Palliative Care for Older People

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Palliative Care for Older People

• Dr Claire Whitehead
• Consultant Community Geriatrician

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Why are older people special?Case Presentations
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Why are older people special?

• They die

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Why are older people special?

• They die
• 2/3 of deaths are in the gt75s
• 3400 in Sheffield / year

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Why are older people special?

• They die
• 2/3 of deaths are in the gt75s
• 3400 in Sheffield / year
• Their numbers are increasing

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(No Transcript)
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Number of men agedgt85 in S.Yorkshire
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Why are older people special?

• They die
• 2/3 of deaths are in the gt75s
• 3400 in Sheffield / year
• Their numbers are increasing

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Why are older people special?

• They die
• 2/3 of deaths are in the gt75s
• 3400 in Sheffield / year
• Their numbers are increasing
• Care Homes
• 36 of gt85s die in care homes

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Why are older people special?

• They die
• 2/3 of deaths are in the gt75s
• 3400 in Sheffield / year
• Their numbers are increasing
• Care Homes
• 36 of gt85s die in care homes
• Death is natural

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Case 1
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Case 1 at home

• 87 year old lady
• Lived alone
• Memory problems
• Incontinence
• generally unwell
• Hospital Admission

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Case 1 in hospital

• UTI
• AF and Acute Coronary Syndrome
• Vascular dementia
• Anaemia, high calcium Myeloma
• Decision for palliative treatment
• Discharged to EMI Nursing Home

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Case 1 in the care home

• 2 months later - deterioration
• Falls
• Increasing anaemia
• Dies
• (6 months after initial hospital admission)

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Would you be surprised if the patient dies in the
next 12 months?
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Advanced Care Planning

• Who should do it?
• Who has the time to do it?

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Case 1
Home
Hospital
Care Home
Death
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District Nurse GP
Home
Ideally ACP discussions should be initiated in
primary care..before individuals become acutely
unwell
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District Nurse GP
Home
Ideally ACP discussions should be initiated in
primary care..before individuals become acutely
unwell
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Professionals should initiate discussions using
their judgement to gauge the appropriate time.
This will depend on the prognosis and pattern of
disease progression
Home
Hospital
Haematology Medical team
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..a professional who has rapport with the
individual ACP discussions should be a process
not a single event
Home
Hospital
Haematology Medical team
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Nuffield Foundation Survey of ACP in Care Homes
for Older People 90 of managers recommend an
ACP process 22 of homes have gt75 of residents
completed an ACP process
Nurse GP
Care Home
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Professionals should avoid initiating
discussions immediately after a move into a care
home
Nurse GP
Care Home
OOH 999
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The ACP process?
District Nurse GP
Home
Nurse GP
Hospital
Care Home
Haematology Medical team
Death
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The ACP process? Or not?
District Nurse GP
Home
Nurse GP
Hospital
Care Home
Haematology Medical team
Death
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Or not?
District Nurse GP
Home
Nurse GP
Hospital
Care Home
hospital admission AE died on MAU
Haematology Medical team
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WHO 2002

• Palliative care is 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.3

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Case 2
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Case 2

• 101 year old lady, in care home for 6 months
• PMH Angina, NOF 02, ARMD cataracts
• No hospital admissions for several years
• Falls and weight loss improved with change in
  care plan
• Regular Holy Communion

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Would you be surprised if the patient dies in the
next 12 months?
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No, because

• Life expectancy at 100
• 2 years
• Life expectancy on moving to care home
• 76 one year survival
• GSF Prognostic Indicators

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GSF Prognostic Indicators for Frailty

• Multiple comorbidities with signs of impairment
  in day to day functioning
• Deteriorating Karnofsky score
• 100 normal, 10 moribund
• At least 3 of
• weakness, slow walking speed, low physical
  activity, weight loss, self reported exhaustion

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• Would you be surprised?........No
• Would the lady and her family be
  surprised?..........No
• Who would be best placed to initiate discussions
  on the end of life?

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But, surely this is natural,do we need advance
care planning?
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End of Life Care Strategy

• People need to be given the opportunity to
  consider what care they wish to receive, based on
  the best available information about what may lie
  ahead of them and what services are available.

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Frailty / dementia
high
Function
Death
low
Quite variable, 6-8 years
Time
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How will she die?

• Sudden collapse and death
• Gradually become frailer and need more care
• Acute illness MI, pneumonia, hip fracture

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How will she want to die?

• We dont know
• The decision makers dont know

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Case 3
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Case 3

• 86 year old lady
• Comes to clinic alone on the bus
• More SOB walking to the shops
• Main problem is the kyphosis
• Echo severe aortic stenosis
• Does not want to be considered for surgery..

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What do we know?

• Not be surprised if she dies in 1 year
• Sudden death
• Worsening heart failure
• Ive had a good innings
• Nephew died suddenly
• Lived in her house for 60 years
• Would like to die there

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Case 3

• Is this the start of the advance care planning
  process?
• Who will continue the discussion?
• Can this avoid her dying of heart failure in
  hospital?
• But the main problem is the kyphosis

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Palliative Care for Older People

• Why older people are special
• Cases
• Multiple professionals, but no plan
• The need to plan for death in the very old
• The main symptom is unrelated

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Thank you