Identifying and Caring for Palliative Patients

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Identifying and Caring for Palliative Patients

• Valerie Schulz MD FRCPC (Anesthesia) MPH
• Palliative Medicine ABHPM (cert)

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Overview

• Identifying patients at risk of dying
• Pre-active dying
• Would you be surprised if this patient died in
  the next 6 months?
• Actively dying
• Finding management strategies
• T-Res requirements for End of Life Care

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Would you be surprised if this patient died in
the next 6 months?

• 6 cases will be presented

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Pre-Active Dying

• Patient presentation unique to the clinical
  situation cancer, organ or system failure

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84 y/o in hospital with this heart disease?

• CHF symptoms at rest
• EF lt 20
• New dysrhythmia
• syncope, and recent CVA
• Frequent ER visits for symptoms

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68 y/o smoker with this pulmonary disease?

• Dyspnea at rest
• Signs or symptoms of right heart failure
• O2 sat lt 88 on oxygen
• pCO2 gt50
• FEV1 lt 25 predicted
• Unintentional weight loss

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88 y/o with these symptoms of dementia?

• Inability to walk
• Incontinence
• Fewer than six intelligible words
• Albumin lt 25 or decreased po intake
• Frequent ER visits

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54 y/o ETOH abuser with this liver disease?

• INRgt5 seconds
• Albumin lt25, Na ,130
• Refractory ascites
• Spontaneous Bacterial Peritonitis
• Jaundice
• Malnutrition and muscle wasting

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64 y/o with irreversible multiple myeloma
developing renal disease?

• Not a candidate for dialysis
• Creatinine clearance lt 15 ml/min
• Serum creatinine gt600

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92 y/o in ER with Failure to Thrive (FTT)?

• Frequent ER visits
• Albumin lt25
• Unintentional weight loss
• Decubitus ulcers
• Homebound/bedconfined

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University of Alabama - Dr. Amos Bailey et.al.

• Identifying the Actively Dying Patient
• screen patients at highest risk of end-of-life
  symptoms and who may be actively dying

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What are the Indicators that Patients are at
High Risk of Entering the Actively Dying Process?
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Indicators of Patients at High Risk of Entering
the Actively Dying Process

• Pre-existing DNAR order
• LOS in hospital gt 7 days
• Bed confinement
• Semi-comatose state
• Minimal oral intake (receiving IV fluids or tube
  feeding)
• Inability or difficulty with taking oral medicine

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Indicators of Patients at High Risk of Entering
the Actively Dying Process

• Decline in functional status with no reversible
  cause
• Receiving optimum disease modifying therapy (e.g.
  patient with COPD declining despite aggressive
  treatment)
• failure to improve by 2-3 days post admission
• Frequent Emergency Room visits or
  hospitalizations over the last 6 months
• primary diagnosis of cancer or dementia

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Patients at Risk of Dying

• If one or more of the indicators are present
• Review patient status for symptom burden
• Discuss illness severity with patient and/or
  family
• determine goals of care
• Document advanced directives

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How do Actively Dying Patients Appear?
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Actively Dying Patient Screen

• Audible retained respiratory secretions
• increased RR (gt18-20/minute)
• sustained tachycardia at rest (gt100 per minute)
• mottling and cyanosis of extremities
• decreasing level of consciousness
• decreasing pulses

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Where can you find the management strategies for
dying patients?
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Just in time learning!
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Resources to assist with assessing and managing
dying patients

• University of Alabama at Birmingham
• The Palliative Response Manual
• http//www.palliative.uab.edu/
• Links to End of Life Care websites
• http//www2.edc.org/lastacts/links.asp
• Summarized in Clerkship handbooks
• Consult Palliative Care

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T- Res, clerkship requirement

• Be present as a part of the health care team for
  any 2 End of Life patients
• Identifying a patient at risk of dying
• Transitioning care from acute care to End of Life
  Care
• Care for a dying patient/family
• Complete to EOL worksheet to give to your senior
  resident during your exit interview
• Check your Palliative Patient on T-Res

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Palliative Patient Checklist

• To be designed (including info on the next 2
  slides in the checklist)

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Be clear about

• Desired Location of death consider where the
  patient should be for care while dying
• Diagnosis record what the patient is dying from
  including primary disease and all co-morbidites
• Condition record patient is dying
• Patient/family preferences goals of care, code
  status

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The Actively Dying Patient

• Communicate with medical team, patient and family
  regarding care preferences
• Patient and family will need support from an
  interdisciplinary team

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Treat Dying as a phase of life

• Avoid avoidance of the
• Situation
• Patient
• Family
• Be present as a caring person

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Dying people die despite acute care- we can
strive for a dignified death