end of life care

Question 1

why is palliative medicine important in geriatrics

Answer 1

• majority of deaths occur in older adults
• seriously ill patients spend most of their ifnal months at home, while most deaths occur in the hospital or nursing home
• N.B. location of death varies regionally (35% in Portland and 80% NY die in hospitals)

Question 2

Quality of end of life care U.S.

Answer 2

• typical deaths = slow decline, associated with chronic disease in people with comorbidities, marked by increased dependency needs
• quality of life during the dying process is often poor because of inadequate treatment of distress, fragmented care, strains on family, support system
• difficult decisions about sue of life-prolonging treatments are commonly necessary.

Question 3

3 trajectories of serious illness

Answer 3

• 1) steady decline, short terminal phase = cancer
• 2) slow decline, periodic crises, sudden death = CHF, COPD
• 3) prolonged dwindling = generalized frailty, dementia

Question 4

what are the three legs of the stool of medicine

Answer 4

• diagnostics
• prognostics
• therapeutics

Question 5

Treatment options at end of life

Answer 5

• Life prolonging care = maximize length of survival even if some compromise other values (Quality of life > quality of life)
• Limited medical care = use of selected medical interventions, often while determining the balance between benefit and burden
• Comfort care = maximize pain and symptom relief, even if life is somewhat foreshortened (Quality of life > quantity of life)

Question 6

Palliative vs hospice

Answer 6

PALLIATIVE MEDICINE
- all stages of disease trajectory
- can be provided along with acute care
- payment source (various)
- locus of care (any location)
- providers (physician/nurse)
HOSPICE
- primarily last six months of life
- usually patient foregoes concurrent acute care
- payment (medicare
- Locus of care (site patient identifies as home
- providers (more inclusive services than PM)

Question 7

Myth and Realities

Answer 7

• Hospice is NOT a place to go to die
• A patient DOES NOT have to sign a DRN in order to enroll in hospice services
• In order to receive hospice services a patient DOES NOT NEED TO transfer his care to the hospice physician
• MANY patients who enroll in hospice services DO NOT starve to death
• On average, patients who transfer to hospice live 29 days longer than similar patients who do not receive hospice support
• One of the benefits of transferring a patient to hospice is knowing that the hospice will pay for all of the patients medications. (meds for terminal diagnosis, but not alternative meds)

Question 8

obstacles to hospice

Answer 8

• limited access
• lack of family support
• LATE REFERRAL
• difficulties in determining prognosis
• -> physician prognosis: 3-5 x longer than actual
• -> better the physician knows the patient; less the accuracy of the prediction

Question 9

Palliative medicine

Answer 9

• specialized medical care for people with serious illnesses. it focuses on providing patients with relief from the symptoms, pain, and stress of a serious illness - whatever the diagnosis
• GOAL is the IMPROVE QUALITY OF LIFE FOR BOTH THE PATIENT AND FAMILY
• Palliative care is PROVIDED BY A TEAM of doctors, nurses and other specialists to provide and EXTRA LAYER OF SUPPORT.
• It is appropriate at ANY AGE AND AT ANY STAGE IN SERIOUS ILLNESS

Question 10

rationale for palliative care

Answer 10

• reach aequate control of pain and other symptoms
• achieve a sense of control
• relieve burden on family members and strengthen relationship
• gain a realistic understanding of the nature of the illness
• understand the pros and cons of available treatment alternatives weighted in context of patients goals and values
• name decision makers in case of loss of decisions capacity
• have financial affairs in order

Question 11

Palliative care services

Answer 11

• ESTABLISHING GOALS OF CARE - essential
• -> communication skills are at the core
• -> advance care planning
• TREATMENT OF SYMPTOMS
• -> pain and non-pain
• PSYCHOSOCIAL SUPPORT/SPIRITUAL CARE

Question 12

hospital-based palliative care programs

Answer 12

TYPES:

• consultation services
• inpatient palliative care unit
• co-management
• -> emergency department, intensive care unit

Question 13

What are the two main barriers to palliative care

Answer 13

• awareness of palliative care services among patients and their families
• tendency of clinicians to equate palliative care with end of life care.

Question 14

physician concerns incorporation of palliative care

Answer 14

• concern that introducing palliative care could interfere with therapy directed at extending life as long as possible
• inadequate patient resources
• issues related to reimbursement
• shortage of palliative care physicians and services