We think you have liked this presentation. If you wish to download it, please recommend it to your friends in any social system. Share buttons are a little bit lower. Thank you!
Presentation is loading. Please wait.
Published byHester Edwards
Modified about 1 year ago
Track I: The Who, What, Where, When, Why, and How of Palliative Care Danielle J. Doberman, MD, MPH Director, Palliative Medicine Program George Washington University Hospital Assistant Professor of Medicine, GWUSOM firstname.lastname@example.org ©Danielle J. Doberman, MD, MPH
Disclosures No Relevant Financial Relationships with Commercial Interests No Conflicts of Interest Danielle J. Doberman, MD, MPH ©Danielle J. Doberman, MD, MPH
Learning Objectives 1. What are the benefits of palliative care for individuals living with dementia and for the people who care for them? 2. When should or is best time for palliative care to be initiated for a loved one who has dementia? 3. What does it mean to "initiate" palliative care? What type of care is commonly provided? ©Danielle J. Doberman, MD, MPH
Case: Millie Millie is an 84 y/o F for new patient evaluation. PMH: Moderate dementia, CVA and COPD Hip fx 3 mo ago 2 UTIs in last year 2 Aspiration PNA ©Danielle J. Doberman, MD, MPH
Case: Millie Weight down 15 lbs in 3 months; now 82 lbs. Eats 50%, 25%, 25% of a pureed diet with thickened liquids “Word salad” speech Chair-bound; scoots Total care Full Code ©Danielle J. Doberman, MD, MPH
Case: Millie “Slowing down” Pleasantly confused Meal times are “difficult” ? Pocketing ? “Doesn’t like pills” 1) Alendronate (Fosamax) 2) Mirtazapine (Remeron) 3) Atorvastatin (Lipitor) 10 mg 4) Aspirin 5) Calcium + D, MVI, FeSO4 6) Ranitidine 7) Advair diskus twice daily 8) Combivent MDI if needed ©Danielle J. Doberman, MD, MPH
Case: Millie Daughter wants to know if she needs a mammogram or colonoscopy? As you discuss a plan of care with family, do you: Address advance directives? Provide anticipatory guidance? Discuss prognosis? Mention options of palliative care or hospice? ©Danielle J. Doberman, MD, MPH
What is Palliative Care? A philosophy of care & multi-disciplinary system for delivering care. Can be combined with life-prolonging treatment or can be the sole focus of care (Hospice). Physical, psychological, spiritual, and practical burdens of illness addressed. Goals: Assist with decision-making/advance care planning Control pain and other suffering Enhance quality of life for patient & family National Consensus Project for Quality Palliative Care www.nationalconsensusproject.org ©Danielle J. Doberman, MD, MPH
H ospice vs. Palliative Care Hospice Prognosis of < 6 mo Focus on comfort care Medicare hospice benefit Volunteers integral & required aspect of the program Palliative Care Any time during illness May be combined with curative care Independent of insurer Complementary therapies often included “Hospice is for the predictably dying” ©Danielle J. Doberman, MD, MPH
When? Trajectory View of Illness DiagnosisDeath Curative Treatments Bereavement Care Hospice Appropriate Palliative Medicine (relieve suffering, improve quality of life) 6m * ©Danielle J. Doberman, MD, MPH
What stage? Is palliative care in dementia different? Does decision making differ by stage? What does the long view hold? MILD MODERATE SEVERE ©Danielle J. Doberman, MD, MPH
Communication is Key! Communication with patients is the core skill of palliative medicine In a typical visit, physicians elicit less than half a patients’ concerns, and consistently fail to discuss their values, goals of care, and treatment preferences Tulsky JA. Geriatric Palliative Care. 2003 ©Danielle J. Doberman, MD, MPH
What are “Goals of Care?” Goals of Care = Patient Values Cure disease Avoid early death Maintain or improve function Prolong life Avoid pain Avoid disability Avoid dependence Maintain alertness Improve life quality Stay in control Support family *Goals may change as an illness evolves ©Danielle J. Doberman, MD, MPH
Values & Goals Assessment “What are your most important hopes? What are your biggest fears about your health?” “What makes life worth living? What if you could no longer do these things?” “Would there be any circumstances under which you would find life not worth living?” “Has anyone close to you ever died? What are your feelings about that experience?” Quill JAMA 2000 ©Danielle J. Doberman, MD, MPH
