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Challenges in End-of-Life Care A Case Based Discussion - Brian H. Black D.O. (11-11-12 update)

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1 Challenges in End-of-Life Care A Case Based Discussion - Brian H. Black D.O. ( update)

2 IU Bloomington Undergrad – B.S. Biology COM - Des Monies University Internship - Union Hospital Residency - Richard Lugar Center for Rural Health Board - Family Medicine Board - Hospice & Palliative Care Medical Director for Great Lakes Caring Hospice IOA Board of Trustee Member I am proud to support Marian University’s new COM

3 Lecture Overview Lecture Overview Case based introduction: Hospice History Epidemiology End-of-Life Directives But Doctor, Morphine Kills People! The Principle of Double Effect Delirium at the End-of-Life What is Essential?

4 Lecture Overview Hospice History & Epidemiology Advanced Directives But Doctor, Morphine Kills People The Principle of Double Effect Delirium at the End-of-Life What is Essential? Other Case Studies

5 Traditional Palliative History & Epidemiology

6 Hospice /hos· pice / ˈ häspis / Latin: "hospitium” Origins: 11 th Century – location for the sick, wounded, & dying 1850s – “Sisters of Charity” 1967 concept pioneered by UK’s Saunders to the U.S Kubler-Ross “On Death and Dying” Hospice Benefit Established 2011 – 1.65 Million pts on hospice, > 5000 companies

7 History & Epidemiology Explosion in number of hospices 1984: : > 5000 *The number of people using hospice is increasing 495,000 in ,650,000 in 2011 *333% increase during that period The population is aging Increases in Hospice utilization are noted in all races

8 History & Epidemiology “Core Services” Attending Med Director Nursing Psychosocial Spiritual Other Patient & Family

9 History & Epidemiology

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13 Some studies have showed patients who are on hospice live on average 27 days longer than those who do not have hospice 2009 Survey looked at cost averages: Hospital inpatient charges per day in 2009 = $6200 Skilled Nursing facility changes per day =$662 Hospice Charges per day = $135

14 Lecture Overview History & Epidemiology End-Of-Life Directives But Doctor, Morphine Kills People! The Principle of Double Effect Dementia at the End-of-Life Terms of Confusion What is Essential Care? Other case studies

15 End-of-Life Directives *Only ~ 5% of patients who require ACLS outside the hospital & only ~ 15% of patients who require ACLS while in the hospital survive **Patients who are elderly, are living in nursing homes, have multiple medical problems, or who have advanced cancer are much less likely to survive. *PMID ^ Zoch TW, Desbiens NA, DeStefano F, Stueland DT, Layde PM (July 2000). **"Short- and long-term survival after cardiopulmonary resuscitation". Arch. Intern. Med. 160 (13): 1969–73. doi: /archinte PMID ^ Ehlenbach WJ, Barnato AE, Curtis JR, et al. (July 2009). **"Short- and long-term survival after cardiopulmonary resuscitation". Arch. Intern. Med. 160 (13): 1969–73. doi: /archinte PMID ^ Ehlenbach WJ, Barnato AE, Curtis JR, et al. (July 2009). **"Epidemiologic study of in-hospital cardiopulmonary resuscitation in the elderly". N. Engl. J. Med. 361 (1): 22–31. doi: /NEJMoa PMC PMID **"Epidemiologic study of in-hospital cardiopulmonary resuscitation in the elderly". N. Engl. J. Med. 361 (1): 22–31. doi: /NEJMoa PMC PMID

16 End-of-Life Directives John a 78 yo BM presents to the hospital with pneumonia. He has a living will. He is admitted in poor overall condition to the ICU. You are paged and notified that John had a bout of chest pain  abnormal rhythm  poor pulse. Nursing calls floor to inform you they are not going to call a code because he has a living will. Discussion: It this ok? Should we call a code? What do you ask? What do you do? Should we defibrillate? Give a med? CRP? Call Hospice? Call next of kin? Call a “full code”, chastise staff, & advise nursing education?

