an institutional (ethics) committee
- Transfer care to another physician
- Transfer to another institution
Quinlan, 1975
First major “right to die” case
Process (Hospital Ethics Committee)
Cruzan, 1990
First US Supreme Court ruling on “right to die”
Process (Patient Self-Determination Act (1991) Advance directive)
Schiavo, 2005
Ruled Terri’s Law unconstitutional
Increased/Enhanced patient-physician communication
What is the order of the Circle of Decision Makers?
Self –> Directions from Individual (Living Will/Durable Power of Attorney for Health Care) –> Best Interests –> Court
What is the focus of Level I, II, and III of End of Life Care Discussions?
Level I: Individual
Level II: HCP
Level III: Institution
Hospice
Is a PHILOSOPHY of care, not a location
