End of Life Care Flashcards
end of life care
o Involves both palliative care and hospice care.
o The terms “palliative care” and “hospice care” are frequently used interchangeably, but they differ.
o Palliative care is not always hospice care.
o Hospice care always involves palliative care.
palliative care
o The goal is symptom relief, improvement of function, and improvement of quality of life.
o Both acute and chronic illnesses may require palliative care.
o The symptoms may be physical, mental, emotional, and/or spiritual.
o Non Hospice Palliative care routinely inform patients and families about hospice and other community based healthcare resources consistent with the patient’s and their families beliefs and values.
hospice care
o The patient has: less than 6 months to live.
o The patient’s goals of care clearly change: from “cure” to “comfort.”
o Treatments and medications are geared to the goal of comfort.
o Not set in stone, patients may leave and return to hospice care during EOL time.
attitudes about dying
o Medical o Societal o Cultural o Individual o Familial
fantasy death
o TO DIE AT HOME. o To die with loved ones at bedside. o To be peaceful. o To be old. o To die quickly and without suffering.
what really happens
o 60% of deaths occur in an acute care setting.
o 20% of deaths occur in a LTC setting.
o 5+% of deaths occur in “other” settings (i.e., accidents, suicides, homicides, other sudden death).
o The remainder of deaths (<20%) occur at home.
o 40+% of people who die in acute and LTC settings die in significant pain – the incidence of pain is greater in LTC.
o 60+% die without spiritual or psychological support.
o <7% of deaths occur in a hospice setting.
o >70% of people who die in acute and LTC settings are alone at the time of death.
o Less than 10% die with hospice support.
hospice eligibility
o Insurance requires a prognosis of < 6 months.
o For Medicare, and some other insurances, recertification can be done at the end of 6 months.
o Patients can sometimes move in and out of hospice care.
-CHF, COPD, Renal failure, cirrhosis/liver failure, dementia, stroke
CHF hospice eligibility
- Class IV failure
- EF <20%
- 2-3 admissions to acute care in one year.
COPD hospice eligibility
- O2 dependent,
- poor response to bronchodilators, tires after walking a few steps, resting PCO2 >50,
- O2 sat on room air <88,
- PO2 < 55 on O2,
- cor pulmonale, wt loss,
- HR >100, 2-3 acute admissions in one year.
Renal failure hospice eligibility
- creatinine >8.0
- off dialysis
cirrhosis/liver failure hospice eligibility
- mostly bed bound,
- albumin <2.5,
- INR >1.5,
- one of the following: encephalopathy, spontaneous bacterial peritonitis, refractory ascites, recurrent variceal bleed, hepatorenal syndrome.
dementia hospice eligibility
- bed bound
- mute (except for occasional vocalization)
- unable to ambulate
- aspiration pneumonia
- progressive wt loss
- and at least one of following occurring in the past year: pyelonephritis, sepsis, pressure ulcers, fever after antibiotics, dysphagia.
stroke hospice eligibility
- poor nutritional status
- albumin <2.5
- recurrent medical problems as with dementia.
hospice eligibility for medicare and most insurance
-DNR is not a requirement – but it is strongly encouraged. It is, however, a requirement of many agencies providing in home hospice
dying trajectories
o Concept of “dying trajectory” introduced by Glaser & Strauss in 1965.
o Refers to the changes in health status over time as the patient nears death.
o Graphically time is shown on the “X” axis and health is shown on the “Y” axis.
predictable trajectory
- Eg: patients with cancer
- Family support
- Symptom control
- Continuity of relationship
- Life closure
- Adaptability to rapid changes
erratic trajectory
- for example, for patients with organ system failure, heart failure, COPD, renal failure
- Preplanning for urgent situations
- Life closure
- Prevention of exacerbations
- Decision making about benefits of low yield treatments
- Support at home
- Prepare family for “sudden death”
long term gradual decline
- Eg patients with dementia and frailty
- Endurance
- Long term home care service and supervision
- Helping carer to find meaning
- Avoiding unnecessary lingering
- Keeping skin intact
- Finding moments of joy and meaning for the patient
- Predictable trajectory
prognosis
o Recent studies indicate 63% of physicians are overly optimistic.
o 17% are overly pessimistic.
o On average, physicians overestimate life expectancy by a factor of 5!
prognosis: delivering the news
o Know about the diagnoses, treatments and medications.
o Know your patient, be familiar with cultural differences, the patient’s family (as the patient defines it).
o Speak in general terms, avoid technical details, go slowly.
o Do not give false hope – but do not take all hope away.
o Leave time for questions.
o Follow-up, schedule another visit within a week.
o Involve the patient’s support system (family, significant others, friends) as the patient desires.
o Refer to ancillary services as needed (SWS, psych, spiritual, etc.).
prognosis: answering how long
o Do not be definitive.
o Admit uncertainty.
o The patient is not a statistic.
o It is always different and depends on a number of factors.
o Give time in hours-to-days, days-to-weeks, weeks-to-months or months-to-years.
prognosis: looking to the future
Follow the GOOD.
- Goals: what are the goals of the patient and the patient’s support system, Involve all stakeholders – patient, family, other clinicians, etc. Major goals first, then specifics, check and recheck understandings, what is valued.
- Options: what are the relevant options, medical and non-medical, risks, benefits, and expected outcomes.
- Opinion: offer your opinion after listening to others. Patients need to know what you think, support your opinions with facts. Validate the beliefs of others.
- Document: List the participants of all discussions, what decisions were made and what was deferred. Current and Advance Directives list what the patient wants now and might want in the future.
- Document: DNR orders need to be specific. (i.e.,” Mr. S states at this time he would like resuscitation attempted. However, if it is believed he would be permanently unable to interact with his environment in a meaningful way, then he would wish comfort measures only.)
- Document – DNR orders: explain the meaning of resuscitation, mechanical vs. chemical, use of paddles and chest compressions, potential effectiveness. Be specific, be sure the patient understands benefits, risks, and percentages.
prognosis: advance planning
- Laws and documents vary from state to state and there is rarely reciprocity.
- Be sensitive to cultural differences.
- Be aware of regulations in your state, institutions, and ethics committees.
- DPA & DPAHC: encourage completion before serious problems arise. Available on line, most doctors offices, all hospitals and NH’s, through attorneys
- Advance Directives/POLST – specific instructions, usually accompany DPAHC.
- Living Wills: less detailed, have been replaced by powers of attorney. Not a legal document in many states. (Living wills mean that all the assets get posted in the newspaper and who gets them.)
- Wills/Living Trusts: not usually important in medical decisions.
communication
o Be gentle, patient, caring.
o LISTEN.
o Keep it simple.
o Repeat important information in different ways.
o Make others feel Heard: Reflect responses to avoid misunderstanding.
