hbm,dying, post
TRANSCRIPT
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8:30-9:10 Final Exam Review9:10-9:20 Break
9:20-10:00 Trauma Survivor Interview10:00-10:10 Break10:10-11:00 Death & Dying
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Death & Dyingor
Is there such a thing as a good death?Sumer Verma M.D.
Director Alzheimer UnitBriarwood Nursing Care and Rehabilitation
Needham MA
Associate Professor Psychiatry , BUSM
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Though shall not kill;
but needst not strive to officiously keep alive.
The Latest Decalogue
Arthur Hugh Clough 1862
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Change in Life Expectancy
CDC/NCHS Vital Statistics System
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Costs of Dying
Dying can be expensive specially when ICU servicesare involved
1:5 deaths involve ICU services
Average terminal ICU hospitalizations
LOS12 day
Cost $ 24,541
Average Non ICU hospitalizations LOS 8.9 days
Cost $ 8,548
Health US 2010
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Deaths-by Age and Cause of
Death
Health United States 2010
CLRD Chronic lower respiratory diseases
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Place of Death 89,97and 07
CDC/NCHS, National Vital Statistics Division
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Palliative or Hospice Care
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Definitions
Curative medicine Care oriented towards seeking a cure for an existent disease
Preventive Care Aims at preventing the appearance of disease
Palliative Care ( L palliare:to cloak) Alleviation of symptoms whether or not there is hope of a cure
Improve quality of life for persons with a life threatening illness
Hospice Care (L hospes:a guest or host) Palliation of a terminally ill (less than 6m to live) patients symptoms
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Palliative Care
1990: WHO definition: the active total care ofpatients whose disease is not responsive to
curative treatment The disease is terminal
An approach that improves the quality of life of
patients and their families facing the problemsassociated with life threatening illness
Not usually applied to chronic disease
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Palliative Care
Palliative care is provided mostly in acute carehospitals
Services are organized around aninterdisciplinary team
A large focus of the team is to involve the familyin treatment decisions
Palliation can be offered without restriction todisease or prognosis
ABHPM can certify physicians in palliative care
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The Hospice Movement
11th century- Crusaders established places fortreating the incurably ill
1967s Cicely Saunders started contemporaryhospice care
1971 Hospice Inc. founded in the USA byFlorence Wald, Dean of the Yale School ofNursingwith more focus on psychological
preparation for death
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We will do all we can to help you die peacefullybut we will also help you to live till you die
Cicely Saunders
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Growth of Hospice in the USA
1995: 1857 programs
Medicare paid$1.9 billion
1998 3200 programs
2003: First childrens facility in SFO
2008 > 1400 palliative care programs
> 4700 hospice programs
1.4 million persons used hospice
Medicare paid $10 billion (80% of costs)
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Hospice Philosophy
To continue an alert pain free life and tomanage other symptoms so that the remaining
days are spent in dignity
What hospice will provide Comfort
Treatment, if it improves quality of life
What hospice will not provide Diagnostic procedures which aim to diagnose or cure
Hastening death or unduly prolong life
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Hospice Utilization
To qualify for hospice a patient should (not must) have alife expectancy of less than six months
A misconception is that patient should have cancer or
AIDS (60% hospice patients have cancer and many ofthe rest have AIDS)
Many if not most patients referred to hospice at thevery end stage
In 2004 average LOS was 57 days
median LOS 22 days
33% of all patients died within 1 week of admission
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Services Offered to Hospice
Care Patients
CDC/NCHS National Home and Hospice Care Study
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Clinical Management of DyingPatients
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ACTION
How Clinicians Think ??
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Concerns of Dying Patients
Adequate pain and symptom management
Avoid inappropriate prolongation of dying
Achieving a sense of control
Relieve the burden on their loved ones
Strengthen relationships with family
Singer et al: Quality end of life care:patients perspectives. JAMA 1999;281: 163-168
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The SUPPORT Study
38% patients spent >10 days in the ICU 46% of DNR orders were written 2 days before
death
Aggressive care was given to 1:10 patients andignored care and comfort orders 40% had moderate to severe pain 50% experienced dyspnea 25% experienced psychiatric symptoms
Lynn et al: Study to Understand Prognoses and Preferences forOutcomes and Risks ofTreatment
Ann Int Med 1997: 126: 97-106
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The Physicians Task
Primum non nocere
Relief of suffering Pain
Uncertainty
Anxiety and depresion Maintaining dignity
Telling the truth
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The Cs of Management
Control
Composure
Communication Continuity
Compassion
Comfort
Adapted from Cassem and Stewart
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Talking about Death
The veil of ignorance and the denial of
death Saying the unthinkable
Does truth telling remove hope
Detached concern?
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Hospice Care Patients -
Symptoms Before Death
CDC/NCHS National Home and Hospice Care Study
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Drugs Prescribed in the Last
Week of Life
CDC/NCHS National Home and Hospice Care Study
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Managing Pain
Use the least invasive route
When possible, use sustained release
medications
Introduce one agent at a time
Allow time to assess effect
Adjust treatment to prevent adverseevents
Allow patient to self administer if possible
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The WHO Step Ladder
Nonopioid with or without adjuvant
Weak opioid with or without non opiod
adjuvant
Strong opioid with or without nonopiod adjuvant
1
2
3
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Undertreatment of Pain
Patient related factors
Under reporting
Difficulty comprehending assessment tools Polypharmacy induced side effects
Physician related factors
Patient does not look like they are in pain
Mistaking ageing for reversible factors
Fear of causing addiction
Lack of education in pain management
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Titrated Sedation
The practice of inducing unconsciousness in aterminally ill person for the remainder of that
persons life usually by means of a continuousinfusion of morphine or benzodiazepines
This is not equated to euthanasia
Extensive experience and studies that show that
these drugs are not fatal as long as the dose isadjusted to prevent respiratory depression
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Killing or Letting die
Does a person have a right to self
determination Euthanasia
Active
Passive Comfort measures only
The slow code
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Kept Alive by a Machine?
A standard living will can state that treatment bewithheld or withdrawn if it:
serves only to prolong the process of my dying
if I should be in an incurable or irreversible mental
or physical condition with noreasonableexpectationof recovery
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Advanced Directives
Do not resuscitate
Do not treat Antibiotics
CPR
Intubation
Hydration
Feeding / NG tube
Comfort measures only Pain control
How much
How aggressive
Hospice care
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Moral and Legal Dilemmas
Years at the end of life or life at the end of years
The slippery slope-- QUALYs
Killing or letting die? Is physician assisted suicide justifiable
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A Good Death
A good death is defined as one that is:
In general accord with the wishes of patientsand families
Reasonably consistent with clinical, cultural andethical standards
Free of avoidable distress and suffering forpatients, families and caregivers
Field and Cassell: Approaching death:Improving Care at the end of Life
Washington DC: National Academy Press 1997:24
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When you were born, you cried
and the world rejoiced.
Live your life in such a manner
so that when you die,
the world cries and you rejoice.
Kabir 1440-1518
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THE NINE COMMANDMENTS
Thou shalt remember that:
1. Old age is not an illness looking to be cured
2. More drugs does not mean better care
3. Suffering is unnecessary at the end of life
4. It is interdisciplinary NOT multidisciplinary
5. You cannot fix everything by yourself
6. Your task is to protect your patients and not yourself
7. Trust but verify evidence based medicine
8. Death is inevitable -- not an option
9. It is faith that heals!
(With sincere apologies to the original author)