Palliative Care and End of Life Issues Denise Spencer, MD Palliative Care Center of the Bluegrass January 10, 2007.

Palliative Care and End of Life Issues

Denise Spencer, MDPalliative Care Center of the

BluegrassJanuary 10, 2007

Objectives

Introduce the vocabulary needed to have an end-of-life (EOL) conversation

Discuss dying as a diagnosis Introduce common physician attitudes toward

the terminal/dying patient and family Discuss basic conversational techniques

helpful when having a patient/family conference

Objectives

Introduce the vocabulary needed to have an end-of-life (EOL) conversation

Discuss dying as a diagnosis Introduce common physician attitudes toward

the terminal/dying patient and family Discuss basic conversational techniques

helpful when having a patient/family conference

Advanced Directive

A general term that describes two kinds of legal documents – living wills and medical power of attorney

Enables patients to give instructions on future medical care should they not be able to participate in their own decisions

Living Will

A type of advanced directive in which patients document their preferences for medical treatment/aggressiveness if they are at the end of life and unable to participate in medical decisions

Translation – How aggressive does the patient want to be to delay death?

Medical Power-of-Attorney

AKA Healthcare Surrogate Makes decisions based on the patient’s

values and what they would want in any given situation

A legal power of attorney usually does not cover healthcare decisions; generally covers financial decisions only…but read the fine print

What if there is no HCS named?

Order of Decision-Makers (KRS 311.637)– Court appointed guardian– Durable Power of Attorney with healthcare

surrogate privileges specified or Attorney-in-Fact– Spouse– Consensus of adult children who are “reasonably

available”– Parents– Consensus of nearest living relatives of the same

relation

Do Not Resuscitate (DNR)

A physician’s order in the chart that states that ACLS protocol (shocks, chest compressions, meds) nor mechanical ventilation will be performed in the event of cardiac or respiratory arrest

What will happen?– Death will occur naturally– Patient will be kept comfortable

Palliative Medicine

The subspecialty of Internal Medicine that addresses aggressive symptom management and goals of care in patients with life-limiting illness

Coincides with aggressive, curative medical care

Palliative Care

Team approach to Palliative Medicine that addresses physical, emotional and spiritual suffering; includes physician, nurse, social worker and chaplain

Hospice

As defined by Medicare – patient has a prognosis of 6 months or less– Services are not terminated if the patient lives

longer than six months

As a philosophy – team approach to care that addresses the spiritual, emotional and physical suffering of the dying patient and their family, as defined by the patient

Objectives

Introduce the vocabulary needed to have an end-of-life (EOL) conversation

Discuss dying as a diagnosis Introduce common physician attitudes toward

the terminal/dying patient and family Discuss basic conversational techniques

helpful when having a patient/family conference

Diagnosing Dying

Physicians usually describe prognosis in terms of– Hours to days– Days to weeks– Weeks to months

Hours to days – that’s “easy”

Every possible life-sustaining intervention has been exhausted and the patient continues to decline

Symptoms increase Mental status decreases Not eating, decreased urine output, etc.

Weeks to months – that’s tougher

Doctor’s tend to over estimate life expectancy– Unsure of their prediction– Unsure how the patient will respond to the news

Patients tend to have expectations beyond their doctor’s over estimation

No great data available for guidance

General Predictors of Survival

Patients’ performance status– Ambulation, ADLs, oral intake, etc

Patients’ clinical signs and symptoms– Symptoms at diagnosis, new symptoms

Physicians’ clinical predictions – SUPPORT trial

Recurrent hospital admissions

Why is prediction important?

Patient/family perspective– Planning for future– Unfinished business– Time to explore/validate the diagnosis– Provides a greater sense of control– Generally helps with the death story and therefore

the grieving process– Increased availability to hospice services

Why is prediction important?

Clinical/societal perspective– Promotes the doctor/patient relationship– Patients who have a realistic idea of their

prognosis are less likely to request therapy that most physicians consider futile

Physician’s personal practice Ethical issues Resource justice issues

Objectives

Introduce the vocabulary needed to have an end-of-life (EOL) conversation

Discuss dying as a diagnosis Introduce common physician attitudes toward

the terminal/dying patient and their family Discuss basic conversational techniques helpful

when having a patient/family conference

Physician Attitudes

The Bomb Dropper– “You’ve got X time to live; get your affairs in

order.” “Don’t Ask, Don’t Tell”

– Supportive but doesn’t provide the full picture– “If they wanted to know how sick they were they

would ask me.”– “If I was that sick my doctor would tell me.”

“Kinder, Gentler” Approach

Objectives

Introduce the vocabulary needed to have an end-of-life (EOL) conversation

Discuss dying as a diagnosis Introduce common physician attitudes toward

the terminal/dying patient and family Discuss basic conversational techniques

helpful when having a patient/family conference

The Patient/Family Conference

Gather the family in private if possible Make sure the decision-makers are present Make introductions Develop a format

– What questions do you have?– What is your understanding of the situation?– This is the time to define the patient’s goals if not already

known

Keep it simple and make a PLAN

Breaking the news……with questions

What is your understanding of your illness? How sick do you think you are? Are you getting better over time? What questions can I answer for you? Would you like to know what I think about

your state of health? When can we talk about that?

Patient Scenarios

Previously healthy patient now with a serious diagnosis

Patient with a serious diagnosis now at the end of curative options

Dying patient with a need to address the family/HCS

Elderly patient with multiple medical problems admitted for acute care

Questions…………

…..about this discussion? …..about Palliative Medicine? …..about hospice? …..about Dr. Rudy?

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