17 End-of-Life Directives A recent study showed that * 78% of physicians misinterpreted living wills as DNRs *as published Oct 29 th, 2012 in American Medical News – Who here reads American Medical News? Perhaps that’s just the M.D.’s? Lets take a quiz and we will see…

18 End-of-Life Directives What is a living will? A.) A medical order that enables a family member or surrogate to speak for the patient if the patient is incapacitated. B.) A legal document that addresses life-sustaining treatments if a patient is terminally ill or in a permanently unconscious state. C.) A legally recognized written or oral statement directing medical treatment during a life-threatening emergency. D.) A made-up term started by the IOA Board

19 End-of-Life Directives What categories best define a “DNR”? A.) a medical document B.) a legal document C.) both a medical & legal document

20 End-of-Life Directives What is contained in a “DNR Order”? A. No intubation or Ventilation B. No artificial nutrition C. No Medications D. No CPR E. No Life Support F. No Surgeries G. Comfort Care Only H. A specific combination of the above I. All of the Above

21 End-of-Life Directives In the U.S. documentation is complicated in that each state accepts different forms Advanced directives and living wills are NOT accepted by EMS as legally valid forms “CODE ORDERS” in the hospital however are often more convoluted with “Code A” / Code “B” / Code “C” options check lists to expressly ALLOW intubation, meds, CPR, or some other combination of “Code Skills”. Only the “state sponsored form” that is co-signed by a physician is valid legally

22 End-of-Life Directives An advance directives name a patient spokesperson for the patient A.) True B.) False

23 End-of-Life Directives Some advanced directives appoint a person to speak on a patient’s behalf However, the provision is not required in order to enact the remainder of the directives

24 End-of-Life Directives What is the proper term for the appointment of a person who can speak on a patient’s behalf? A.) Health Care Power of Attorney B.) Health Care Proxy C.) An Informatics Surrogate D.) The Agent E.) All of the above

25 End-of-Life Directives One essential component of a living will is A.) Pt is unconscious and needs treatment B.) Pt is critically ill despite initial emergency treatment C.) Pt is terminally ill despite sound medical treatment D.) Unable to breathe on own and requires intubation E.) All of the above

26 End-of-Life Directives The majority of living wills say not to treat a patient after a “terminal condition”, despite sound medical treatment OR if the patient remains in a permanently unconscious state. A living will can be written to accept or refuse specific life-saving medical care during such an event, including mechanical respiration, antibiotics, or feeding tube insertion.

27 End-of-Life Directives What is necessary for a health care power of attorney to begin making health care choices for the patient? A. ) One doctor must determine that the patient is unable to communicate to make health care decisions B.) Two physicians must determine that the patient is unable to communicate to make health care decisions C.) A physician and nurse can deem a patient unfit D.) A doctor and the patients family must agree that the patient requires a health care power of attorney. E.) It depends on the state

28 End-of-Life Directives When is an advance directive enacted A.) When the patient is dying. B.) When the patient or a family member asks that it be enacted. C.) When triggers outlined in the directive are present. D.) When the patient no longer can communicate.

29 End-of-Life Directives Advanced directives are activated based on the details within the document The language of the directives have to be read closely to determine if the patient’s circumstances call for the directives to be triggered This can be a source of conflict and confusion, especially in a critical situation. The better we help prepare patients ahead of time the easier this process is to follow. That is until the daughter from California arrives…

30 End-of-Life Directives Back to John: Chest pain  Abnormal Rhythm  poor pulse. Nursing calls floor to inform you they are not going to call a code because he has a living will. It reads: “ If a situation should arise in which there is no reasonable expectation of my recovery from extreme physical or mental disability, I direct that I be allowed to die and not be kept alive by medications, artificial means or "heroic measures”.

31 End-of-Life Directives Advance Directive - A general term describing both living wills and the medical power of attorney. These documents allow you to give instructions about future medical care and appoint a person to make healthcare decisions if the pt is unable. Do-Not-Resuscitate Order (DNR) - A DNR order is a physician's written order instructing healthcare providers not to attempt cardiopulmonary resuscitation (CPR) in case of arrest. A person with a valid DNR order will not be given CPR. Although the DNR order is written at the request of a patient or family, it must be signed by a physician to be valid.

