2Altenheim Nursing Home Palliative Care Changing your practice, yourself, and the system one patient at a timeWilliam D Smucker MDAltenheim Nursing HomeStrongsville, OH
3Compare and ContrastWhen people describe nursing homes and nursing home care, they use words like…..When people describe hospice care, they use words like……
4GoalsIdentify nursing home residents who would benefit from a Palliative Care PlanCommunicate prognostic pathways to caregivers and familyDevelop practical approaches to managing symptomsIntegrate Palliative Care into Your Nursing Home Practice – BillSmucker
5Bill’s Agenda Good palliative care is your responsibility Hospice is not the panacea in LTCThink of patients and families first, enrollment criteria second
6National Consensus Project ‘The goal of palliative care is to prevent and relieve suffering and to support the best possible quality of life for patients and their families, regardless of the stage of the disease or the need for other therapies’Persons living with progressive chronic conditions(e.g., frailty, advanced heart, lung, renal or liver disease, dementia, and neurodegenerative disorders)
8Palliative Care = Ethical Practice “Competence is the first ethical duty of physicians-the goals of medicine cannot be served unless physicians posses and exercise at least basic knowledge and skill.”“The ability to manage pain is an ethical duty”BeneficenceProviding symptom control as well as psychosocial and spiritual supportUNIPAC 6
9Who Needs a Palliative Care Plan? “…good end of life care cannot be dependent upon the ability to predict imminent demise or 6-month mortality.”AMDA Toolkit: Palliative Care in the Long-Term Care Setting
10Site of Death Home Long Term Care Hospitals 1989 1997 17.3% 24.1% 18.6%Hospitals64.1%51.8%Nearly one third of nursing home residents die within 12 months of admission
11Jacob Dimant MD, CMD Caring for the Ages, November 2004 Palliative Care“My own notion is that palliative care is aconcept of care that should be given to allnursing home residents, regardless of theirstatus as ‘terminally ill’ or not,”“All residents need alleviation of symptoms,pain management, psychosocial intervention,and spiritual care…”Jacob Dimant MD, CMD Caring for the Ages, November 2004
12Symptoms of Advanced Chronic Illness in Community Elders COPDCHFCancerSymptomDyspnea65%18%19%Pain28%20%33%Anxiety32%2%Depressed feelings17%6%9%Anorexia11%7%14%Walke LM Arch Intern Med 2004;164:
13Symptoms in Dying LTC Patients Hall P, Schroder C, Weaver L. The last 48 hours of life in long-term care: A focused chart audit. J Am Geriatr Soc 2002; 50:A study done in the late 1990’s included 100 dying patients in various Canadian long term care centers.The results of the study showed that:60% experience shortness of breath50% painagitation is often present– especially in patients with cognitive impairment – can be an underlying symptom for other problems29% experience deliriumThis study shows the level of need for variable efforts for successful intervention.Pain management has improved over last 5-10 years so that nearly all dying patients are on some type of pain regimen – buteffectiveness is not always optimalmany are still under-treated for painover-treatment of pain is equally detrimental to quality of life during last daysHall P, et al. JAGS 50:3;501 Mar 2002
14Dying LTC Patients’ Treatments DyspneaPainNoisy Breathing23% No Tx1% No Tx39% No Tx64% Oxygen72% Opioids(mostly PRN)27% Scopolamine27% Opioids37% ASA, NSAIDs23% suctioningHall P, et al. JAGS 50:3;501 Mar 2002
15Hospice is not the Palliative Panacea ‘You have to know what to do until the cavalry arrives’Typical hospice census ≤ 10%
16Palliative Care and Hospice ‘Palliative care refers to whole-person care for patients whose diseases are not responsive to curative treatment.’‘Hospice refers to a program that provides coordinated comprehensive palliative care for terminally ill patients and their families…’American Academy of Hospice and Palliative Medicine UNIPAC One
17Prognostic Pathways“The key to caring well for people who will die in the (relatively) near future is to understand how they may die and then plan appropriately”Murray SA et al Illness trajectories and palliative care. Clinical Review. Br Med J 2005;330:Murray SA Br Med J 2005;330:
18Prognosis LTC median survival 2.75 years 43% admitted with dementia survive 2 yearsSystolic HF 1 year mortality13% Class III, % Class IVUnintentional weight loss, recurrent pneumonia, non-healing or extensive pressure ulcers, increasing functional decline, are key prognostic signs
20Symptom ControlAs sickness progresses toward death, measures to minimize suffering should be intensified. Dying patients require palliative care of an intensity that rivals even that of curative efforts…Eric Cassels 1989 NEJM
21Common End of Life Symptoms DyspneaDry mouthNausea, vomitingConstipationAnorexia & Weight lossNon-healing woundsFeverDelirium, restlessnessAnxietySedationFatigueDepressionThere is an enormous amount of symptom burden at end of life.As patients with chronic disease approach end of life, the burden of symptoms is very much like that of cancer patients.Read through list of symptoms on slide and share from your own experience which of these are mostoften seen together.
