End of Life Care: An Overview

1. End of Life Care: An Overview

2. Objectives • Address issues surrounding end-of-life care and vulnerable older adults - definition of palliative care - logistics of end-of life-care - surrogate decision making and advance directives - symptom management • ACOVE indicators and EOL care

3. WHAT IS PALLIATIVE CARE? • Interdisciplinary • Goal : • to prevent and alleviate suffering • assist towards the best possible quality of life • optimize function • assist with decision making for patients with serious illness and their families. • Can be the main focus of care or offered concurrently with all other life - prolonging medical treatment.

4. END-OF-LIFE DEMOGRAPHICS • The majority of deaths occur in elderly adults • Very ill patients may spend much of their final time at home, but… • Hospitals or nursing homes are actual location of most deaths • There is regional/ geographic variability in location of deaths (home vs. institution) Adapted from Geriatrics Review Syllabus, Sixth Edition

5. END-OF-LIFE (EOL) IN THE U.S. • For elderly, death is typically slow and associated with chronic disease • Patients experience increased dependency in their care needs • EOL care can be complicated by family stress, poor symptom control, and discontinuity of care • In this age of technology, commonly decisions need to be made about the use of these agents Adapted from Geriatrics Review Syllabus, Sixth Edition

6. SUDDEN DEATH, UNEXPECTED CAUSE • < 10%, MI, accident, etc. HealthStatus Death Time

7. Steady DeclineShort “Terminal Phase”

8. SLOW DECLINEPeriodic Crises, Sudden Death

9. Curative / Life Prolonging Presentation Death Sx Control / Palliative Care Adapted from Institute of Medicine Historical trajectories of care pathways

10. Consider an alternative trajectory… • Inclusion of palliative concepts from time of diagnosis • This piece of the care plan may become more prominent as curative therapies are less available • More gradual transitions at the end of life

11. Curative / Remissive Therapy Death Presentation Hospice Palliative Care Adapted from EPEC curriculum, 1999

12. WHAT IS “HOSPICE”? • Location • Place for the care of dying patients • Group • Organization that provides care for the dying patient • Approach to care • Philosophy of care for the dying patient • A Medicare benefit Adapted from Geriatrics Review Syllabus, Sixth Edition

13. THE HOSPICE MEDICARE BENEFIT • For beneficiaries with an expected prognosis of 6 months or less • Exchange curative treatments for symptomatic/ palliative treatments • Can be revoked at any time • Reimbursed per diem for one of four levels of care • Can be utilized in the home, nursing home, inpatient hospice units See referenced reading, AAHPM Bulletin

14. THE HOSPICE MEDICARE BENEFIT • Covered Services • physician services, nursing care • medical equipment and supplies • medications related to the terminal illness designated • short-term inpatient care (symptom management & respite) • PT or OT based on the goals • bereavement services • home-health aide services

15. OBSTACLES • Limited access, i.e. rural areas • Logistical support • Late referral – median duration time spent with hospice is only 21 days (Hospice Association of America 2006) • Difficulties in determining prognosis

16. PROGNOSIS • More straightforward for cancer diagnosis • Often unpredictable for chronic disease COPD Alzheimer’s Disease Heart disease Failure to Thrive/ Debility

17. PROGNOSIS • In general: Patient’s condition is life limiting, and pt/ family are aware Pt/ family have elected relief of sx treatment goals rather than curative goals Pt has either documented clinical progression of disease or documented recent impaired nutritional status related to the terminal process

18. Karnofsky Scale

19. DELIVERING BAD NEWS • Prepare • Plan an agenda • Ensure availability of all medical facts • Pick an appropriate setting • Minimize interruptions • What does the patient understand? What does the patient want to know? • Deliver the news • Be straightforward, avoiding medical jargon • Provide a “warning shot” • Allow time for discussion • Create a plan and organize for follow-up

20. DECISION MAKING • Autonomous choices are voluntary, adequately informed and based on reasoning • Does the patient have the ability to choose? • Does the patient understand pertinent information? • Does the patient appreciate the clinical situation/ choices/ consequences? • Can the patient reason through choices?