“Moms living will” ©Danielle J. Doberman, MD, MPH
How stressed is daily life? “How much effort did it take to get in to the office today?” ©Danielle J. Doberman, MD, MPH
Case: What are Millie’s Goals? More time? More quality? What is “acceptable” vs. “unacceptable” QOL? Do Mammogram and Colonoscopy fit into the goals? “Hospice?” ©Danielle J. Doberman, MD, MPH
How: Palliative Care = Shared Decision Making Paternalism Shared Decision Making Autonomy ©Danielle J. Doberman, MD, MPH
American Bar Association’s Commission on Law & Aging, Consumer’s Tool Kit for Health Care Advance Planning: http://www.abanet.org/aging/toolkit/ Resources ©Danielle J. Doberman, MD, MPH
Are Some Conditions Worse Than Death? What is QOL? What is suffering? http://www.abanet.org/ aging/toolkit/ ©Danielle J. Doberman, MD, MPH
What treatment would you want if: You could no longer talk or think clearly? You could no longer recognize or interact with your family? You couldn’t swallow safely and a feeding tube was suggested? You couldn’t breathe and needed a breathing machine indefinitely to keep you alive? You could no longer control your bowel or bladder? You lived in a nursing home? You had pain most of the time? http://www.abanet.org/aging/toolkit/ ©Danielle J. Doberman, MD, MPH
Palliative Care for the Older Adult Needs differ from younger pts * Capacity evaluation Withhold/withdraw life-sustaining treatments Greater time Jettison guidelines? Respect debility & multi-morbidity * Evers, Meier, Morrison. JPSM. 23(5) 2002. 424-432. ©Danielle J. Doberman, MD, MPH
Palliative Care for the Older Adult Anticipatory Guidance & Advance Care Planning are Key! Educate on usual disease course Describe possible disease complications Ex: Dementia: Normalize weight loss Discuss artificial feeding/hydration early Assess social/financial needs of patient/family Empower family to be advocates in a complex medical system Define quality of life ©Danielle J. Doberman, MD, MPH
Is Dementia a Terminal Illness? CASCADE Study: Prospective study of 323 pts with advanced dementia followed for 18+ months; 177 died during study “CASCADE” = Choices, Attitudes, and Strategies for Care for Advanced Dementia at End-of-Life Pneumonia, fever and eating problems were the events most associated with 6 month mortality Pain, pressure ulcers, dyspnea and aspiration also common and increased in frequency at EOL Mitchel NEJM 10/15/2009 ©Danielle J. Doberman, MD, MPH
PNA Febrile Eating Prob Survival following first PNA, Febrile Illness and Start of Eating Problems ©Danielle J. Doberman, MD, MPH
Dementia Prognostication: Acute Illness Survival 6 mo mortality following hospitalization: end-stage dementia vs. cognitive intact Pneumonia: 53% versus 13% New hip fx: 55% versus 12% ☼ Majority of dementia pts from NHs 70% of dementia+PNA lacked Adv Dir 90% lacked documented goals of care in hospital Suggests that DNHosp is key area of intervention Morrison and Siu JAMA. 2000; 284:47-52. ©Danielle J. Doberman, MD, MPH
Tube Feeds: The Evidence No evidence for: Decreasing aspiration risk Improving nutritional status Decreasing risk of pressure sores Prolonging survival 60% mortality at 6 months Improving quality of life Lower rates of PEG placement with prior advance care planning ©Danielle J. Doberman, MD, MPH
Dementia Statistics 5.2 million Americans have Alzheimer’s disease. 1 in 3 seniors dies with Alzheimer's or another dementia. 6 th leading cause of death in the US Est.1.8 million in US with “end-stage” dementia Unable to recognize family Dependent in ADLs Unable to communicate meaningfully Experience infections due to frailty Morrison & Siu. JAMA. 2000; 284:47-52 Alzheimer’s Association, 2014 ©Danielle J. Doberman, MD, MPH
Eligibility 2 Physician prognosis of 6 months or less to live, “if disease runs its usual course.” Philosophical desire to focus on comfort, dignity and quality of life “Forgo further curative treatment” 100% covered by Medicare, Medicaid, VA, most insurances DNR/DNI not required!! ©Danielle J. Doberman, MD, MPH
Benefits of Hospice: General Earlier hospice enrollment reduces the risk of depression in family caregivers. Bradley et al. Am J Psych 2004;161:2257-2262. Survival is on avg 29 days longer for enrolled pts compared with matched peers. Connor et al. JPSM. 2007;33(3):238-46. ©Danielle J. Doberman, MD, MPH
