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Diagnosing Dying

My Proposition. There is often an unspoken understanding that a person is dying, but this tacit knowledge doesn't result in appropriate action. Resources are inappropriately directed, resulting in suboptimal care of patient, family, other staff members and ourselves. . Nicholas Christakis Death Foretold: Prophesy and prognosis in medical care University of Chicago Press 1999 p178.

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Diagnosing Dying

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    1. Diagnosing Dying David Brumley PCV 2009

    2. My Proposition There is often an unspoken understanding that a person is dying, but this tacit knowledge doesn’t result in appropriate action. Resources are inappropriately directed, resulting in suboptimal care of patient, family, other staff members and ourselves.

    3. Nicholas Christakis Death Foretold: Prophesy and prognosis in medical care University of Chicago Press 1999 p178 “the ritualisation of optimism, although useful in many respects, can also have harmful effects……..At its starkest, too much optimism near the end of life may mean patients never see the end coming, never prepare for it, and fight vainly against it.”

    4. Why is Dying not Overtly Acknowledged by Doctors and Nurses? Our behavior might reflect a death denial in general society We might have an individual fear of death of a kind which impacts on our behavior We might believe that the death of a patient is a failure on our part, thus making it difficult to acknowledge We might not know what to do when a patient is dying

    5. A Culture of Death Denial in Australia? Death denial from Sigmund Freud Denial has many meanings, is often adaptive But probably yes…

    6. BWV [2003] VSC 173 (29 May 2003) (Gardner re BWV) in Victoria 68 yo with Fronto-temporal dementia No cognitive capacity 3 years No apparent perception of any sensory input Total nursing dependency; hoist PEG

    7. BWV Husband and family all in accord Request cessation of PEG feeds GP unwilling: may be illegal Husband approached Public Advocate, Julian Gardner Law requires clarification PA applies to VCAT for Guardianship

    8. Woody Allen “I’m not afraid of dying. I just don’t want to be there when it happens.”

    9. A Culture of Death Denial in Australia? The West Australian 1970 “With some exceptions - some individual, some ethnic - our society is steadily moving down a path that is taking us further and further away from involvement with death.”

    10. Denial of Death and Grief Ruth Park: Fishing in the Styx 1993 “Our culture knows little about meeting grief head-on. It has come to be our most impregnable tower of Babel, the very symbol of non-communication. We stand about in tears, wishing we could assuage the pain of persons dumbfounded by woe, but mostly we don’t know what to say…”

    11. Less Involvement With Death Pat Jalland: “Changing Ways of Death in 20th Century Australia” UNSW Press 2006 Demographic change Religion and ritual The Great War Medicine and cure

    12. Demographic Change

    13. Religions in Australia 1996 Census: http://www.adherents.com/loc/loc_australia.html Christian 70% Atheist/Agnostic 16% Unknown/Not stated 10% Islam 1% Buddhist 1%

    14. First World War? Catalyst for change in Australian culture for dying and grieving Mass slaughter - Two out of three uniformed Australians were killed or wounded Total of 60,000 dead Every second Australian family was bereaved

    15. First World War? The deaths of heroes came at a price for grieving families, since overt expression of individual sorrow was seen to denigrate the national cause.

    16. Medicine: With Cures comes Shame. – Death as Failure Medicalisation of death Doctors could finally cure This becomes paradigmatic Those who could not be cured were then seen as failures for medicine, as an embarrassment.

    17. Not Knowing What to Do Abraham Verghese My Own Country NY Vintage Books 1995 “Give me a patient with massive GI bleeding or VF and I am a model of efficiency and purpose. Put me at a deathbed, a slow dying, and purpose is what I lack. I, who till then have been supportive, involved, can find myself mute, making my visits briefer, putting on an aura of great enterprise - false enterprise….”

    18. Solutions Change in Us? Undergraduate education Change in Models of Care? Dying elsewhere! Pathways of care

    19. Undergraduate Education Delese Wear Academic Medicine 77(4);2002:271-277 Students are worried and uncertain “I didn’t know any better..” “I stood there frozen…” “I felt stumped…” “I felt so completely helpless…”

    20. Undergraduate Education Delese Wear Academic Medicine 77(4);2002:271-277 “The best learning grows out of direct experiences with patients and families, so that students develop a sense of intimacy and manageable personal responsibility for suffering people.”

    21. Maybe we should go Home! http://www.arc.gov.au/news/media/media_16Jan03.htm Pat Jalland ”…in the 1980s, a cultural shift slowly developed, as some people began to express concerns about dying alone in a sterile institution, having their deaths prolonged by medicine, and about dying without dignity."

    22. Where do we die? Patients of Victorian Palliative Care Services 1994-1995 Department of Human Services Palliative Care in Victoria: The Way Forward October 1996

    23. Where do we want to die? Ashby M, Wakefield M Attitudes to some aspects of death and dying….. Palliative Medicine 1993:7:273-82

    24. In Hospitals: Care Pathways? Perhaps we need a simple tool - as simple as a tickchart - to check that we’ve done all the things we need to do.

    25. Is the Patient Dying? No cookbook for every diagnosis, but.. Increasing weakness Bedbound Delirium Not taking adequate fluids or oral medication

    26. Dying with Heart Failure? Previous admissions with worsening heart failure No identifiable reversible precipitant Receiving optimum tolerated conventional drugs Deteriorating renal function Failure to respond within two or three days to appropriate changes in diuretic or vasodilator drugs.

    27. Liverpool Care Pathway John Ellershaw Initial Assessment and Care Goals Comfort measures Psychological insight Religious/Spiritual Support Communication Summary

    28. Liverpool Care Pathway John Ellershaw Comfort Measures Current medications assessed and non-essentials discontinued PRN subcut. Medication for comfort Treatment for pain, nausea, respiratory secretions Discontinue inappropriate interventions

    29. Liverpool Care Pathway John Ellershaw Psychological Insight Ability to communicate assessed Insight into condition assessed

    30. Liverpool Care Pathway John Ellershaw Religious/Spiritual Support Assessed

    31. Liverpool Care Pathway John Ellershaw Communication Identify how family/other will be informed of patient’s impending death Family provided with Hospice information GP practice made aware

    32. Liverpool Care Pathway John Ellershaw Summary Plan of care explained and discussed with patient and family Family express understanding of plan of care

    33. Liverpool Care Pathway John Ellershaw If these 11 simple steps were followed, the care of the dying in hospital would be improved, at no cost in time and substantial savings in costs.

    34. Woody Allen Again… “Eighty percent of success is showing up.”

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