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Altenheim Nursing Home

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2 Altenheim Nursing Home
Palliative Care Changing your practice, yourself, and the system one patient at a time William D Smucker MD Altenheim Nursing Home Strongsville, OH

3 Compare and Contrast When people describe nursing homes and nursing home care, they use words like….. When people describe hospice care, they use words like……

4 Goals Identify nursing home residents who would benefit from a Palliative Care Plan Communicate prognostic pathways to caregivers and family Develop practical approaches to managing symptoms Integrate Palliative Care into Your Nursing Home Practice – Bill Smucker

5 Bill’s Agenda Good palliative care is your responsibility
Hospice is not the panacea in LTC Think of patients and families first, enrollment criteria second

6 National 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)

7 One way or another, it’s your responsibility

8 Palliative 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” Beneficence Providing symptom control as well as psychosocial and spiritual support UNIPAC 6

9 Who 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

10 Site of Death Home Long Term Care Hospitals 1989 1997 17.3% 24.1%
18.6% Hospitals 64.1% 51.8% Nearly one third of nursing home residents die within 12 months of admission

11 Jacob Dimant MD, CMD Caring for the Ages, November 2004
Palliative Care “My own notion is that palliative care is a concept of care that should be given to all nursing home residents, regardless of their status 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

12 Symptoms of Advanced Chronic Illness in Community Elders
COPD CHF Cancer Symptom Dyspnea 65% 18% 19% Pain 28% 20% 33% Anxiety 32% 2% Depressed feelings 17% 6% 9% Anorexia 11% 7% 14% Walke LM Arch Intern Med 2004;164:

13 Symptoms 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 breath 50% pain agitation is often present – especially in patients with cognitive impairment – can be an underlying symptom for other problems 29% experience delirium This 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 – but effectiveness is not always optimal many are still under-treated for pain over-treatment of pain is equally detrimental to quality of life during last days Hall P, et al. JAGS 50:3;501 Mar 2002

14 Dying LTC Patients’ Treatments
Dyspnea Pain Noisy Breathing 23% No Tx 1% No Tx 39% No Tx 64% Oxygen 72% Opioids (mostly PRN) 27% Scopolamine 27% Opioids 37% ASA, NSAIDs 23% suctioning Hall P, et al. JAGS 50:3;501 Mar 2002

15 Hospice is not the Palliative Panacea
‘You have to know what to do until the cavalry arrives’ Typical hospice census ≤ 10%

16 Palliative 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

17 Prognostic 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:

18 Prognosis LTC median survival 2.75 years
43% admitted with dementia survive 2 years Systolic HF 1 year mortality 13% Class III, % Class IV Unintentional weight loss, recurrent pneumonia, non-healing or extensive pressure ulcers, increasing functional decline, are key prognostic signs

19 Prognostic Pathways Anorexia Functional Dysphagia Inadequate intake
Aspiration Dehydration Malnutrition Pressure Ulcer Pneumonia Multi-system failure Sepsis

20 Symptom Control As 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

21 Common End of Life Symptoms
Dyspnea Dry mouth Nausea, vomiting Constipation Anorexia & Weight loss Non-healing wounds Fever Delirium, restlessness Anxiety Sedation Fatigue Depression There 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 most often seen together.

22 Assessment and Treatment
Consider benefits and burdens of workup and treatment/intervention in light of: Current stage of illness; prognosis Patient’s preferences and goals of care Consider non-pharmacological interventions Often as important as meds Often work synergistically Repeat assessment process frequently Reassess efficacy, appropriateness Determine 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 staff i.e., rehab therapy, use of antibiotics, transfusions understand 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 reassess efficacy of current treatments need for adjustments in interventions need to discontinue or change combinations of interventions – pharmaceutical and non-pharmaceutical

23 Maximize Chances of Success
Try to anticipate & prevent symptoms Maximize patient and family control If you educate pts/families before symptoms occur, they will be grateful (e.g., noisy breathing, Cheyne-Stokes) Involve team members and community resources It is of great importance that patients and families continue to exert maximum control in decision making and 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.

24 Mrs. Flowers 92 yo woman with severe dementia, vision and hearing loss, severe peripheral arterial disease, diabetes and hypertension Unavoidable weight loss 108 to 83 lbs over 12 months due to dementia, dysphagia, anorexia Increasing confusion and weakness Less oral intake past few days Last bowel movement 3 days ago Review the case on the next few slides and direct learners to begin to create a palliative care plan

25 Mrs. Flowers Prior evaluations Goals of care
Multidisciplinary team has evaluated her for reversible causes of decline and interventions have not been successful Goals of care Family 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.

26 Mrs. Flowers Appears short of breath at rest
Noisy breathing, coarse breath sounds, dry mucus membranes Temp of 100.5, RR 30 Sacral wound has thin slough, 1-2 cm undermining, foul odor On pressure-relieving mattress Getting HTN & DM meds Morphine (20 mg/ml) 15 mg Q 4 hrs ATC Now Mrs Flowers has an acute change in her condition, with signs and symptoms that may benefit from a palliative care plan.