22Assessment and Treatment Consider benefits and burdens of workup and treatment/intervention in light of:Current stage of illness; prognosisPatient’s preferences and goals of careConsider non-pharmacological interventionsOften as important as medsOften work synergisticallyRepeat assessment process frequentlyReassess efficacy, appropriatenessDetermine whether or not there is more benefit than burden for evaluation as well as the level of evaluation.Discuss realistic treatment plans with patient, family and staffi.e., rehab therapy, use of antibiotics, transfusionsunderstand that patient goals and focus on curative and comfort care will change during the progress of the disease.Consider non-pharmaceutical interventions to enhance the quality of care.Repeat the full assessment process frequently and reassessefficacy of current treatmentsneed for adjustments in interventionsneed to discontinue or change combinations of interventions – pharmaceutical and non-pharmaceutical
23Maximize Chances of Success Try to anticipate & prevent symptomsMaximize patient and family controlIf you educate pts/families before symptoms occur, they will be grateful (e.g., noisy breathing, Cheyne-Stokes)Involve team members and community resourcesIt is of great importance that patients and families continue to exert maximum control in decision makingand goal and care planning.Educating patients and families is empowering.They know what to expect and how to help.They understand that symptoms are normal in the process of dying.Anticipation and discussion of fears allays panic and anxiety.Physicians and staff should try to anticipate symptoms and prevent them from occurring whenever possible.
24Mrs. Flowers92 yo woman with severe dementia, vision and hearing loss, severe peripheral arterial disease, diabetes and hypertensionUnavoidable weight loss 108 to 83 lbs over 12 months due to dementia, dysphagia, anorexiaIncreasing confusion and weaknessLess oral intake past few daysLast bowel movement 3 days agoReview the case on the next few slides and direct learners to begin to create a palliative care plan
25Mrs. Flowers Prior evaluations Goals of care Multidisciplinary team has evaluated her for reversible causes of decline and interventions have not been successfulGoals of careFamily understands her end stage condition and wants team to avoid intensive evaluations or hospital transfer. ‘Just keep her comfortable.’A key element in creating a palliative care plan is know about prior evaluations and treatments as well as the goals of care for the patient.
26Mrs. Flowers Appears short of breath at rest Noisy breathing, coarse breath sounds, dry mucus membranesTemp of 100.5, RR 30Sacral wound has thin slough, 1-2 cm undermining, foul odorOn pressure-relieving mattressGetting HTN & DM medsMorphine (20 mg/ml) 15 mg Q 4 hrs ATCNow Mrs Flowers has an acute change in her condition, with signs and symptoms that may benefit from a palliative care plan.
27How Would You Proceed? History? Assessment? Labs? Interventions? Discuss working diagnoses, problem listsAsk audience to participate and answer the questions belowGiven Mrs Flowers history, goals of care signs and symptoms, what would you do?Get more history?Do a physical exam? Order some labs?What interventions seem appropriate?What are your working diagnoses or your problem list?
28Problem List Dyspnea End stage state? Noisy breathing Infection? Dry mouthMalodorous pressure ulcerDeliriumFeverMalnutritionEnd stage state?Infection?Pain?Adverse medication effect?Nausea?Constipation
29Dyspnea 60% of patients dying in LTC have dyspnea Subjective sensation of uncomfortable breathingNot linked to measurements of blood gases, respiratory rate or oxygen saturationMay limit activity and quality of lifeStrongly associated with anxietyPatient’s complaint may be ‘nerves, anxious’Each may cause or exacerbate the otherVery frightening to patient and caregiversDyspnea is the most common symptom in cancer patients and patients with chronic disease.Many members of the care providing staff as well as family members are not comfortable with this symptom.
