Lec 5: End of Life Care Flashcards
LO: Palliative care vs Hospice
-Palliative care – specialized medical care for people with serious illness that focuses on providing relief from the pain, symptoms and distress of serious illness
- Hospice - type of care and a philosophy of care that focuses on the palliation of a terminally ill patient’s symptoms (Terminal illness – estimated survival 6 months or less)
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-ALL hospice care is palliative but NOT all palliative care is hospice. BOTH are team-based approaches with focus on improving quality of life including spiritual and psychosocial support
LO: Palliative Care: Unlike hospice, palliative care can be provided________________________?
Talk about Supportive Care
-Unlike hospice, palliative care can be provided at the same time as curative treatments
- Appropriate at any age and at any stage of serious illness
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- Supportive care – extra layer of support
—- Time devoted to intensive family meetings and patient/family counseling
—- Resolves questions and conflicts between families/patients and physicians on achievable goals of care
—- Provides expertise in pain and symptom management
Palliative Care/ End of Life Care/ and Last Hours Care
Palliative Care and Oncology
A Study by Temel et al – NEJM 2010;363:733-42…Talk about it
- 151 patients with newly-diagnosed metastatic NSCLC randomized to standard treatment or standard treatment + PC
- Primary Outcome: QOL
- Secondary outcomes: mood, aggressive treatment at EOL
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The results?
Results in intervention arm (Standard tx + PC)
-Better understanding of the disease, prognosis, and options
-Significantly higher QOL scores (p=0.03)
-Fewer depressive symptoms (p=0.01)
-Less aggressive end of life care (p=0.05)
-Less use of chemotherapy near end of life
-Less hospitalization and intubation
-More and longer use of hospice
-Survival 2.7 months longer (p=0.02)
NOTE: just know that overall standard care + PC in combo is better!! Increase patient’s survival ! PC combo also decrease admission/readmission and cost!
Medicare Hospice Benefit (Passed by Congress in 1982): Criteria for enrollment and certification period?
4 criteria for enrollment
- Eligibility for Medicare Part A (hospital insurance)
- Medicare approved hospice program
- Signed statement by patient choosing hospice care instead of “regular” Medicare
- Certification by attending physician and hospice medical director of terminal illness
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Certification periods
- Initially eligible for two 90-day periods
- Re-certification every 60 days thereafter (Terminally ill certification by attending physician)
Levels of Hospice Care (4 of them)
LO: Why is prognostication important? but why is it so difficult?
- It allows for better informed decision making.
- It helps determine risk and benefits for treatment decisions.
- Patients and families want to know.
- It is necessary for the Medicare Hospice Benefit
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Why is it so difficult? - Lack of training
- We tend to be overly optimistic
- Lower amounts of quality research
- Tools are often meant to determine prognosis for a single disease state
- Predictions tools may lag newer therapies
LO: How good are we in prognostication? Talk about the studies
Our Prognosis → Overestimate!
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Study looked at 326 patients with cancer in 5 Chicago hospices
- 20% accuracy in predicting prognosis
- 63% overestimate, 17% underestimate
- Only 37% would give frank disclosure, even when patient requested survival estimate
- Closer the relationship – more likely to err (error)
- Prognostication – < 1 month, 1-6 months, or > 6 months
- Correct category - 58% accurate
- 85% accurate if prognosis 0-3 days (s/s is apparent when closer to death)
LO: Advanced Cancer (general) / scales?
- 30% of all deaths
- Single biggest predictive factor in cancer is functional status!
- Patients with solid tumors typically lose ~ 70% of their functional ability in the last 3 months of life.
- Karnofsky Scale, ECOG, and Palliative Performance Scale most often used.
Advanced Cancer: Karnofsky Scale
- Normal (100)
- Dead (0)
- 50 – considerable assistance with frequent medical care
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NOTE- just know the general trend on the scale!
100-80: able to preform/ no need for assistant
80-40: unable to work, but able to care for self at home, may need assistant with various things
Under 40: unable to care for self, need institution/ hospital help
Advanced Cancer: Eastern Cooperative Oncology Group (ECOG)
- Normal (0)
- Dead (5)
- 3 – limited self care / bed or chair > 50% of waking hours
Advanced Cancer-KS and ECOG: important
- Karnofsky < 40 or ECOG 3 ➔ median survival 3 months
- How do you spend your time? How much time do you spend in a chair or lying down? If the response is >50% of the time, and is increasing, you can roughly estimate the prognosis at 3 months or less.
- Survival time decreases further with increasing numbers of physical symptoms, especially dyspnea, if secondary to the cancer.
Advanced Cancer: Various situations and estimated survival time
1.) Malignant hypercalcemia: 8 weeks, except newly diagnosed breast cancer or myeloma
2.) Malignant pericardial effusion: 8 weeks
3.) Carcinomatous meningitis: 8-12 weeks
4.) Multiple brain metastases: 1-2 months without radiation; 3-6 months with radiation.
5.) Malignant ascites malignant pleural effusion or malignant bowel obstruction: < 6 months.
6.) A patient with metastatic solid cancer, acute leukemia or high-grade lymphoma, who will not be receiving systemic chemotherapy (for whatever reason) ➔ prognosis < 6 months. Exceptions are patients with metastatic breast or prostate cancer with good performance status, as these cancers may have an indolent course.
Principles of Symptom Management
- Use frequent, standard assessment
- Oral medications when possible, altering the route as needed
- Assess for medication side effects; anticipate and treat as necessary
- Discontinue medications no longer contributing to symptom control
- Address possible reversible contributing causes
Importance of Deprescribing?
N/V: Suspected Cause, Mechanism, Antiemetic (only know the 3 that are starred)
Anticholinergic Effects : peripheral vs central