27 How Would You Proceed? History? Assessment? Labs? Interventions?
Discuss working diagnoses, problem lists Ask audience to participate and answer the questions below Given 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?

28 Problem List Dyspnea End stage state? Noisy breathing Infection?
Dry mouth Malodorous pressure ulcer Delirium Fever Malnutrition End stage state? Infection? Pain? Adverse medication effect? Nausea? Constipation

29 Dyspnea 60% of patients dying in LTC have dyspnea
Subjective sensation of uncomfortable breathing Not linked to measurements of blood gases, respiratory rate or oxygen saturation May limit activity and quality of life Strongly associated with anxiety Patient’s complaint may be ‘nerves, anxious’ Each may cause or exacerbate the other Very frightening to patient and caregivers Dyspnea 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.

30 Causes of Dyspnea End stage state Pneumonia Bronchospasm COPD
Mucus plugs Pulmonary embolus Pleural effusion Deconditioning CHF Cardiac ischemia Cardiac arrhythmia Tumor invasion Damage from radiation/chemo Severe anemia Read through slide – Consider history and physical and need for more extensive evaluation to learn the underlying cause(s) of air hunger.

31 Dyspnea Assessment and Management
Approach to symptom relief may benefit from review of PMH, meds, limited evaluation Physical exam, CXR Treatment should be directed at specific pathology when appropriate (eg. CHF, COPD) Base assessment intensity on benefits vs burdens Use appropriate numerical or descriptive scales to monitor dyspnea and chart symptom control

32 Non-Pharmacologic Treatments
Find what works for this person: Energy conservation, positioning, fan, open window, relaxation techniques Emotional support Trial of oxygen (4-6 liters/min) Avoid suctioning in most patients Non pharmacological approaches for symptom reduction should be tried by the patient, family members and nursing personnel Emotional support can alleviate the severity of symptoms Oxygen may relieve dyspnea unrelated to the impact on pulse oximetry, so a trial of high flow oxygen is warranted. If effective, it should be continued Avoid suctioning if at all possible as it is quite uncomfortable and distressing to the patient.

33 Opioids: Dyspnea Tx of Choice
Morphine is most studied & versatile PO, SL, SC, IV, (not via aerosol) Generally, doses and intervals are the same as for frail elders with pain Q4H ATC with breakthrough Q30 min PRN If already on opioids, increase dose 25-50% For intermittent dyspnea, PRN use OK Tips for Getting to Yes for opiates Adding to optimum therapy, trial of small doses Opioids 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.

34 Initial Opioid Dose: Frail Elderly
Morphine 2 mg PO/SL Q4H 0.1cc morphine 20mg/cc (Roxanol) Morphine 0.5mg SC/IM/IV Q4H Oxycodone 2mg PO/SL 0.1cc oxycodone 20mg/cc (Oxyfast) Hydromorphone 0.5mg PO/SL Q4H 0.5cc 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 Morphine ½ Percocet 5mg ½ Darvocet N 50

35 Dyspnea: Medication Options
Benzodiazepines for anxiety Lorazepam PO/SL/IV mg Q4H Bronchodilators for wheezing Chlorpromazine (Thorazine) 10-25 mg Q4-6H Steroids, diuretics, anticoagulation, erythropoietin in appropriate settings Use adjunctive medications with opioids to relieve shortness of breath if patient can tolerate drug interactions are safe Helpful adjunctive therapies may include: bronchodilators lorazepam to reduce anxiety that can be an underlying cause of shortness of breath steroids for COPD and heart failure fluid reduction if causing shortness of breath Lorazepam 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.

36 Noisy Breathing What prognostic information is given by the onset of noisy breathing?

37 Death Rattle / Noisy Breathing
25-50% of dying patients 65% will expire within 48 hours Due to weak upper airway muscles plus Due to inability to control secretions Adult normal: 1.5 liters saliva, 2 liters oropharyngeal mucus/day Suctioning usually ineffective, may cause discomfort, reactive edema Noisy 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.

38 Death Rattle / Noisy Breathing
Patient experience of suffering is unlikely due to semi-comatose state Provide music to ‘mask’ noisy breathing Position on side Antimuscarinic medications Reduce production of secretions, relax tracheo-bronchial muscles Will not ‘dry’ existing secretions, so use early on before symptoms are severe Noisy 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

39 Antimuscarinic Medications
Glycopyrrolate (Robinul) Does not cross blood-brain barrier, so treatment of choice in frail patients mg SC/IV/IM (0.2mg/ml) Repeat 4X/24H, typical ‘max’ dose 1.2mg/24 H 1-2 mg SL/PO (1,2mg tab; 1mg/10cc solution) Repeat 4 X/24H, typical ‘max’ dose 8 mg/24H Glycopyrrolate (Robinul®) 1mg, 2 mg tablet (tablets may be crushed); 1mg/10cc solution for oral, sublingual administration; 0.2mg/ml ampule for injection Dosing 1 mg PO 1 to 4 times daily (maximum 8 mg/day) mg SC/IM/IV initially, repeat as needed ,200microgram/24h CSCI Atropine Atropine 1% eye drops Dosing: 1-2 drops SL or PO every 4 to 6 hours initially. Titrate to effect In addition, anticholinergics have other potential benefits such as: decrease GI secretions and acidity, relax tracheobronchial smooth muscle useful in bowel obstruction (if octreotide not needed or not available)