30Causes of Dyspnea End stage state Pneumonia Bronchospasm COPD Mucus plugsPulmonary embolusPleural effusionDeconditioningCHFCardiac ischemiaCardiac arrhythmiaTumor invasionDamage from radiation/chemoSevere anemiaRead through slide –Consider history and physical and need for more extensive evaluation to learn the underlying cause(s)of air hunger.
31Dyspnea Assessment and Management Approach to symptom relief may benefit from review of PMH, meds, limited evaluationPhysical exam, CXRTreatment should be directed at specific pathology when appropriate (eg. CHF, COPD)Base assessment intensity on benefits vs burdensUse appropriate numerical or descriptive scales to monitor dyspnea and chart symptom control
32Non-Pharmacologic Treatments Find what works for this person:Energy conservation, positioning, fan, open window, relaxation techniquesEmotional supportTrial of oxygen (4-6 liters/min)Avoid suctioning in most patientsNon pharmacological approaches for symptom reduction should be tried by the patient, family members and nursing personnelEmotional support can alleviate the severity of symptomsOxygen may relieve dyspnea unrelated to the impact on pulse oximetry, so a trial of high flow oxygen is warranted. If effective, it should be continuedAvoid suctioning if at all possible as it is quite uncomfortable and distressing to the patient.
33Opioids: Dyspnea Tx of Choice Morphine is most studied & versatilePO, SL, SC, IV, (not via aerosol)Generally, doses and intervals are the same as for frail elders with painQ4H ATC with breakthrough Q30 min PRNIf already on opioids, increase dose 25-50%For intermittent dyspnea, PRN use OKTips for Getting to Yes for opiatesAdding to optimum therapy, trial of small dosesOpioids are the treatment of choice for dyspnea.Opioids are thought to improve dyspnea via several possible mechanisms; decreasing the activity of mechanoreceptors in the lungs and respiratory muscles, diminishing ventilatory responses to hypoxia or hypercapnia, dilating pulmonary vessels and decreasing anxiety. (Fabbro JPall Med).Morphine is the most widely studied opioid for treatment of dyspnea, but oxycodone, hydromorphone and fentanyl have also been used.Morphine should not be given via aerosol, but all other traditional routes of administration are effective.In contrast, one report of aerosol fentanyl (25 mcg in 2/5 cc normal saline Q 2-3 hours) showed good efficacy . (Coyne P. J Pain Symp Manage 2002)Dosing of opioid for dyspnea should follow the same general principles used when prescribing for pain described above. If a patient is already receiving an opiate for pain, it is customary to increase the total daily dose by 25-50%.To get to Yes for opiates, it can help to identify the symptom, shortness of breath, review that optimum therapy currently prescribed, but not controlling symptoms, next step is to add another medicine that is very well studied and effective – woiudl they be willing to see if it works for them? Best meds at this stage are opiates, like morphine.
34Initial Opioid Dose: Frail Elderly Morphine 2 mg PO/SL Q4H0.1cc morphine 20mg/cc (Roxanol)Morphine 0.5mg SC/IM/IV Q4HOxycodone 2mg PO/SL0.1cc oxycodone 20mg/cc (Oxyfast)Hydromorphone 0.5mg PO/SL Q4H0.5cc hydromorphone 1mg/cc (Dilaudid)Frail elderly opioif naïve patients may need only small dose of medication for relief of symptoms.Physicians may titrate the dose upward to achieve the desired control of symptoms.Equivalent to 2mg Morphine½ Percocet 5mg½ Darvocet N 50
35Dyspnea: Medication Options Benzodiazepines for anxietyLorazepam PO/SL/IV mg Q4HBronchodilators for wheezingChlorpromazine (Thorazine)10-25 mg Q4-6HSteroids, diuretics, anticoagulation, erythropoietin in appropriate settingsUse adjunctive medications with opioids to relieve shortness of breath ifpatient can toleratedrug interactions are safeHelpful adjunctive therapies may include:bronchodilatorslorazepam to reduce anxiety that can be an underlying cause of shortness of breathsteroids for COPD and heart failurefluid reduction if causing shortness of breathLorazepam is versatile for its routes of administration . It can be given sublingual by crushing a tablet dissolving it in water of a small volume (1to 2 cc). Then dribbling one or 2 cc into the buccal space between cheek and gum. It can also be given rectally by using the IV solution squirted into the rectum.
36Noisy BreathingWhat prognostic information is given by the onset of noisy breathing?
