Palliative Care and End of Life Issues

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

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

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

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

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

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? • dspencer@hospicebg.org

Palliative Care and End of Life Issues