40 Antimuscarinic Medications
Atropine 1% eye drops 1-2 drops SL/PO every 4-6 H, titrate to effect Alternatives: 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 injection Dosing 1 mg PO 1 to 4 times daily (maximum 8 mg/day) mg SC/IM/IV initially, repeat as needed ,200microgram/24h CSCI Atropine Atropine 1% eye drops Dosing: 1-2 drops SL or PO every 4 to 6 hours initially. Titrate to effect In addition, anticholinergics have other potential benefits such as: decrease GI secretions and acidity, relax tracheobronchial smooth muscle useful in bowel obstruction (if octreotide not needed or not available)

41 Subcutaneous Medications
Opiates Morphine, methadone Benzodiazepines Midazolam, lorazepam (short term) Antipsychotics Haloperidol Antiemetics Metoclopramide Aqua-C clysis system

42 Mrs. Flowers Now RR 30, moist dry cough, dry mucus membranes, coarse breath sounds

43 Oral Care Basics Potent memory Assess frequently (feeding, med pass)
Good way to involve family, CNAs Use whatever works Frequent sips of favorite liquids, popsicles, frozen fruit or fruit juices or tonic water, hard candies, artificial saliva Avoid alcohol mouth washes, glycerine swabs; they are drying Oral 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.

44 Oral Care Tips If patient is unconscious,
Swab the mouth Q 1-2 H with water or NS Spray with an atomizer Water based lubricant to lips and front teeth Avoid petroleum jelly (Vaseline): potentially flammable if O2 in use

45 Mrs Flowers Temperature 100.5, RR 30
Plans for evaluation, treatment of fever? “How might you respond to the elevated temperature and elevated respiratory rate?

46 Fever Near the End of Life
Onset triggers a time of decision Best discussed in advance if possible Consider benefits and burdens of evaluation, treatment Discuss plan for curative vs. palliative treatment of infections in advance Fever responds to acetaminophen May be sign of terminal dehydration and multisystem organ failure Fever 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.

47 Myoclonus Up to 30% of dying LTC patients have sudden brief involuntary movements May continue during sleep, worse with stimuli Muscular ‘delirium equivalent’ Causes: progressive neurological disorders, organ failure, electrolyte disorders, hypoxia, hypercarbia, medication Treat primary cause if possible Benzodiazepines reduce signs, symptoms Myoclonus is a syndrome of sudden brief involuntary movements that may be misidentified by staff or families as seizure activity Many 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.

48 Nausea and Vomiting Non-pharmacological Treatment
Cool damp cloth to forehead, neck, wrists Bland, cool or room-temperature foods Decrease noxious stimuli, e.g., odors, noise Limit fluids with food Fresh air, fan Relaxation techniques Oral care after each emesis Acupuncture/pressure or TENS to P6 Non-pharmacologic interventions are effective and augment medications used for nausea and vomiting

49 Opioid-induced Nausea
Chemoreceptor Trigger Zone stimulation Due to rising opioid levels The most common mechanism: 28% of patients Transient (3-7 days) if dosing is steady Upper GI dysmotility (gastroparesis) Tolerance does not develop Vestibular apparatus Unusual; note spinning sensation Constipation, impaction Opioids 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 constipation Treatment should be directed at the underlying cause when possible. EPERC Fast Facts

50 Nausea Treatments Prochlorperazine (Compazine) Haloperidol
Potent antidopaminergic, weak antihistamine, anticholinergic agent Preferred for opioid related nausea Haloperidol Very potent anti-dopaminergic agent Prochlorperazine is the preferred agent to treat opioid related nausea because its antidopaminergic effect helps reduce stimuiation of the chemotacit

51 Nausea Treatments Promethazine (Phenergan) Scopolamine
Antihistamine with potent anticholinergic properties, very weak antidopaminergic agent Useful for vertigo and gastroenteritis due to infections and inflammation Not useful for opioid-related nausea Scopolamine A 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 constipation The goal is to relieve symptoms quickly – especially if evaluations cannot get at the root cause A 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 properties EPERC Fast Facts

52 Agitation, Terminal Delirium
Potent Memory Common in final hours, days of life Delirium may not clear May intensify as death approaches Try to identify contributing factors Physical exam and symptom review Medications are most common reversible cause Look for environmental triggers Delirium 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.

53 Terminal Delirium Often requires multifactorial intervention
Environmental modification(s) Psychological support Recruit family and staff Medications Neuroleptics (for delirium) Haloperidol 0.5-1mg PO/SL/IM Q1H PRN Morphine (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)

54 Never underestimate the power of a few committed people to change the world. Indeed, it is the only thing that ever has. Margaret Mead

55 References Palliative Care in the LTC Setting Information Tool Kit. American Medical Directors Association Fast Facts Opiate conversion tool The Clinician’s Ultimate Reference ( 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;12:35-41 Meyers 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 “ the 21st Century”

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