Common Ethical Concerns in Palliative Care of patient with Dementia 1) Healthcare decision making Patient Capacity? Full or partial? Proxy DPOA? Guardian? State Surrogacy Laws Living Will/Advanced Directives? ? Artificial hydration and nutrition documented What if SNF placement dictates a PEG? ©Danielle J. Doberman, MD, MPH
Common Ethical Concerns 2) Treatment Decisions Withdrawal/Withhold ≠ Euthanasia “Withholding” of treatment: conscious selection/application of technology being mindful of QOL (palliative care!) CPR? Ventilator? Antibiotics? Artificial nutrition? Hospitalization? Compassionate withdrawal of technology that is not achieving its goal or worsening QOL ©Danielle J. Doberman, MD, MPH
Common Ethical Concerns 3) Financial Medicare reimbursement supports skilled care Physicians are reimbursed more “to do” (ex: place PEG) than “not do” (have conversation on pros/cons) ? Financial disincentives to hospice in acute hospitals “We can’t place your mom without a PEG” “Her assisted living can’t take her if she doesn’t walk to dinner” Difficult to obtain LTC beds direct from community or acute hospital ? Are families “pushed” to make decisions or “motivated” to make decisions based on finances alone? Ex: skilled comfort care, vs. hospice Ex: skilled with PEG, vs. following living will no PEG ©Danielle J. Doberman, MD, MPH
Summary Dementia is a terminal illness. Pneumonia, febrile illness and feeding difficulties are markers of the last 6 months of dementia. As the disease progresses, a gradual shift from focusing on function and cure to palliation and comfort is what families want. Palliative medicine is guided by patients’ goals For those with advanced dementia, Hospice improves patient and family comfort. ©Danielle J. Doberman, MD, MPH
Thank you for listening! Questions? Danielle J. Doberman, MD, MPH email@example.com ©Danielle J. Doberman, MD, MPH
Abid Iraqi, M.D Geriatric & Palliative Medicine Syracuse VA.
Understanding Hospice, Palliative Care and End-of-life Issues Richard E. Freeman MD.
Palliative Care “101“. Definition Palliative Care Specialized medical care for people with serious illnesses. It is focused on providing patients with.
Overview of Palliative Care Suzann Bonzo, MD. The Greatest Barrier The greatest barrier to end of life care is Clinicians Due to the lack of confidence.
Understanding Hospice, Palliative Care and End-of-life Issues This presentation is intended as a template Modify and/or delete slides as appropriate.
Understanding Hospice and Palliative Care This presentation is intended as a template. Modify and/or delete slides as appropriate for your organization.
Chapter 14 Death and Dying. Death and Society Death as Enemy; Death Welcomed A continuum of societal attitudes and beliefs Attitudes formed by –Religious.
HEALTH CARE DECISIONS ACROSS THE TRAJECTORY OF ILLNESS Susan Barbour RN MS ACHPN.
Alzheimer’s Disease has edged out Diabetes as the sixth leading cause of death in Americans aged 65 or older. In 2004, Medicare beneficiaries were.
Insert your organization’s logo here. Understanding Hospice, Palliative Care and End-of-life Issues This presentation is intended as a template. Modify.
ADVANCE CARE PLANNING. ACP – why is it important Not yet getting it right with care towards the end of life Not yet getting it right with care towards.
Sharing Your Wishes ™ ….. Give Them Peace of Mind Presented by Gina Fedele Hospice Buffalo Where Hope Lives.
Understanding Hospice, Palliative Care and End-of-life Issues This presentation is intended as a template Modify and/or delete slides as appropriate for.
Introduction to Palliative Care Dr. Sandhya Bhalla-Regev, MD.
1240 College View Drive, Riverton, WY Phone A non-profit organization 5 I MPORTANT H OSPICE F ACTS 1.Hospice is NOT only for the last.
Eshiet I.. Every competent adult has the right to determine what treatment he/ she does or does not wish to receive. There is no ethical or legal distinction.
Cultivating Meaningful Conversations to Guide Care: An Initiative to Encourage End-Of-Life- Care Planning for People with Dementia Elizabeth Balsam Hart,
EPECEPECEPECEPEC EPECEPECEPECEPEC Goals of Care Goals of Care Module 7 The Project to Educate Physicians on End-of-life Care Supported by the American.
