1. Abid Iraqi, M.D Geriatric & Palliative Medicine Syracuse VA

2. The opinions expressed are those of the presenter and do not necessarily represent the opinion/position of Veterans Affairs.

3. What is End of Life Care Preaching to choir— Managing patients toward the end of their life

4. Why End of Life Care is important The majority of deaths occur in elderly adults Terminally ill patients spend most of final months at home, but most deaths occur in the hospital or nursing home More people are living with chronic illness with typically declining condition before the end of earthly journey of life. For patient who are at end of life, care in acute hospital may have little to offer but may induce unnecessary suffering.

5. Components of Good end of life care discussion diagnosis ( of terminal illness) specific treatments (for illness) expected outcome of treatment (of illness) expected outcomes without treatment (of illness) potential untoward effect of treatment (of illness) what to anticipate (in illness) with the passage of time. prognosis elicit treatment preferences assess psychosocial support & spiritual needs

6. Why These Discussions are important It enables healthcare professionals to recognize their patient’s values and preferences.

7. How End of Life Care is accomplished Depends on the spectrum of disease process

8. As disease progresses from Advance care planning/directive to Palliative care to Hospice discussion & referral— Comfort care

9. What is meant by Advance care planning Palliative care Hospice care Comfort care

10. Before we proceed, perhaps we should review what is approach by default

11. Default care is Traditional care

12. curative intent focus is in why focus is to fix why full code

13. What is meant by Advance care planning Palliative care Hospice care Comfort care

14. Advance directive/care planning a communication process between a patient and his/her medical providers, which may involve family or friends, about the goals and desired the direction of care at the end of life in an event when patient loses his/her decision making capacity,1,2 1 Seymour J., Almack K, Kennedy S. implementing advance care planning; a qualitative study of community nurses views and experiences.BMC palliative care 2010;9:4. 2. Teno JM. Advance care planning for frail, older persons. In : Morrison RS, Meier DE, eds. geriatric palliative care. New York: Oxford University press, 2003; 307-313.

15. What is advance care planning living will health care proxy Code status A realistic discussion regarding nutrition and hydration in advance directive is also useful

16. Why advance directives are important initiate the discussion for end of life preference/wishes ensure that patients receive care that is consistent with their preferences it may prove improve quality of end-of-life care by achieving control over their care when/if they lose decision making capacity

17. Do Advance directives alone suffice for end of life care?

18. NO It requires

19. a mechanism/system where patients’ wishes can be honored Our job is to clarify focus of care, provide education and then follow the decision of our patients- Role of palliative care may come into place

20. What is palliative care Palliative care is a specialized medical care that grew out of hospice tradition, and is focused on comfort and quality of life irrespective of the aggressiveness & focus of care regardless of the stage of illness.

21. What is Hospice care Hospice is a philosophy of care focusing on holistic care of persons with terminal illness rendering life expectancy less than six months, and forgoing curative treatment.

22. What is comfort care Focus is comfort without any aggressive treatment- depending on facility may be when death is imminent to years, and depending on medical providers ( patients still receiving IVF, antibiotics and lab. work, and other medical providers like me – same approach as in hospice with no blood work /antibiotics etc.)

23. Confusion often arise b/w hospice & palliative care- Not the same though palliative care grew out of hospice tradition

24. Differences between Hospice and Palliative Care HOSPICE PALLIATIVE CARE Appropriate when one has a terminal disease Life expectancy is less than 6 months Requires Physician certification Patient has agreed to stop active/ curative treatment Payment: per diem payment system Serious illness regardless of stage of disease Irrespective of life expectancy/not time limited Does Not require physician certification Can be provided with active/ curative treatment Payment: fee for service model

25. Similarities between Hospice and Palliative Care HOSPICE PALLIATIVE CARE Focus on symptom management, & quality of life Support to patient, family and caregiver Interdisciplinary in nature Covered under Medicare, Medicaid and private insurance Addresses goals of care, focus on symptom management, & quality of life Support to patient, family and caregiver Interdisciplinary in nature Covered under Medicare, Medicaid and private insurance

26. Hospice is Palliative Care but Palliative Care is not necessarily Hospice Care

27. Role of Health care providers (MD,NP,PA,CNS) in end of life care No matter where we work, it is never too early to help patients begin discussion of advance directives including health care proxy, and then as time goes on assist the patients with further end of life care discussion.

28. Case Description A 76 year old started having abnormal cognitive deficits at the stage of mild cognitive impairment which over the next 8 years progressed to dementia. Then over the next 3 years worsened to advanced stage where he became dependent for all of his IADLs and required supervision for ADLs. Over the next 2 years dementia further worsened to terminal stage.

29. How to proceed MCI stage: managed at home with support of his family, removed fire-arms, completed health care proxy and financial POA Onset of dementia: family initiated support services and he started exploring assisted living. At advanced stage: moved to assisted living, and over next 9 months to special dementia unit. Terminal stage: DNR by surrogate and no feeding tube. Palliative care, and ongoing discussion with HCP regarding burden & benefits of interventions

30. Conclusion Palliative care is simply a good medical practice to ensure patients’ comfort and quality of life and keeping in view how patients would like to proceed with their medical care

31. Questions?