21. The patient identifies the goal(s). The plan follows the goal.

22. SURROGATE DECISION MAKING • May be required with both younger and older adults • Specific surrogate may be identified via a DPOA (durable power of attorney) for health care • Goal of surrogate is to advocate for patient based on what they know of patient’s wishes - based on prior discussions, advance directives/ living wills

23. SOME DEFINITIONS • Durable Power of Attorney for Health Care • Appointing someone to make medical decisions for you if you cannot make them yourself • Does not require presence of AD or living will • Living Will • Description of wishes about life sustaining medical treatments if one is terminally ill • Advance directives • Instructions / guidance for for health care should one become incapacitated • Can name an “agent” to make decisions for them • Wishes stated must be honored by surrogate unless court orders otherwise • Can be revoked at any time Adapted from University of New Mexico SoM

24. DECISION MAKING • If a patient cannot make their medical decision and has not identified a surrogate decision maker, does not have an advance directive, or has not made their wishes known, a surrogate may have to be identified. • Some states have an automatic order of priority for identifying surrogates • Kansas and Missouri have no such statues available

25. OTHER PALLIATIVE CARE ISSUES • Symptom management • Cross-cultural issues • Spiritual concerns • Psychosocial issues See recommended readings for further information

26. SYMPTOM MANAGEMENT • Multiple symptoms of concern near the end of life - Pain - Dyspnea - Constipation - Nausea - Anxiety - Delirium - Fatigue - Anorexia

27. PAIN • Treatment based on assessment - severity - nociceptive vs. neuropathic - step-wise approach • Potential modalities - Non-opioid acetominophen NSAIDs/ COX-2 –I - Opioid - Adjunctive Anti-convulsants Steroids TCAs

29. And now a little about opioids… • Bind to one or more of the opiate receptors (mu, kappa, delta) • Mu receptor is 7 transmembrance G protein coupled receptor - binding stabilizes the membrane so neuron doesn’t fire • Where are the mu receptors? - periphery, dorsal root ganglia of spinal cord, periaqueductal grey of brainstem, midbrain, gut

30. Opioids • “weak” opioids - codeine - hydrocodone - oxycodone • “strong” opioids - hydromorphone - fentanyl - morphine

31. Opioids • Distribution • Hydrophilic * morphine, oxycodone, hydromorphone • Lipophilic * fentanyl, methadone

32. Opioids • IV- morphine, hydromorphone, fentanyl • PO- morphine (LA & SA), oxycodone (LA & SA), hydromorphone, methadone, fentanyl, hydrocodone • Transdermal- fentanyl • Initial decisions based on - route of administration - need for continuous vs. intermittent dosing - severity of pain LA= long acting SA= short acting

33. Opioids-Pharmacology • All water soluble opioids behave similarly: • Cmax is 60-90 minutes after PO dose 30 minutes after SQ or IM 6-10 minutes after IV dose • All are conjugated in liver and 90% excreted via the kidney • With normal renal fx, all have ½ life of 3-4 hours, reach steady state in 4-5 ½ lives

34. Special Notes • Morphine - low protein binding - dialyzes off - active metabolite is morphine 6- glucuronide (10%) * accumulates in renal failure and causes neuroexcitation * prolonged CNS effects

35. Special Notes • Fentanyl - little or no active metabolites - Not dialyzable - Elderly more sensitive to effects - Unclear how TD route is affected by low subcutaneous fat • Hydromorphone - Generally considered to have inactive metabolites - Drug of choice with renal failure

36. Special Notes • Methadone • binds mu and blocks NMDA receptors • highly protein bound • highly variable and prolonged half life • Phase I metabolism and may prolong the QT interval • caution when changing from another opioid to methadone

37. Potential opioid side effects • Nausea • CNS depression/ sedation • Pruritis • Constipation • Delirium • Endocrine dysfunction with long term use

