Transcript Introduction to Palliative Medicine

Introduction to Palliative Medicine
and Decision-Making
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A historical perspective
They endeavoured to do good, and to save the lives of
others. But we were not to expect that the physicians could
stop God's judgements, or prevent a distemper eminently
armed from heaven from executing the errand it was sent
about...it is not lessening their character or their skill, to say
they could not cure those that had the tokens upon them, or
those who were mortally infected before the physicians were
sent for, as was frequently the case.
Daniel Dafoe
A Journal of the Plague Year (1722)
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A historical perspective
Nor doe they (physicians) so much feed the
imagination with apprehension of danger, as the
understanding with comfort...In many diseases, that
which is but an accident, but a symptom of the main
disease, is so violent, that the Physician must attend
the cure of that...
John Donne Meditation VII (1624)
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A historical perspective
Billy: Oh yeah. We see stuff like this in our ER all the
time... Guys come in all shot up like this, all
discombobulated and by the time they leave they’re
whistlin’ a tune.
Chicago Hope “The Day of the Rope”
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Why palliative care now?
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Growing number of persons with chronic
illness
Recognition of inadequacies in the care of the
dying
Social factors - medicalization and
institutionalization of experience of dying
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Growth in chronic illness

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Demography: life expectancy increased from
50 to 80 years during 20th century, boomers
Medical Treatment: sequelae of previously
fatal illness, life-extending therapies
17.1 million elderly had some form of
disability in 1990 (7.3 million require
assistance)
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Social factors

Institutional death
 50% of deaths in 1949
 74% of deaths in 1992

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Family and social networks
Physician-assisted suicide
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Sudden death, unexpected
cause
< 10%, MI, accident, etc.
Health Status

Death
Time
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Steady decline, short terminal
phase
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Slow decline, periodic crises,
sudden death
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Inadequacies in the care of the
dying (SUPPORT)

Severe symptoms prior to death:
 20-40% confused
 30-90% short of breath
 40-50% in severe pain

Patients who did not die during the study
also experienced severe symptoms
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Inadequacies in the care of the
dying (SUPPORT)

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55% of persons who preferred to die at home
died in the hospital
Advance directives did not affect treatment or
resource use
Giving doctors more prognostic information
did not affect their treatment of dying
patients
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The current paradigm
Curative Therapy
Palliative Therapy
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Multiple goals of care
In reality:
 Multiple goals apply simultaneously
 Goals may be contradictory
 For a particular patient, some goals take
precedence over others
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A New Paradigm
Curative AND Palliative
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Definition: Palliative Care
“The active total care of patients whose disease
is not responsive to curative treatment.
Control of pain, of other symptoms, and of
psychological, social, and spiritual problems,
is paramount. The goal of palliative care is
achievement of the best quality of life for
patients and their families.” (WHO)
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Dimensions of palliative care

Decision making / autonomy
 advanced directives, preferences, site of care and
death


Symptom management
Overall quality of life
 physical, psychological, and spiritual wellbeing

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Family support in care / grieving
Medical care preceding death
 survival duration, appropriateness, and resource
use
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Case: History
•Elderly male in rehab facility
•Recent lacunar stroke with dense L hemiparesis
•New onset confusion, somnolence
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Case: History

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PMH: HTN, benign positional vertigo,
depression and mild dementia
PSH: none
Meds: Clopidogrel, Aspirin, Meclizine, Surfak
NKDA
Pers: No tobacco or alcohol use
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Case: Physical Exam
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Vital signs: BP 148/88 R12 P75 T97.6 oral
Mental status: somnolent but arousable,
oriented to person, location
Neurologic: L facial droop, LUE held in clasp
knife position with decreased spontaneous
motion, moving legs vigorously, reflexes 2+ R,
3+ L with + Babinski reflex on the left.
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Questions


Should this patient be receiving palliative
care? Why or why not?
How should that consideration affect the
treatment he is receiving?
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Case: Further History
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MRI confirms new stroke in the occipital
region involving part of the cerebellum
Routine labs, CXR, and EKG are nl
Day 5 the patient remains confused, NPO
Neurologist indicates “We need to put in a
feeding tube if he doesn’t get better.”
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Step 1: Preparing for the
discussion

Who should be involved?
“We need to make some decisions about the
care of your father and grandfather. Is
everyone here who could help us think
through what we should do?”
“Let’s meet tomorrow morning at 7AM in the
family conference room.”
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Step 2: Determine what the
patient / family know

What is the family’s understanding of the
patient’s condition?
“Tell me how he has been doing recently. Tell
me how that compares to a year ago, 6 months
ago?”
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Mr. M’s recent history

Family describes decline in his interaction,
recognition, and ability to eat and drink.
“A year ago he used to drive his car over to
Ryan’s steakhouse ‘most every day. Since
then, he’s just been going downhill. He’s not
the same dad I’ve always known and loved.”
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Step 2: Clarify what the
patient / family know

Clarify the family’s understanding of the
disease and its prognosis.
“Unfortunately, Mr. M. has had a disabling
stroke. I don’t expect his body or his mind to
recover significantly at this point.”
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Step 3: Explore what they are
hoping for

Ascertain the family’s sense of what would
best honor his goals and values
“We want to care for him in a way that makes
us confident that after he’s gone we can say he
was treated with dignity and respect.”
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Step 3: Explore what the
patient / family are hoping for

Elicit the family’s understanding of the
patient’s wishes
“How do you think he would feel about being
fed through a tube? Have you or anyone else
in your family ever had any experience with
this kind of care?”
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Step 4: Suggest realistic goals

Provide guidance on the basis of medical data
and clinical expertise
“What is the likely outcome if we do / do not
place a feeding tube?”
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Step 5: Make a plan

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Family believes the patient wishes to avoid
feeding tubes or gastric tubes
Family believes that patient would not want
to experience treatment that creates further
dependence. Patient has made previous
statements that generally support limiting
care under such circumstances.
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Summary of steps
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Identify and convene key participants
Determine and clarify what they know and
what they want to know about the patient’s
condition
Explore expectations, hopes, and fears
Establish goals of care
Use principles of negotiation to focus on
agreement
Make a specific plan
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Conclusion
“ On special occaisons only, in sickness and in
sorrow, or in the presence of some great
catastrophe, do disturbing thoughts arise:
‘Whence are we, and why are we? Of what
scene the actors or spectators?’ and man’s
heart grows cold at the thought that he must
die, and that upon him too, the worms shall
feed sweetly.”
Sir William Osler Science and Immortality (1904)
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References for further
exploration
Buckman R. How to Break Bad News:A Guide for Health Care
Professionals. Baltimore, M.D. The Johns Hopkins Press’ 1992.
EPEC curriculum www.jama-assn.org/ethic/epec
SUPPORT comprehensive bibliography and findings supplement J
American Geriatrics Society May 2000
Annals of Internal Medicine ACP-ASIM Consensus Panel on End of
Life Care reports including “Palliative Care in Patients Lacking
Decision Making Capacity” 18 May 1999
Oxford Textbook of Palliative Medicine. Eds. Doyle, Hanks, and
McDonald. Oxford University Press 1999
Approaching Death: Improving Care at the End of Life.
Washington, DC. Institute of Medicine / National Academy
Press. 1997.
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Hospices serving [the local area]
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