37Death Rattle / Noisy Breathing 25-50% of dying patients65% will expire within 48 hoursDue to weak upper airway muscles plusDue to inability to control secretionsAdult normal: 1.5 liters saliva, 2 liters oropharyngeal mucus/daySuctioning usually ineffective, may cause discomfort, reactive edemaNoisy breathing, “death rattle” (Palliative drugs, Wildiers, Plonk, Elman)The presumed pathophysiology of the inspiratory and expiratory noise emanating from the upper airway near the end of life, know as death rattle, is the inability of the weakened and lethargic dying patient to expectorate accumulated oropharyngeal and tracheobronchial secretions. (Wildiers JPSM 2002) Normal adults produce 1.5 liters of saliva and 2 liters of oropharyngeal and tracheobronchial mucus. (Elman J Pall Med 2005) Twenty five to fifty percent of dying patients experience death rattle, and nearly 65% will expire within 48 hours of the emergence of this sign. (Plonk J PallMed 2005)In the absence of visible, copious secretions in the oropharynx, suctioning is not only ineffective for death rattle, it may actually increase patient discomfort, and increase edema of the oropharynx, causing increased noise of breathing. Non-pharmacologic interventions include using music to mask the noisy breathing, positioning the patient on their side, and limiting or stopping parenteral fluids. It is essential to educate caregivers and family members that this sign, usually does not produce discomfort for the patient. Antimuscarinic medications [i.e., hyoscine hydrobromide (scopolamine), hyoscine butylbromide (Bucospan®), glycopyrrolate (Robinul®), atropine] reduce noisy breathing by reducing production of secretions and relaxing tracheobronchial muscles. These medications do not affect existing secretions, so they should be used early on in the treatment of death rattle, rather than in the last minutes of life. They may be less effective in patients with pulmonary malignancies, pneumonia or pulmonary edema. A reduction in the noise of breathing can be expected for the majority of patients. Both hyoscine hydrobromide and hyoscine butylbromide work quicker than glycopyrrolate. Subcutaneous or intravenous administration shortens the onset of action, but does not necessarily improve efficacy compared to sublingual administration. A potential advantage of glycopyrrolate and hyoscine butylbromide is that they do not cross the blood brain barrier, and are less likely to contribute to delirium.
38Death Rattle / Noisy Breathing Patient experience of suffering is unlikely due to semi-comatose stateProvide music to ‘mask’ noisy breathingPosition on sideAntimuscarinic medicationsReduce production of secretions, relax tracheo-bronchial musclesWill not ‘dry’ existing secretions, so use early on before symptoms are severeNoisy breathing, “death rattle”Noisy breathing is disturbing to family and friends and a cause of concern about suffering. Discuss with your patient and his/her family that the patient will not become distressed and that certain steps can be taken to alleviate anxiety, such as playing music that the patient likes. Most patients with death rattle are comatose or semi-comatose, and it can be reassuring to tell them that in such a state, patients are unlikely to be able to experience suffering
39Antimuscarinic Medications Glycopyrrolate (Robinul)Does not cross blood-brain barrier, so treatment of choice in frail patientsmg SC/IV/IM (0.2mg/ml)Repeat 4X/24H, typical ‘max’ dose 1.2mg/24 H1-2 mg SL/PO (1,2mg tab; 1mg/10cc solution)Repeat 4 X/24H, typical ‘max’ dose 8 mg/24HGlycopyrrolate (Robinul®)1mg, 2 mg tablet (tablets may be crushed); 1mg/10cc solution for oral, sublingual administration; 0.2mg/ml ampule for injectionDosing1 mg PO 1 to 4 times daily (maximum 8 mg/day)mg SC/IM/IV initially, repeat as needed ,200microgram/24h CSCI AtropineAtropine 1% eye dropsDosing:1-2 drops SL or PO every 4 to 6 hours initially. Titrate to effectIn addition, anticholinergics have other potential benefits such as:decrease GI secretions and acidity, relax tracheobronchial smooth muscleuseful in bowel obstruction (if octreotide not needed or not available)
40Antimuscarinic Medications Atropine 1% eye drops1-2 drops SL/PO every 4-6 H, titrate to effectAlternatives:HyoscineHBr (Scopolamine, Levsin),HyoscineBuBr (Bucospan)Glycopyrrolate (Robinul®)1mg, 2 mg tablet (tablets may be crushed); 1mg/10cc solution for oral, sublingual administration; 0.2mg/ml ampule for injectionDosing1 mg PO 1 to 4 times daily (maximum 8 mg/day)mg SC/IM/IV initially, repeat as needed ,200microgram/24h CSCI AtropineAtropine 1% eye dropsDosing:1-2 drops SL or PO every 4 to 6 hours initially. Titrate to effectIn addition, anticholinergics have other potential benefits such as:decrease GI secretions and acidity, relax tracheobronchial smooth muscleuseful in bowel obstruction (if octreotide not needed or not available)
41Subcutaneous Medications OpiatesMorphine, methadoneBenzodiazepinesMidazolam, lorazepam (short term)AntipsychoticsHaloperidolAntiemeticsMetoclopramideAqua-C clysis system
43Oral Care Basics Potent memory Assess frequently (feeding, med pass) Good way to involve family, CNAsUse whatever worksFrequent sips of favorite liquids, popsicles, frozen fruit or fruit juices or tonic water, hard candies, artificial salivaAvoid alcohol mouth washes, glycerine swabs; they are dryingOral care is often neglected, but is paramount to keeping a patient comfortable.Physicians must be involved with frequent medical examinations to rule out infection, e.g., thrush.Oral care should be administered 3-4 times a day if the patient is unconscious.Oral care provides a good way to involve family in the patient’s care.