32 End-of-Life Directives Life-Sustaining Treatment - Medical procedures that replace or support an essential bodily function. Include cardiopulmonary resuscitation, mechanical ventilation, artificial nutrition and hydration, dialysis, and certain other treatments. Capacity – In relation to end-of-life decision-making, a patient has medical decision making capacity if he or she has the ability to understand the medical problem and the risks and benefits of the available treatment options. The patient’s ability to understand other unrelated concepts is not relevant. The term is frequently used interchangeably with competency but is not the same. Competency - is a legal status imposed by the court.

33 End-of-Life Directives Allow Natural Death - Advocated as alternative terminology to DNR Explicitly only applied to a terminal patient. AND orders ensure that only comfort measures are taken. This would include withholding or discontinuing resuscitation, artificial feedings, fluids, and other measures that would prolong a natural death. The term is evolving and lacks the specificity of a physician signed “DNR Order”.

34 End-of-Life Directives Physicians and other health care professionals need to understand the values and preferences of their patients You need to understand the terminology, but most importantly it the need to u nderstand the patient and h elp them state their goals using this defined language If not you, then who?

35 Other good places to start a conversation: The One Slide Project ( engage with grace.org) The Five Wishes Program ( aging with dignity.org)

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37 End-of-Life Directives 5 Wishes ( aging with dignity.org) Wish 1: The Person I Want to Make Decisions When I Can't Wish 2: The Kind of Medical Treatment I Want or Don’t Want Wish 3: How Comfortable I Want to Be Wish 4: How I Want People to Treat Me Wish 5: What I Want My Loved Ones to Know Very specific, nearly comprehensive, & “plain language” Not legal as advanced directives in the State of Indiana Preset pharases

38 End-of-Life Directives POLST PROJECT (http://www.polst.org) Started in Oregon in 1991 “…translates values expressed in advance directives into immediately active medical orders which do not require interpretation or further activation ” Provide continuity of care across all settings (e.g. ER, ICU, hospice, long-term care, and home) which is transferred with the patient Its better but not perfect. Especially if not initiated! Please, go the the website, review, and get involved

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40 Barriers to the POLST program in Indiana State Statute IC , which contains language which is in compatible with POLST using the term “terminal” which may exclude some people who would like to limit interventions when the burdens of tx outweigh the benefits. Currently, out of hospital DNR forms require 2 signatures from unrelated witnesses (can’t be employees) Confusion regarding hierarchy of “decision makers” in the event the patient can not speak on their own Questions regarding who can enact them (mid-levels?)

41 End-of-Life Directives Indiana: Legally only state approved forms can be used, but the state of Indiana does not currently support “POLST forms” nor “5 Wishes” as official advanced directives Need to have support from physicians on this important issue immediately Contact for further information and to get support: IU Nurse: Susan Hickman

42 Lecture Overview Hospice History & Epidemiology Advanced Directives But Doctor, Morphine Kills People! The Principle of Double Effect Terms of Confusion at the End-of-Life What is Essential? Case Studies

43 But Doctor, Morphine Kills People! A will known 57 yo Caucasian plant manager of your practice becomes hospitalized due to severe abdominal pain which has been worsening despite OTC treatment Subsequently found stage IV pancreatic CA mets to liver & lung As this patients Family Physician, what do you suggest for him? P.S. I hope you did encourage him to get 5-wishes packet filled out and have conversations with his family prior to this rights?

44 But Doctor, MoreFine Kills People! What would you recommend? A.) Heavy Sedation B.) A referral to Oncologist Inpatient Palliative care team Surgery Outpatient hospice group Chaplin Pain management C.) Further imaging to define lesions D.) A frank discussion with pt & family

45 But Doctor, Morphine Kills People! Pts pain gets worse and the hospice medical director suggests starting morphine for pain control, but the family is reluctant stating quote: “ Dr. I Googled ‘Morphine and Hospice’ and it says that the double effect and will kill him, & anyway everyone knows opiates are addictive! We don’t want him to start them”

46 But Doctor, Morphine Kills People! Which of the following is true regarding Morphine and the family’s concerns? A.) Morphine has an unusually high risk of addiction B.) Morphine is likely to cause respiratory depression as an early effect, especially in the frail and elderly C.) The principle of double effect does not apply D.) Using morphine for patients with cancer or at the end-of-life is likely to trigger an immediate DEA investigation E.) None of the above

