Introduction to Palliative Care and Hospice

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Introduction to Palliative Care and Hospice

• VA Palo Alto
• Inpatient Hospice

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Palliative Care

• Interdisciplinary care that aims to relieve
  suffering and improve quality of life for
  patients with advanced illness and their
  families.
• It is offered simultaneously with all other
  appropriate medical treatment.

3
Hospice

• Hospice is a concept of care designed to provide
  comfort and support to patients and families when
  cure-oriented treatments are no longer
  desirable.
• Hospice offers bereavement and counseling
  services to families before and after a patient's
  death.
• Hospice care neither prolongs life nor hastens
  death.
• Hospice care is provided by an interdisciplinary
  team.

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Brief Overview of End-of-Life Care

• How are we doing in end-of-life care (ELC) in
  this country?

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Self-Assessed Knowledge Rating Study

• Most physicians lack knowledge about the physical
  changes of dying
• On a scale of 1 - 5, the mean self-assessed
  knowledge rating of interns on physical changes
  of dying was 1.70
• The lowest score of 6 items rating clinical
  expertise
• Hallenbeck and Bergen, 1999

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Learning Objectives

• Module 1 Death and Dying in the U.S.A.
• Describe how and where people die in the U.S.A.
• Identify patterns of dying and related issues of
  prognosis
• Identify the characteristics of what a good
  death might be for different populations and for
  yourself
• Increase your understanding of events in the last
  48 hours of life

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Top Five Causes of Death

• 1900
• Influenza, pneumonia 11.8
• Tuberculosis 11.3
• Gastritis, enteritis 8.3
• Heart Disease 8.0
• Stroke 6.2
• Brim et al., 1970

• 2000
• Heart Disease 25.7
• Cancer 20.0
• Stroke 6.0
• COPD 4.5
• Accidents 3.4
• Minino Smith, 2001

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Where We Die
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Dying in the U.S.A. Epidemiology Economics

• Annual deaths (2000) 2.40 million
• Percentage in Hospice 17
• Up from 11 in 1993
• Expense of dying (1987)
• 0.9 of population
• Last six months cost 44.9 billion (in 1992
  dollars)
• This is 7.5 of total personal health care
  expenditures
• Cohen et al., 1995

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Dying is Largely Publicly Funded in U.S.A.

• 70 of people dying are covered by Medicare
• 13 of Medicare recipients also receive Medicaid
• Gornick et al., 1996

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Trajectory of Steady Decline
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Other Dying Trajectories
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Brainstorm

• Implications of different trajectories of dying

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Different Dying Trajectories Affect

• Our ability to predict who is dying
• Reimbursement systems
• Where people die
• Medical needs of dying patients
• The impact of the dying process on patient and
  family

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Fantasy Death Exercise

• What are your criteria for a good death?
• The only hitch, as in life, is that you have to
  die.
• Imagine you are there right now.
• Notice where you are, what your are doing, who is
  with you, what it is like, perhaps sounds,
  smells, other sensory specifics

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Themes for a Good Death

• Home
• Comfort
• Sense of completion (tasks accomplished)
• Saying goodbye
• Life-review
• Love

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Common Ideal Death Scenarios

• Sudden death in sleep
• Dying at home
• Dying engaged in meaningful activity

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Discussion

• What do these themes and scenarios imply for our
  work as physicians?
• Few ideal deaths contain medical settings or
  staff
• What does this mean to us, and how do we deal
  with it?

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The Last 48 Hours

• How do you know a person is dying?
• What are some of the signs of imminent death?

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Signs that Suggest Active Dying

• No intake of water or food
• Dramatic skin color changes
• Respiratory mandibular movement (RMM)
• Sunken cheeks, relaxation of facial muscles
• Rattles in chest
• Cheyne-Stokes respirations
• Lack of pulse

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Symptoms Signs in the Last 48 Hours

• Symptom Percent
• Noisy, moist breathing 56
• Urinary incontinence 32
• Urinary retention 21
• Pain 42
• Restlessness, agitation 42
• Dyspnea 22
• Nausea, vomiting 14
• Sweating 14
• Jerking, twitching 12
• Confusion 08
• Lichter and Hunt, 1990

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Events of the Last 48 Hours

• Orderly loss of the senses and desires
• Hunger
• Thirst (but persistent dry mouth)
• Speech
• Vision
• Hearing and touch

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Loss of Hunger

• Families tend to want to nurture
• A basic way to nurture is to feed
• Families may be distressed if patient doesnt eat
• - Distress arises from
• Inability to nurture loved one who is dying
• Fear that patient is starving (suffering)

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Loss of Thirst

• Dry mouth is misinterpreted as thirst

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Loss of Speech

• Loss of two-way verbal exchange is a challenge
• At this point the family may realize that the
  patient is really dying
• Difficulty with communication brings up many
  questions

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Loss of Vision

• Patient may appear to stare off in space, as if
  looking through people

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Loss of Hearing Touch

• These senses appear to be the last to go
• Knowing this allows families to be involved far
  into the dying process

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Terminal Syndrome Characterized by Retained
Secretions

• Lack of cough
• Multi-system shut-down
• Not always associated with dyspnea
• Vigorous hydration may flood lungs
• Deep suctioning is generally ineffective
• Role of IV and antibiotics is controversial

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Learning Objectives

• Describe how and where people die in the U.S.A.
• Identify patterns of dying and related issues of
  prognosis
• Identify the characteristics of what a good
  death might be for different populations and for
  yourself
• Increase your understanding of events in the last
  48 hours of life
• Incorporate this content into your clinical
  teaching

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Learning Objectives

• Describe how and where people die in the U.S.A.
• Identify patterns of dying and related issues of
  prognosis
• Identify the characteristics of what a good
  death might be for different populations and for
  yourself
• Increase your understanding of events in the last
  48 hours of life