44Oral Care Tips If patient is unconscious, Swab the mouth Q 1-2 H with water or NSSpray with an atomizerWater based lubricant to lips and front teethAvoid petroleum jelly (Vaseline): potentially flammable if O2 in use
45Mrs Flowers Temperature 100.5, RR 30 Plans for evaluation, treatment of fever?“How might you respond to the elevated temperature and elevated respiratory rate?
46Fever Near the End of Life Onset triggers a time of decisionBest discussed in advance if possibleConsider benefits and burdens of evaluation, treatmentDiscuss plan for curative vs. palliative treatment of infections in advanceFever responds to acetaminophenMay be sign of terminal dehydration and multisystem organ failureFever may be due to multiple causes near the end of life. Patients may develop terminal dehydration or a new infection (pneumonia, UTI, cellulitis)The clinician and family must decide whether to treat the fever symptomatically or to evaluate for and treat the underlying cause.It can be beneficial to discuss whether the benefits of evaluation and treatment of fever and infection outweigh the burdens when a person is in the last days of life. Choosing to evaluate and treat pneumonia, for example, may focus caregivers and families on a likely futile attempt to ‘cure’ an infection and distract them from symptom control and providing comfort to the dying patient.
47MyoclonusUp to 30% of dying LTC patients have sudden brief involuntary movementsMay continue during sleep, worse with stimuliMuscular ‘delirium equivalent’Causes: progressive neurological disorders, organ failure, electrolyte disorders, hypoxia, hypercarbia, medicationTreat primary cause if possibleBenzodiazepines reduce signs, symptomsMyoclonus is a syndrome of sudden brief involuntary movements that may be misidentified by staff or families as seizure activityMany progressive illnesses (Alzheimer’s, vascular dementia) are associated with myoclonus.Most metabolic abnormalities and progressive renal, hepatic, cardiac or pulmonary failure can cause myoclonus.Multiple medications are associated with myoclonus, most notably high doses of opioids, SSRIs and tricyclic antidepressants, quinolones, cephalosporins.When possible stop or reduce offending medications and optimize organ function.Benzodiazepines are the treatment of choice if medications are needed to control symptoms.