47 Double Effect The principle of “double effect” refers to the ethical construct where a treatment is given, for an ethical intended effect where the potential outcome is good (eg, relief of a symptom), knowing that there will certainly be an undesired secondary effect (such as death) A Medical example of double effect : Separating conjoined twins who will die without a surgery, but yet for which also, one will die if the surgery takes place at all

48 Double Effect Many physicians inappropriately call the risk of a potentially adverse event, a double effect but it is in fact a secondary & unintended consequence Patients receiving palliative care whose pain can be adequately treated with opioid drugs may well value quality additional days, hours, or minutes of life It is therefore unjustified to assume that the hastening of death is itself a form of merciful relief for patients with terminal illnesses and not a regrettable side effect to be minimized

49 Double Effect Although this principle of “double effect” is commonly cited with morphine, it does not apply, as the secondary adverse consequences are unlikely Morphine-related toxicity will be evident in sequential development of drowsiness, confusion, & loss of consciousness well before respiratory drive is significantly compromised In Hospice pts, it is common to titrate to effect and only hold doses if pts respiratory rate drops below set parameters set 8-10 breaths per minute

50 Side Effect All of the following have potential good effects and potential bad side effects leading up to even death, but none of them would be considered a “double effect” in most settings: TPN Pain Medications Chemotherapy Radiation treatment Surgery

51 Lecture Overview Hospice History & Epidemiology Advanced Directives But Doctor, Morphine Kills People! The Principle of Double Effect Terms of Confusion at the End-of-Life What is Essential Care? Case Studies

52 Terms of Confusion Mr. Stevens is a 79 yo new hospice c Alzheimer’s. At 2am a page from the ECF nurse, “confused and agitated worse than usual” What do you suggest to to aid this normally pleasant patient? Testing? Do you suggest medications? What kind? Do you want to ask questions first? What testing do you want to do? Send to the ER? Get a CT scan? Get his wife in there to calm him down?

53 Terms of Confusion Confusion is not a helpful or accurate term Do you mean delirium, dementia, psychosis, obtundation, or other disease? work to find a cause Delirium is common complaints require a good history and exam A good validated mental status equivalent needed helps to understand the baseline helps to chart pt course / changes Aids in understanding appropriateness for hospice

54 Terms of Confusion Which of the following are considered validated assessment tools for dementia? A.) Mod Mini-Mental Status (Modified-MMSE = 3MS) B.) Alzheimer’s Disease Assessment Scale (ADAS-Cog) C.) Practitioner Assessment of Cognition (GPCOG) D.) Psychogeriatric Assessment Scale (PAS) E.) All of the above

55 Terms of Confusion MMSE is very familiar / easy. Updated M-MMSE is a better test assessment.com.au/cognitive/index.html assessment.com.au/cognitive/index.html The GPCOG is very similar / quick. Added benefit of interviewing optional observer

56 Terms of Confusion Delirium – is a sudden and severe loss of brain function that occurs with physical or mental illness. Often caused by a temporary and reversible factors. Dementia Disorders– Describes a family of gradual progressive neruodegenerative brain disorders of enough severity to interfere with normal activities of daily living and multiple categories of higher cortical function, lasting more than six months, not present since birth, and not associated with a loss or alteration of consciousness.

57 Terms of Confusion Delirium can be hypoactive OR hyperactive Key feature is an ACUTE CHANGE in the level of arousal may also feature a change in the sleep wake cycle mumbling speech disturbance of memory and even delusions & hallucinations.

58 Terms of Confusion Most common causes of delirium is drugs Anti-cholinergics (anti-secretion, anti-emetic, anti- histamine, TCA, etc…) Sedative-Hypnotics (Benzos especially) Opiates Infection also common CNS pathology should be considered Drug / EtOH withdraw Any new medications are suspect

59 Terms of Confusion Consider the environment: Reduce sensory stimulation as needed Ask family to stay to calm the patient Increase nursing care Frequent reminders of time and place Treatment of choice: Major Tranquilizer. Superior to benzos in sx control and SE profile Haldol can be used in escalating doses. Start 0.5-1mg po q1 hr and titrate Quetiapine (Seroquel) is atypical with less extraparmidal risk. Especially useful if longer term use. Also more sedating than other atypicals. Documentation is essential (as is informed consent) when using these agents