38. DYSPNEA • Subjective symptom • Pathophysiology can reflect disorder in regulation or act of breathing • Treatment directed at underlying cause - Most common reversible causes bronchospasm, hypoxia, anemia - Both non-pharmacologic and non-pharmacologic treatments can be helpful - Opioids used for sx relief when more directed therapy doesn’t reverse the dypsnea

39. NAUSEA • Potentially debilitating symptoms near the end of life • Treatment based on source - Brain chemoreceptor trigger zone, cerebral cortex, vestibular apparatus - GI tract obstruction, motility, mucosal irritation

40. www,aafp.org, Sept.1, 2001, Vol.64, No.5

41. DELIRIUM • Common near the end of life - geriatric patients with multiple risk factors for development • Large number of cases can be reversible • Control of delirium may be important for both patient and family - pharmacologic and non-pharmacologic means

42. ACOVE Indicators • Assessing Care of Vulnerable Elders • Comprehensive set of quality assessment tools for ill older adults - Covering domains of prevention, diagnosis, treatment, and follow up • Designed to evaluate health care at system level rather than individual level

43. DECISION MAKING (ACOVE) • If a vulnerable older adult is admitted directly to the intensive care unit (from the outpatient setting or emergency department) and survives 48 hours, THEN within 48 hours of admission, the medical record should document consideration of the patient’s preferences for care or that these could not be elicited or are unknown

44. DECISION MAKING (ACOVE) • ACOVE indicator for quality care of the older adult: • If a vulnerable older adult with dementia, coma, or altered mental status is admitted to the hospital, THEN within 48 hours of admission, the medical record should contain an advance directive indicating the patient’s surrogate decision maker • Document a discussion about who would be surrogate decision maker or a search for a surrogate, or • Indicate that there is no identified surrogate

45. DECISION MAKING (ACOVE) • If a vulnerable older adult carries a diagnosis of severe dementia, is admitted to the hospital, and survives 48 hours, THEN within 48 hours of admission, the medical record should document consideration of the patient’s previous preferences for care or that these could not be elicited or are unknown

46. DECISION MAKING (ACOVE) • All vulnerable older adults should have in their outpatient charts 1) An advance directive indicating the patient’s surrogate decision maker, or 2) Documentation of a discussion about who would be a surrogate decision maker or a search for a surrogate, or 3) Indication that there is no identified surrogate

47. CASE 1 (1 of 3) • A 79-year-old man with a history of prostate cancer has had worsening back pain for 3 weeks. He recalls no recent accident or injury. • The pain limits the patient’s ability to dress and bathe himself. He cannot get comfortable in bed and has been sleeping in a reclining chair for the past few nights. He took acetaminophen with codeine last night with no relief. • Physical examination is normal except for tenderness on palpation over the lower spine. • Bone scan demonstrates metastatic disease in the lumbar spine and pelvis.

48. CASE 1 (2 of 3) • Which of the following is the most appropriate initial management strategy for this patient’s pain? • (A) Immediate-release oxycodone • (B) Sustained-release oxycodone • (C) Propoxyphene • (D) Transdermal fentanyl • (E) Acetaminophen with codeine

49. CASE 1 (3 of 3) • Which of the following is the most appropriate initial management strategy for this patient’s pain? • (A) Immediate-release oxycodone • (B) Sustained-release oxycodone • (C) Propoxyphene • (D) Transdermal fentanyl • (E) Acetaminophen with codeine

50. CASE 2 (1 of 3) • For the third time in 6 months, an 84-year-old man with advanced dementia is admitted to the hospital for aspiration pneumonia. • He has lost 9.5 kg (20 lb) over the past 10 months and has a sacral pressure ulcer. He is nonverbal, unable to ambulate, and dependent for all ADLs.His wife cares for him at home. He does not want to go to a nursing home. • A swallow study indicates that all food consistencies are unsafe. The hospitalist suggests tube feeding. The advanced care plan states that the patient’s wife is his agent and that he does not want extraordinary measures used to extend his life, including artificial nutrition.