48Nausea and Vomiting Non-pharmacological Treatment Cool damp cloth to forehead, neck, wristsBland, cool or room-temperature foodsDecrease noxious stimuli, e.g., odors, noiseLimit fluids with foodFresh air, fanRelaxation techniquesOral care after each emesisAcupuncture/pressure or TENS to P6Non-pharmacologic interventions are effective and augment medications used for nausea and vomiting
49Opioid-induced Nausea Chemoreceptor Trigger Zone stimulationDue to rising opioid levelsThe most common mechanism: 28% of patientsTransient (3-7 days) if dosing is steadyUpper GI dysmotility (gastroparesis)Tolerance does not developVestibular apparatusUnusual; note spinning sensationConstipation, impactionOpioids can contribute to nausea via several mechanisms. The commonest is due to the stimulation of the CTZ (chemoreceptor trigger zone) caused by rising opioid levels. Patients will eventually develop tolerance to this mechanism of nausea.Other causes include gastroparesis, vestibular system stimulation, and constipationTreatment should be directed at the underlying cause when possible.EPERC Fast Facts
50Nausea Treatments Prochlorperazine (Compazine) Haloperidol Potent antidopaminergic, weak antihistamine, anticholinergic agentPreferred for opioid related nauseaHaloperidolVery potent anti-dopaminergic agentProchlorperazine is the preferred agent to treat opioid related nausea because its antidopaminergic effect helps reduce stimuiation of the chemotacit
51Nausea Treatments Promethazine (Phenergan) Scopolamine Antihistamine with potent anticholinergic properties, very weak antidopaminergic agentUseful for vertigo and gastroenteritis due to infections and inflammationNot useful for opioid-related nauseaScopolamineA very potent, pure anticholinergic agent.Lots of gastrointestinal problems are associated with medications– monitor medications and potential side effects-- use medications that best treat underlying causes-- skin gels help with nausea and patients usually become better; skin gels are well tolerated by most patients-- watch for side-effects of opioids over 7-days to monitor for tolerance and need for adjunctive medications-- watch for side-effects such as constipationThe goal is to relieve symptoms quickly – especially if evaluations cannot get at the root causeA variety of medications are used to relieve nausea– compazines helpful for nausea from opioids-- phenergan is not helpful in relieving opioid related nausea and is not well tolerated;phenergan is best used for its antihistamine and anticholinergic propertiesEPERC Fast Facts
52Agitation, Terminal Delirium Potent MemoryCommon in final hours, days of lifeDelirium may not clearMay intensify as death approachesTry to identify contributing factorsPhysical exam and symptom reviewMedications are most common reversible causeLook for environmental triggersDelirium and agitation, with hallucinations and delusions, may complicate the last days and hours of the dying process. It may not be possible to restore normal cognition or eliminate these distressing symptoms.
53Terminal Delirium Often requires multifactorial intervention Environmental modification(s)Psychological supportRecruit family and staffMedicationsNeuroleptics (for delirium)Haloperidol 0.5-1mg PO/SL/IM Q1H PRNMorphine (for dyspnea, pain)Avoid benzodiazepines (paradoxical agitation)Ideally, elimination of contributing factors such as pain and medications associated with delirium can control symptoms. If not, antipsychotic medications are the preferred agents to control delirium. Benzodiazepines should generally be avoided due to their propensity to cause a worsening of the delirium (paradoxical agitation)
54Never underestimate the power of a few committed people to change the world. Indeed, it is the only thing that ever has. Margaret Mead
55ReferencesPalliative Care in the LTC Setting Information Tool Kit. American Medical Directors AssociationFast FactsOpiate conversion tool The Clinician’s Ultimate Reference (http://www.globalrph.com/narcoticonv.htm).Agarwal P Myoclonus. Curr Opin Neurol 2003; 16:Jimenez-Jimenez FJ Drug-induced myoclonus CNS Drugs 2004; 18(2):Walsh D, Strategies for pain management Supportive Cancer Therapy 2004;1:Winn PA Effective pain management in LTC. JAMDA 2004; 5(5):Winn PA, Quality palliative care in LTC JAMDA 2004; 5(3):Walke LM et al The burden of symptoms among community dwelling older persons with advanced chronic disease. Arch Intern Med 2004;164:Strumpf NE et al. Implementing palliative care in the nursing home. Annals of Long-Term Care 2004;12:35-41Meyers FG, Linder J. Simultaneous care: disease treatment and palliative café throughout illness. J Clinical Oncology 2003;l21:Buchanan RJ, Choi MA, Wang S, Ju H. End of life care in nursing homes: residents in hospice compared to other end stage residents. J Palliat Med 2004;7:Parker-Oliver D. Hospice experience and perceptions in nursing homes. J Palliat Med 2002;5:Parker-Oliver , Porock D, Zweig S. End of life care in US nursing homes: a review of the evidence. J Am Med Dir Assoc 2005:6;S21-30.Kiely DK, Flacker JM. Common and gender specific factors associated with one-year mortality in nursing home residents. J Amer Med Dir Assoc 2002;3:Gillick MR. Rethinking the central dogma of palliative care. J Palliat Med 2005;8:Schonwetter, et al. Predictors of six-month survival among patients with dementia: an evaluation of hospice Medicare guidelines Am J Hosp Palliat Care 2003;20(2):Aqua-C Hydration System 7350 N. Ridgeway, Skokie, IL • tel: • fax: •7350 N. Ridgeway, Skokie, IL • tel: • fax:•PATENT PENDING“HypoDermoClysis.....in the 21st Century”