60 Terms of Confusion Back to Mr. Stevens 79 yo debility pt confused and agitated at 2am Further questions revealed he was started on ativan recently for bouts of confusion and also benadryl to help sleep A CBC and temp ordered to identify possible infection A BMP was ordered to identify metabolic causes (quick finger stick helpful in diabetics) O2 sat taken to rule out hypoxia Lastly,we verified he had not hx of EtOH so withdraw was not expected to be a concern

61 Terms of Confusion Benadryl was stopped Ativan was stopped Pt did very well with 1mg of haldol which was repeated in 4 hours x 1. A week later he required repeated haldol doses x 2 Pt eventually started on Seroquel at a low dose 50mg po bid, then titrated to a full dose at 300mg po bid. He did not have over-sedation and functioned well until his demise over 2 months later

62 Lecture Overview Hospice History & Epidemiology Advanced Directives But Doctor, Morphine Kills People! The Principle of Double Effect Terms of Confusion at the End-of-Life What is Essential Care? Case Studies

63 What is Essential What % of patients in the U.S. die in the hospital? What % of Medicare dollars are spent on the last year of life for a patient?

64 What is Essential? Walter is a 62 yo in ER. Chest pain & SOB. Multiple recent prior admissions for CHF. Has pacemaker/defibrillator. Pale. Anorexic. Fatigued. Meds in his bag include: Coumadin, Amoxil, Norvasc, Nitroglycerin spray, Synthroid, Valsartan, Lasix, Plavix, Iron, Folic Acid, Ambien, Vicodin, Paxil, Lyrica, St. John’s Wart, Lipitor, Blond psyllium, CoQ10, MVI, & Nexium What do we do now????

65 What is Essential? Information returns: Albumin was 2.1 ( ) Hgb was 7.2 ( ) INR was 5.2 ( ) EF was estimated at 10-15% 3 weeks ago (Normal range 50-60%) Pacer/defib was placed hospital last visit What do we do now? Feeding tube? Blood Transfusion? Vitamin K, FFP, Platelets? Transplant list? Hospice Consult? Turn off defib?

66 What is Essential? Communication re med & tx essential at every patient encounter It is vital questions are appropriately answered Goals of care & personal philosophy is key Med list needs to be trimmed Realistic expectations Advanced directives are underutilized at best

67 What is Essential? Meds list was trimmed down: Coumadin stopped. ISMO started. Morphine started as prn. DNR written. Advanced directives discussed Defib turned off Symptom management Pt discharged to a residential hospice

68 What is Essential Care? Betty is an unfortunate 42 yo type I diabetic pt with pancreatic cancer living in an ECF. She is now 112 lbs (down from 146 six months ago). You are covering call for Betty’s PCP. Hospice calls to inform you that Betty’s BS is 450 and she has nausea and vomited, but lets you know “I don’t really worry about the blood sugars in dying diabetics” so this is more of “just an FYI” based on protocols. What targets should you give the nurse? Tx? Would your advice vary in DM II?

69 What is Essential Care? Hospice DM Tips: Tight glycemic control prevents long term complications Hospice Goals” minimizing symptomatic episodes Hypoglycemia  panic, tremors, weakness, and seizures. Hyperglycemia (days)  dehydration, thirst, and polyuria, lethargy, & coma Type I DM - risk of rapid DKA  acidosis, abdominal pain, & nausea/vomiting

70 What is Essential Care? Hospice DM tips: In hospice pts, relax tight BS control There is no role for an A1c Continue insulin to prevent DKA (DM I) Decrease glucose checks unless symptomatic Decrease pill burden Frame family discussion with therapeutic goals Clarify stopping meds  pt safety

71 Lecture Overview Hospice History & Epidemiology Advanced Directives But Doctor, Morphine Kills People The Principle of Double Effect Delirium at the End-of-Life What is Essential? Other Case Studies

72 Other Case Studies Other case studies to be discussed will be reviewed during the course of the lecture

73 Hospice Tips If you believe that a patient with an advanced, “progressive illness” is likely to die within a year, hospice may be an excellent option. Any “terminal diagnosis” likely meets criteria Prognoses do not have to be certain, as some end- stage conditions have unpredictable courses Patients may initially improve in hospice Patients may be in hospice longer than six months

