Geriatrics SC051: End Of Life Care For Hospitalised Older Adults

Question 1

“Routine” approach to care for patients at end of life

Answer 1

1. Repeated crisis admissions
2. Patients receive “routine” acute interventions
   - CPR
   - Tube feeding
   - Inotropes
   - Mechanical ventilation
   - IV antibiotics
   —> Poor QoL
   —> Discharged
   —> Re-admitted again
   —> Vicious cycle

Question 2

End-of-life experiences in HK

Answer 2

• COPD / CHF: Longer hospitalisation, Higher rates of death in ICU, ventilation rate, CPR rate (compared to cancer patients)
  —> Cancer patients better access to palliative care + better disease trajectory than COPD / CHF
• Most people die in hospital (compared with other countries: much lower rate)

Access to palliative care in HK:

• No. of deaths per year: ~50,000
• No. of palliative care and hospice beds: 450 (no. in HA: 300) —> accommodate only 10% of dying patients

Question 3

What do patients want at end-of-life?

Answer 3

1. Receive care that gives you comfort but does not necessarily prolong your life (majority)
2. 1/3 would choose to die at home

Attributes rated as important:

1. Free of pain, anxiety, kept clean
2. Feeding self and family are prepared for one’s death: affairs in order
3. Achieve sense of completion about one’s life
4. Be treated as a whole person (maintain dignity, being listened to, family / friends present, not die alone)
5. Have autonomy over treatment decisions at EOL
6. Have a trusting physician, nurse with whom one feels comfortable and can discuss fears

Attributes rated as important by patients but not physicians:

1. Be mentally aware
2. Be at peace with God
3. Not be a burden to family / society
4. Be able to help others
5. Have funeral arrangements plan
6. Feel one’s life is complete

Question 4

Reversible causes of weight loss

Answer 4

1. Chewing difficulties (e.g. poor dentition, dry mouth)
2. Decreased sense of taste, smell
3. Oral ulcers, thrush
4. SE from medications
5. Constipation, nausea
6. Depression, anxiety
7. Pain
8. Poor appetite

Question 5

Key steps in provision of quality EOL care

Answer 5

1. ***Determine prognosis
   - EOL: likely to die within next 12 months
   —> death is imminent
   —> advanced, progressive, incurable conditions (cancer, organ failure)
   —> general frailty and co-existing conditions that mean they are expected to die within 12 months
   —> existing conditions if they are at risk of dying from a sudden acute crisis in their condition
   —> life-threatening acute conditions caused by sudden catastrophic events

• Ask “Surprise” question: would you be surprised if the patient were to die within next year?
  —> if no —> trigger to assess for palliative care needs

2. ***Understand treatment options
3. ***Communication: discuss prognosis + treatment options with patients and families
4. ***Clarify goals of care and needs
5. ***Determine care plan that matches goals of patient / family
6. ***Advance care planning

Question 6

1. Determine prognosis: Disease trajectory

Answer 6

Dementia / Frailty:

• Dementia is a terminal illness
• Prolonged gradual decline
• Onset: deficits in activities of daily living, speech, ambulating
• Time to decline: variable: up to 4-8 years
• Advanced dementia: Median survival 1.3 years
• High incidence of eating problems (dysphagia, refusal to eat), infection (pneumonia, UTI)

Cancer:

• Able to maintain relatively stable and high level of function from onset of disease until very last weeks of life —> Steep drop in function
• Decline usually <2 months

Organ failure (e.g. CHF, COPD, ESRD):

• Unpredictable course with periods of gradual decline punctuated by episodes of acute deterioration followed by some recovery of function (health status decline with each exacerbations)
• Any of exacerbations can lead to death

Question 7

1. Determine prognosis: Functional assessment staging (FAST) for Dementia

Answer 7

7 Stages:

1. No difficulties (normal)
2. Subjective forgetfulness (normal)
3. Decreased job functioning and organisational capacity (early)
4. Difficulty with complex tasks, IADL (mild)
5. Requires supervision with ADL (moderate)
6. Impaired ADL with incontinence (moderately severe)
7. Severe
   - Ability to speak limited to 6 words
   - Ability to speak limited to single word
   - Loss of ambulation
   - Inability to sit
   - Inability to smile
   - Inability to hold head up

Question 8

1. Determine prognosis: ***Gold Standard Framework Prognostic Indicators: General indicators to identify EOL

Answer 8

1. Increasing dependence in most ADLs
2. Multiple co-morbidities
3. General physical decline and increasing need for support
4. Decreasing response to treatments (irreversibility)
5. Choice of no further active treatment
6. Progressive weight loss (>10%) in past 6 months (albumin <25)
7. Repeated unplanned / crisis admissions
8. Specific clinical indicators related to certain conditions

Question 9

2. Understand treatment options

Answer 9

1. Purpose of treatment
   - Prolong life
   - Relieve symptoms
   - Preserve function
2. Risks / Benefits of treatments
3. Likelihood of success
4. Alternatives

Question 10

***Tube feedings

Answer 10

Evidence for advanced dementia:

• NOT shown to prevent recurrent aspiration pneumonia / prolong life for advanced dementia
• NOT reduce rates of aspiration pneumonia
• NOT improve functional status
• NOT improve pressure-ulcer healing
• NOT improve nutritional status
• NOT reduce rates of hospitalisation
• NOT reduce mortality

Potential harms:

1. Incorrect insertion into airways
2. Nasal mucosal ulcers
3. GI bleeding
4. Diarrhoea / Vomiting
5. Sinus + Ear infections
6. Dislodgement, blockage —> Discomfort with reinsertions
7. Agitation —> Restraint use
8. Decreased mobility (∵ kept in bed) —> Functional decline

Question 11

3. Communication: discuss prognosis + treatment options with patients and families

Answer 11

Conversation about feeding at EOL: Informed consent

1. Explain natural disease course = EOL
2. Feeding tube unlikely to alter life expectancy but has many risks + negatively impacts QoL
3. Patient unlikely to suffer from feelings of hunger

Alternatives:

1. Careful hand feeding
   - downside: aspiration risk, time of carer, choking risk

Frame in positive terms:

1. NOT feeding tube or nothing
   - there is choice: feeding tube vs careful hand feeding / feeding for comfort

Question 12

4. Clarify goals of care and needs

Answer 12

1. Assess patients’ ***non-medical goals and values
   - what is most important to your loved one at this time?
   - what would your loved one hope for?
   - what would she be most worried about?
   - what would not be an acceptable quality of life / way of living for her?
2. Present the outcomes
   - what matters most to patients is outcomes rather than treatment themselves —> best / worst outcome, most likely outcome

Question 13

6. Advance care planning

Answer 13

Prepare for possibility of aspiration pneumonia + further deterioration

• Introduce to EOL care program at OAH for symptom management
• Future hospitalisation: option of ***direct admission to geriatric convalescent hospital
• Preferences regarding Antibiotics, IV fluid, Other treatments, DNACPR
• Assess for needs / spiritual / psychosocial support to patient / family: involve interdisciplinary team