EPECEPEC Elements and Gaps in End-of-life Care Plenary 1 The Education in Palliative and End-of-life Care program at Northwestern University Feinberg School.
ADVANCE DIRECTIVES Presented by Barbara Wojciak, Chaplain St. Vincent’s Birmingham Pastoral Care.
The Continuum of Advance Care Planning Kathie Supiano, PhD, LCSW Associate Professor University of Utah College of Nursing.
The Case for Palliative Care. The Eperc Project How Americans died in the past Early 1900s average life expectancy 50 years childhood mortality high adults.
1 Palliative Care and Shared Decision-Making HOW TO BECOME AN INFORMED HEALTHCARE DECISION MAKER.
Palliative Care of the Person with Dementia Judy C. Wheeler MSN, MA, GNP-BC Nurse Practitioner, Palliative Care Detroit Receiving Hospital.
Long Term Care in Older Adults Seki Balogun, MD, FACP.
End of Life Care in the ICU. Goals in Critical Care and Medicine Save the lives of salvageable patients, restore health, relieve suffering and offer the.
A Program for LTC Providers GUIDELINES FOR END-OF-LIFE CARE IN LONG-TERM CARE FACILITIES With Emphasis on Developing Palliative Care Goals.
Sarah E. Shannon, PhD, RN. Slide 2 Ethics: Forgoing Medical Therapy TNEEL-NE One exception is the state of Oregon where in 1999, about 1/3 of expected.
Hospice Dis-Enrollment and Quality of Care at the End-of-Life Melissa D.A. Carlson, Ph.D., M.B.A. Brookdale Department of Geriatrics & Adult Development.
PALLIATIVE CARE Sheri Kittelson, MD. Palliative Care Learning Objectives: Meet the team Define Palliative Care and Hospice Review of Key Research Advance.
Mary’s Care Needs Progress Mary’s dementia progressed and she now needs 24 hour residential care. She develops behavioural difficulties in residential.
Mental Health Nursing I NURS 1300 Unit VIII Spirituality, Death, and Grief.
Tulsa Estate Planning Forum October 11, 2011 Jennifer K. Clark, MD, FAAP Division Director, Palliative Medicine Departments of Internal Medicine and Pediatrics.
1 The Goals of End of Life Care Adapted from:The PERT Program Pain & Palliative Care Research Department Swedish Medical Center, Seattle, Washington Module.
Take Time to Plan Oklahoma Association of Homes and Services for the Aging.
Lecture: Introduction to palliative care March 2011 v?
PALLIATIVE CARE: ANY STAGE, ANY AGE WHAT PROVIDERS NEED TO KNOW May 2013.
Diana J. Wilkie, PhD, RN, FAAN. Slide 2 Comfort: Comfort Goals TNEEL-NE Health Care Goals: Trajectory of Cure & Palliative Care Talking about end of life.
Long Term Care in Geriatrics Seki Balogun, MD, FACP.
Carousel Cases. CASE 1 The patient, a 94 year old, has requested in Section B, Comfort Measures Only. He has had a significant stroke and now cannot make.
Anticipatory Care Planning in Dementia Dr Rebecca Bancroft Consultant Geriatrician.
Hospice A philosophy of care to assist those in the end stage of life Model of care originated in England First hospice in United States was in New Haven,
BEST PRACTICES IN CARE OF THE DYING James Hallenbeck, MD Hospice Medical Director VA Palo Alto HCS In Search of.
Reduction Of Hospital Readmissions Hany Salama, MD Diplomat ABIM IM Hospice and Palliative Care Sleep Medicine.
Inpatient Palliative Care: What is it and Why it’s Important Lyra Sihra MD Associate Medical Director Gentiva Hospice.
Chang Gung University Lai-Chu See, Ph.D. Professor Department of Public Health, College of Medicine, Chang Gung University, Taiwan
EPE C for VE T E R A N S EPE C for VE T E R A N S Education in Palliative and End-of-life Care for Veterans is a collaborative effort between the Department.
EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC EPECEPECEPECEPEC American Osteopathic Association AOA: Treating Our Family and Yours.
Anne Cavanagh, MD Background in Internal Medicine and Public Health Board Certified in Hospice and Palliative Care HealthLINC Conference February 22, 2013.
Advance Care Planning: Making Preparations in the Event Life Changes Unexpectedly.
© 2017 SlidePlayer.com Inc. All rights reserved.