74 Hospice Tips Patients with cancer and non-cancer diagnoses benefit from hospice services and should be referred when their prognosis is still longer than two months The most effective length of stay with hospice is debated, but most estimates say at least two to three months; very short stays have been associated with increased caregiver morbidity and depression

75 Hospice Tips Discussions with patients and families about hospice should take place as early as possible Approach in the context of the larger goals of care Late referrals are associated with decreased family satisfaction with services and increased caregiver morbidity

76 Hospice Tips Switch essential medications to non-pill route Stop unnecessary meds / procedures / monitoring Don’t forget to approach Biologic Psychologic Socio & Spiritual aspects of patient care Family Others on the team

77 Resources and References EPERC: End of Life/Palliative Education Resource Center Delivering Bad News-Part 1 | Delivering Bad News - Part 2 Discussing Hospice Delivering Bad News-Part 1Delivering Bad News - Part 2 Discussing Hospice National Hospice and Palliative Care Organization Talking About Treatment Options and Palliative Care: A Guide for Clinicians Talking About Treatment Options and Palliative Care: A Guide for Clinicians American Family Physician End-of-Life Care: Guidelines for Patient-Centered Communication 1/15/08 End-of-Life Care: Guidelines for Patient-Centered Communication JAMA Commentary Communicating With Seriously Ill Patients (Better Words to Say) JAMA. 2009;301(12): doi: /jama Communicating With Seriously Ill Patients (Better Words to Say) British Medical Journal Spotlight: Palliative Care Beyond Cancer Having the difficult conversations about the end of life 9/16/10 Having the difficult conversations about the end of life

78 Resources and References Journal of Clinical Oncology American Society of Clinical Oncology Statement: Toward Individualized Care for Patients With Advanced Cancer 1/24/11 American Society of Clinical Oncology Statement: Toward Individualized Care for Patients With Advanced Cancer Journal of Clinical Oncology Faculty Development to Change the Paradigm of Communication Skills Teaching in Oncology 3/1/09 Faculty Development to Change the Paradigm of Communication Skills Teaching in Oncology CA: A Cancer Journal for Clinicians Making Difficult Discussions Easier: Using Prognosis to Facilitate Transitions to Hospice 6/17/09 Making Difficult Discussions Easier: Using Prognosis to Facilitate Transitions to Hospice Medscape Today (free registration required) Communicating Diagnosis and Prognosis to Patients with Cancer: Guidance for Healthcare Professionals 1/07/11 Communicating Diagnosis and Prognosis to Patients with Cancer: Guidance for Healthcare Professionals Canadian Medical Association Journal What people want at the end of life CMAJ - November 9, 2010; 182 (16). What people want at the end of life

79 Resources and References Fast Facts from the University of Wisconsin The book GONE FROM MY SIGHT The book THE 36 HOUR DAY Grief Share Program

80 Resources and References ERERC: End of life / Palliative Resource Center Delivering Bad News-Part 1 | Delivering Bad News - Part 2 Discussing Hospice Delivering Bad News-Part 1Delivering Bad News - Part 2 Discussing Hospice National Hospice and Palliative Care Organization Talking About Treatment Options and Palliative Care: A Guide for Clinicians Talking About Treatment Options and Palliative Care: A Guide for Clinicians American Family Physician End-of-Life Care: Guidelines for Patient-Centered Communication1/15/08 End-of-Life Care: Guidelines for Patient-Centered Communication

81 Resources and References JAMA Commentary Communicating With Seriously Ill Patients (Better Words to Say) JAMA. 2009;301(12): doi: /jama Communicating With Seriously Ill Patients (Better Words to Say) British Medical Journal Spotlight: Palliative Care Beyond Cancer Having the difficult conversations about the end of life 9/16/10 Having the difficult conversations about the end of life

