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? DEATH and DYING (just like hospice) PAIN MANAGEMENT ADVANCE DIRECTIVES DEPRESSION BREATHLESSNESS NAUSEA AND VOMITTING ANOREXIA FATIGUE HOME CARE/ HOUSECALLS ETHICS CANCER ANXIETY WITHDRAWAL OF CARE DIFFICULT FAMILIES PHYSICIAN BURNOUT MORPHINE SUBSTANCE ABUSE LIABILITY HIV SHARING INFORMATION SPIRITUALITY GIVING UP PATIENT SATISFACTION DELAYED DISCHARGE DEA CURE QUALITY OF LIFE 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 Palliative Care Medicare Hospice Benefit Diagnosis of Serious Illness Death www.capc.org Disease Progression

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 Life Prolonging Care “Dying” Palliative/ Hospice Care Disease Progression DEATHDEATH www.capc.org Diagnosis of Serious Illness

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

23. Trajectories of Dying Sudden Death Terminal Illness Organ Failure Frailty Percent 7221647 Mean Age 73778083 % Nursing Home 12244252 % Hospice Care 24688 % Died in Hospital 1274739 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 The SUPPORT Principal Investigators. JAMA. 1995;274:1591-1598 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

25. Opportunities for Improvement: Long-Term Care Sites of DeathUSGeorgia Hospital49.255.2 NH23.715.9 Home23.220.5 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 http://www.chcr.brown.edu/dying/FACTSONDYING.HTM Cancer: 52.8% Terminally ill: 39.3% Nationally: 41.6%

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

28. Report Card: Access to Palliative care Hospital GroupGARegionNational Mid/large38%(28/74)41%53% For Profit0%(0/15)18%20% Non-Profit47%(16/34)54%61% Public42%(8/19)35%41% Community provider 14%(1/7)17%29% Large80%(16/2065%75% Mid22%(12/54)32%45% Small17%(5/29)13%20% www.CAPC.org

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

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