Transcript End-of-life care - Palliative care

Abid Iraqi, M.D
Geriatric & Palliative Medicine
Syracuse VA
 The opinions expressed are those of the
presenter and do not necessarily
represent the opinion/position of
Veterans Affairs.
What is End of Life Care
Preaching to choir—
Managing patients toward the end
of their life
Why End of Life Care is important
 The majority of deaths occur in elderly adults
 Terminally ill patients spend most of final months at
home, but most deaths occur in the hospital or
nursing home
 More people are living with chronic illness with
typically declining condition before the end of earthly
journey of life.
 For patient who are at end of life, care in acute hospital
may have little to offer but may induce unnecessary
suffering.
Components of Good end of life
care discussion
 diagnosis ( of terminal illness)
 specific treatments (for illness)
 expected outcome of treatment (of illness)
 expected outcomes without treatment (of illness)
 potential untoward effect of treatment (of illness)
 what to anticipate (in illness) with the passage of time.
 prognosis
 elicit treatment preferences
 assess psychosocial support & spiritual needs
Why These Discussions are
important
It enables healthcare professionals
to recognize their patient’s values
and preferences.
How End of Life Care is
accomplished
Depends on the spectrum of
disease process
As disease progresses from
 Advance care planning/directive
to
 Palliative care
to
 Hospice discussion & referral—
Comfort care
What is meant by
 Advance care planning
 Palliative care
 Hospice care
 Comfort care
Before we proceed, perhaps
we should review what is
approach by default
Default care is
Traditional care
Traditional care
 curative intent
 focus is in why
 focus is to fix why
 full code
What is meant by
 Advance care planning
 Palliative care
 Hospice care
 Comfort care
Advance directive/care planning
 a communication process between a patient
and his/her medical providers, which may
involve family or friends, about the goals and
desired the direction of care at the end of life in
an event when patient loses his/her decision
making capacity,1,2
 1 Seymour J., Almack K, Kennedy S. implementing advance care planning; a
qualitative study of community nurses views and experiences.BMC palliative
care 2010;9:4.
 2. Teno JM. Advance care planning for frail, older persons. In : Morrison RS,
Meier DE, eds. geriatric palliative care. New York: Oxford University press,
2003; 307-313.
What is advance care planning
 living will
 health care proxy
 Code status
A realistic discussion regarding nutrition
and hydration in advance directive is
also useful
Why advance directives are
important
 initiate the discussion for end of life
preference/wishes
 ensure that patients receive care that is
consistent with their preferences
 it may prove improve quality of end-of-life
care by achieving control over their care
when/if they lose decision making capacity
Do Advance directives alone
suffice for end of life care?

NO
It requires
a mechanism/system where
patients’ wishes can be honored
Our job is to clarify focus of care, provide
education and then follow the decision of our
patients- Role of palliative care may come
into place
What is palliative care
Palliative care is a specialized
medical care that grew out of
hospice tradition, and is focused on
comfort and quality of life
irrespective of the aggressiveness &
focus of care regardless of the stage
of illness .
What is Hospice care
Hospice is a philosophy of care
focusing on holistic care of persons
with terminal illness rendering life
expectancy less than six months,
and forgoing curative treatment.
What is comfort care
 Focus is comfort without any aggressive
treatment- depending on facility may be
when death is imminent to years, and
depending on medical providers
( patients still receiving IVF, antibiotics and
lab. work, and other medical providers like
me – same approach as in hospice with no
blood work /antibiotics etc.)
Confusion often arise b/w hospice
& palliative care-
Not the same though
palliative care grew out of
hospice tradition
Differences between Hospice and
Palliative Care
HOSPICE
 Appropriate when one has




a terminal disease
Life expectancy is less than
6 months
Requires Physician
certification
Patient has agreed to stop
active/ curative treatment
Payment: per diem
payment system
PALLIATIVE CARE
 Serious illness regardless
of stage of disease
 Irrespective of life
expectancy/not time
limited
 Does Not require physician
certification
 Can be provided with
active/ curative treatment
 Payment: fee for service
model
Similarities between Hospice and
Palliative Care
HOSPICE
PALLIATIVE CARE
 Focus on symptom
 Addresses goals of care, focus
management, & quality of
life
 Support to patient, family
and caregiver
 Interdisciplinary in nature
 Covered under Medicare,
Medicaid and private
insurance
on symptom management, &
quality of life
 Support to patient, family
and caregiver
 Interdisciplinary in nature
 Covered under Medicare,
Medicaid and private
insurance
Hospice is Palliative
Care but Palliative Care
is not necessarily
Hospice Care
Role of Health care providers
(MD,NP,PA,CNS) in end of life care
 No matter where we work, it is never
too early to help patients begin
discussion of advance directives
including health care proxy, and then
as time goes on assist the patients with
further end of life care discussion.
Case Description
 A 76 year old started having abnormal cognitive
deficits at the stage of mild cognitive impairment
which over the next 8 years progressed to
dementia. Then over the next 3 years worsened to
advanced stage where he became dependent for
all of his IADLs and required supervision for ADLs.
Over the next 2 years dementia further worsened
to terminal stage.
How to proceed
 MCI stage: managed at home with support of his
family, removed fire-arms, completed health care
proxy and financial POA
 Onset of dementia: family initiated support services
and he started exploring assisted living.
 At advanced stage: moved to assisted living , and over
next 9 months to special dementia unit.
 Terminal stage: DNR by surrogate and no feeding
tube.
Palliative care, and ongoing discussion with HCP
regarding burden & benefits of interventions
Conclusion
Palliative care is simply a good
medical practice to ensure patients’
comfort and quality of life and
keeping in view how patients
would like to proceed with their
medical care
Questions?