Geriatric Palliative Medicine

1. Geriatric Palliative Medicine Adam Herman, MD Assistant Professor Division of Geriatric Medicine and Gerontology Wesley Woods Health Center

2. Palliative Medicine Case Mrs. F. was an 87 year-old widow living in the home of one of her daughters. She required 24-hour supervision because of moderately advanced dementia of the Alzheimer’s type.

3. Palliative Medicine Case • Her daughter, age 65, herself widowed and medically frail because of congestive heart failure, was struggling physically, emotionally, and financially to provide care for her mother. • A rapid decline in Mrs. F’s mental status and increase in agitation precipitated a hospitalization, during which she was diagnosed with breast cancer that had spread to the spine.

4. Palliative Medicine Case After a 3-day stay in the acute hospital, Mrs. F. was transferred to a local nursing home for “terminal care”.

5. Palliative Medicine Case • It took several days for her daughter to convince the nursing home staff and physician (none of whom had cared for Mrs. F. previously) that her mother’s agitation represented pain. • Opioids were prescribed, but caused Mrs. F. to become sedated, nauseated and severely constipated.

6. Palliative Medicine Case • Still lethargic and nauseated after one week in the nursing home, Mrs. F. vomited, aspirated, and went into acute respiratory distress. • The staff called 911, and Mrs. F. was transported back to the hospital where she was intubated and admitted to the ICU.

7. Palliative Medicine Case Upon arrival at the hospital Mrs. F.’s daughter was extremely distressed to see her mother on a respirator, and requested she be removed from it.

8. Palliative Medicine Case • After several hours of discussion, Mrs. F. was placed on a morphine drip and removed from the respirator. • She died 6 hours later.

9. What is Palliative Medicine? CANCER SHARING INFORMATION PATIENT SATISFACTION DELAYED DISCHARGE DEATH and DYING (just like hospice) ANXIETY HOME CARE/ HOUSECALLS ANOREXIA DIFFICULT FAMILIES HIV MORPHINE GIVING UP DEPRESSION BREATHLESSNESS SUBSTANCE ABUSE WITHDRAWAL OF CARE SPIRITUALITY LIABILITY PAIN MANAGEMENT ETHICS FATIGUE DEA PHYSICIAN BURNOUT CURE NAUSEA AND VOMITTING QUALITY OF LIFE ADVANCE DIRECTIVES TUBE FEEDS

10. What is Palliative Medicine? …an approach that improves the quality of life of patients and their families facing the problems associated with life threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. http://www.who.int/cancer/palliative/definition/en/

11. What is Palliative Medicine? • provides relief from pain and other distressing symptoms; • affirms life and regards dying as a normal process; • intends neither to hasten or postpone death; • integrates the psychological and spiritual aspects of patient care; • offers a support system to help patients live as actively as possible until death; • offers a support system to help the family cope during the patients illness and in their own bereavement; • uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated; • will enhance quality of life, and may also positively influence the course of illness; • is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications. http://www.who.int/cancer/palliative/definition/en/

12. Model of Modern Palliative Medicine Life Prolonging Therapy Death Disease Progression Diagnosis of Serious Illness Palliative Care Medicare Hospice Benefit www.capc.org

13. The Role of Hospice/EOL Care • Hospice: insurance sponsored program that cares for people at the end of life • 1974: Connecticut Hospice opens, funded by NCI—primarily serves cancer patient • 1982: Medicare hospice benefit enacted • Hospice: Necessary but not sufficient (only 25% of potential enrollees) • Why?

14. Life Threatening Illness in Young Adults • Often a single disease process (trauma, cancer) • Few or no comorbidities • Tolerate therapy well • Spouse/partner likely to be healthy, and provide care • Fairly rapid (and predictable) decline before death

15. Life Threatening Illness in Older Adults • Difficult to recognize • 80% of deaths occur in those >65 • Illness and death in the older population is different • Comorbidities increase complexity

16. Emergence of Geriatrics • Geriatrics is different • Geriatrics addresses the care of those who have had multiple chronic diseases, often for many decades, and require multiple medications to remain functional and well • All clinicians will be caring for these patients

17. Demographic Changes 2003 Chartbook on Trends in the Health of Americans, http://www.cdc.gov/nchs/data/hus/hus03cht.pdf

18. Demographic Changes 2003 Chartbook on Trends in the Health of Americans, http://www.cdc.gov/nchs/data/hus/hus03cht.pdf

19. The Cure-Care Dichotomy: The Traditional Model D E A T H “Dying” Palliative/ Hospice Care Life Prolonging Care Disease Progression Diagnosis of Serious Illness www.capc.org

20. Defining “Dying” • Is there a clear distinction between two states? • Four different trajectories of illness prior to death among older adults have been identified by clinicians, and supported by data.

21. Trajectories of Dying • Lunney et al. reviewed physician Medicare claims in the year before death. • They divided 7,258 decedents into 4 previously described conceptual categories • Do these groupings classify decedents? Lunney JR, et al. JAGS. 2002;50:1108-1112

22. Trajectories of Dying Acute illness Cancer Alz, CVA, PD, hip fx, incont, PNA, dehydration, syncope CHF, COPD Lunney JR, et al. JAGS. 2002;50:1108-1112

23. Trajectories of Dying Lunney JR, et al. JAGS. 2002;50:1108-1112

24. Opportunities for Improvement: Hospital-Based Care SUPPORT Trial: 4-year study in 5 major teaching hospitals; 9105 patients with life-threatening illness • 47% of MDs knew their patients wanted DNR • 46% were ventilated within 3d of death • 38% of those who died spent ≥ 10d in ICU • 50% of those who died were in moderate-severe pain ≥ half time within 3d of death The SUPPORT Principal Investigators. JAMA. 1995;274:1591-1598

25. Opportunities for Improvement: Long-Term Care • Site of terminal care is projected to change • NH population projected growth from 2.5 to 3.4 million by 2020 • 1 in 2 adults is likely to die in NH in 2020 Brock DB, Foley DJ. Hospice J. 1998;13:49–60. http://www.chcr.brown.edu/dying/FACTSONDYING.HTM

26. Opportunities for Improvement: Long-Term Care Nationally: 41.6% Cancer: 52.8% Terminally ill: 39.3% http://www.chcr.brown.edu/dying/FACTSONDYING.HTM

27. Opportunities for Improvement: Long-Term Care Nationally: 45.4% Terminally ill: 23.4% http://www.chcr.brown.edu/dying/FACTSONDYING.HTM

28. Report Card: Access to Palliative care www.CAPC.org

29. How Georgia Compares… Percentage of mid-size and large hospitals with a palliative care program (50+ beds) Nationally: C grade Georgia: D grade www.CAPC.org

30. Questions? Special thanks to Laurent Adler, MD the original creator of these slides. (updates and edit have been added)