82 Resources and References Yennaurjalingam S et al. Pain and terminal delirium research in the elderly. Clin Geriatr Med. 2005;21(1): Lawlor PG, et al. Occurrence, causes and outcome of delirium in patients with advanced cancer. Arch Int Med. 2000;160: Brietbart W, Marotta R, Platt M, et al. A double blind trial of Haloperidol, Chlorpromazine and Lorazepam in the treatment of delirium. Am J Psych. 1996; 153: Breitbart W, Alici Y. Agitation and delirium at the end of life. “We couldn’t manage him.” JAMA 2008; 300(24): Cummings, J.L., et al., Guidelines for managing Alzheimer’s disease:part I. Assemment and Part II. Treatment. American Family Physician, (11): p , American Academy of Family Physicians

83 Resources and References Susan E. Hickman, Bernard J. Hammes, Alvin H. Moss, and Susan W. Tolle, “Hope for the Future: Achieving the Original Intent of Advance Directives,” Improving End of Life Care: Why Has It Been So Difficult? Hastings Center Report Special Report 35, no. 6 (2005): S26-S30.

84 Resources and References ^ Seymour, J. E; D. Clark, M. Winslow (2004). "Morphine use in cancer pain: from 'last resort' to 'gold standard'. Poster presentation at the Third research Forum of the European Association of Palliative Care". Palliative Medicine 18 (4): 378.^ a b Center to Advance Palliative Care, ^ Seymour, J. E; D. Clark, M. Winslow (2004). "Morphine use in cancer pain: from 'last resort' to 'gold standard'. Poster presentation at the Third research Forum of the European Association of Palliative Care". Palliative Medicine 18 (4): 378.^ a b Center to Advance Palliative Care, Joanne Lynn (2004). Sick to death and not going to take it anymore!: reforming health care for the last years of life. Berkeley: University of California Press. p. 72. ISBN ^ "WHO Definition of Palliative Care". World Health Organization. Retrieved March 16, Joanne Lynn (2004). Sick to death and not going to take it anymore!: reforming health care for the last years of life. Berkeley: University of California Press. p. 72. ISBN ^ "WHO Definition of Palliative Care". World Health Organization. Retrieved March 16, 2012.

85 Resources and References Angelo M, Ruchalski C, Sproge BJ. An approach to diabetes mellitus in hospice and palliative medicine. J Palliat Med. 2011; 14(1):83-7.Boyd K. Diabetes mellitus in hospice patients: some guidelines. Palliat Med. 1993; 7(2): Budge P. Management of diabetes in patients at the end of life. Nurs Stand. 2010;25(6):42-6.Ford-Dunn S, Smith A, Quin J. Management of diabetes during the last days of life: attitudes of consultant diabetologists and consultant palliative care physicians in the UK. Palliat Med. 2006; 20(3): Budge P. Management of diabetes in patients at the end of life. Nurs Stand. 2010;25(6):42-6.Ford-Dunn S, Smith A, Quin J. Management of diabetes during the last days of life: attitudes of consultant diabetologists and consultant palliative care physicians in the UK. Palliat Med. 2006; 20(3): King EJ, Haboubi H, Evans D, et al. The management of diabetes in terminal illness related to cancer. QJM. 2012; 105:3-9. King EJ, Haboubi H, Evans D, et al. The management of diabetes in terminal illness related to cancer. QJM. 2012; 105:3-9. McCoubrie R, Jeffrey D, Paton C, Dawes L. Managing diabetes mellitus in patients with advanced cancer: a case note audit and guidelines. Eur J Cancer Care. 2005; 14(3): McCoubrie R, Jeffrey D, Paton C, Dawes L. Managing diabetes mellitus in patients with advanced cancer: a case note audit and guidelines. Eur J Cancer Care. 2005; 14(3): Quinn K, Hudson P, Dunning T. Diabetes management in patients receiving palliative care. J Pain Symptom Manage. 2006; 32(3): Quinn K, Hudson P, Dunning T. Diabetes management in patients receiving palliative care. J Pain Symptom Manage. 2006; 32(3): Vandenhaute V. Palliative care and type II diabetes: A need for new guidelines? Am J Hosp Palliat Care. 2010; 27(7): Vandenhaute V. Palliative care and type II diabetes: A need for new guidelines? Am J Hosp Palliat Care. 2010; 27(7):444-5.

86 Thank you… Thanks for your attention Please contact me with questions I welcome further discussion on any interesting patients you have (Hospice or otherwise)


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