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Title: Geriatric Care: Soul Opportunity System


1
Geriatric CareSoulOpportunitySystem
Dr David Dai Consultant Geriatrician Prince of
Wales Hospital 28th November, 2008
2
Ageing of the Aged Frailty of old age and the
Risks Hospitalization death, dying and
dignity Medicine and Humanity System changes
Contents

3
The Riddle of the Sphinx ????
What is it that has one voice and yet becomes
four-footed and three-footed?

4
Risks and Opportunities 2008
5
Gray Dawn(Peter Peterson, 1999)
  • Theres an iceberg dead ahead. Its called
    global aging, and it threatens to bankrupt the
    great powers. As the populations of the worlds
    leading economies age and shrink, we will face
    unprecedented political, economic, and moral
    challenges. But we are woefully unprepared. Now
    is the time to ring the alarm bell.

6
Chief Executives Address 2008
  • 70. The ageing population is another challenge
    we must address. The number of people aged 65 or
    above is expected to increase to 2.17 million by
    2033, or 2.5 times the present figure. By then, 1
    in 4 persons in HK will be in this group.
    Individuals, families and society should have the
    responsibility for taking care of our elderly
    people.

7
Hong Kong Bycensu 2006
  • gt 65 yrs
  • 1996 10.1 (630,000)
  • 2006 12.4(853,000)
  • 2033 27
  • Median age(yrs)
  • 1996 34
  • 2006 39

Ageing of the Aged
8
??
Blessing or Curse?
9
Longevity ??
  • Increased Active (Disability free) Life
  • or
  • Pandemic of Disabilities

10
Sydney Older Persons Study
11
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12
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13
Fries HypothesisCompression of
Morbidity/Disability ????
1.Mechanism of disabilities 2.Prevent, delay,
reverse, disabilities
Functional Decline Disability
Compression of disability
AGE
14
Disabilities in old age ????
  • Humanity has traded a longer life for a wretched
    life -Faust-
  • ?mortality associated with fatal diseases
  • ( cancer, cardiovascular)
  • ?duration of morbidity and disability with
    these diseases
  • 2) ?chronic diseases
  • eg. Arthritis, dementia

15
Soul In Distress
Frailty ??
16
Brief History of Geriatrics in Hong Kong
  • 1970s Rehabilitation within Acute
  • 1980s Acute geriatric wards (gt70 yrs)
  • 1990s Stand alone geriatric and
    rehabilitation units in non-acute
  • CGAT
  • 2000s Medical care in residential setting
  • Now is the Time for another change
  • Geriatric Role in Acute Care

17
CGAT 1990s
18
Shaping forces
  • Demographic changes ageing of the aged
  • Professional training and competing disciplines
  • Resources rationing and business model
  • Public expectations
  • Private practice
  • Medical technology

19
The Older Personhood at Risk
  • Potential for rehabilitation
  • Object of transfer
  • Bed blocker
  • Recurrent admitter
  • Research subject
  • AED waiter
  • Business opportunity
  • Abuse

20
Potential Object for transfer Recurrent
admitter OAH resident Bed blocker
21
Waiter at AED
22
Elder Abuse
23
Soul Neglected Prey to Business
Opportunity
24
Hospitalization is a risk for frail elders ?????
25
Effect of Hospitalization
Acute illness
Dementia
Hospitalization
Complications Restraints Medications Functional
decline BPSD Bladder Infections
Gait/Falls
26
The Dying Experience in theAcute Hospital
Advanced Dementia Advanced Cancer
27
  • Acute hospitals are the most common setting where
    people actually die. There is a need for skilled
    and compassionate provision for the care of dying
    patients.
  • ( Pall Med 2001 15 207-212)
  • A need for further palliative care education for
    medical and nursing staff working within the
    acute hospital settings.
  • (Pall Med 2001 15 451-460)

28
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29
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30
Dying experience
  • Provision of palliative care to elderly patients,
    in acute care hospitals, at their last admission
    before death because of dementia and other
    non-oncological end-stage diseases must be
    improved. (Age Ageing 2006)
  • Incurably ill patients often receive
    non-palliative interventions. Patients with
    cancer receive more diagnostic tests, but
    patients with dementia receive more enteral
    feeding.
  • ( Arch Intern Med 1996 156 2094-2100)

31
The Boxer tied
32
Technological medicine and the elderly who
cares?Mary Bliss, JRSM 1998, 91(3) 152-153
  • As we learn more about the human body and its
    functions, we devise more ways in which it can
    manipulatedSometimes it is really difficult and
    less compatible with normal life and may take
    away our last pleasure in life-for example,
    feeding by tube.

33
  • Many old people do not want more life, but all
    want attention, kindness, comfort and freedom
    from pain-
  • rarer and rarer priorities in hospitals and
    healthcare.
  • Who cares? Is the present system really
    supporting some right to life, or is it blind
    stupidity and cruelty?

34
Soul in Pain
The 5th Vital Sign
35
Sanctity of Life
36
Dignity rises above Sanctity of Life Restore the
Personhood
The Elderly
37
DignityHarvey Max Chochinov(J Pall Med 2008,
11(5) 674-675)
  • Dignity-conserving Care for the dying
  • A attitude
  • B behaviour
  • C compassion
  • D dialogue

38
????
Dr....
39
Confucian Personhood
??
40
1960
41
Therapeutic Advocacy(Geriatrics 2003, 58(2)
9-15)
  • Doctors role the
  • 21st Century
  • Teacher and Advocate
  • Helping children help their patients make
    decisions
  • Educate, inform and convince older patients about
    what is in their best interest
  • Covert relatives into therapeutic advocates to
    your recommendations

42
Ethics Narration in EOL care
43
Personal
Advance Directive
Autonomy Control
Personal Relationships
Advance Care Planning
Consensus Building Family Covenant
Advance Proxy Planning
Person- hood
Narrative Ethics
Community Perspectives
Communal
44
Palliative Care
Advance Care Planning
45
Ms. A provided care for her father since he was
diagnosed dementia in his early 90s. On An
episode of acute illness in August 2001, Ms A
realized that she could not take care of Her
father alone at home. He was subsequently
admitted into a nursing home. Since then, eating
difficulties became the major issue. The nursing
home staff had discussed with Ms A several times
on commencing long-term tube feeding. However,
Ms A resisted the idea as she knew that her
father loved food very much, forgoing oral
feeding meant taking away the only pleasure from
him. She was able to learn over time how to feed
her father. In October 2003, her father an
episode of acute illness that rendered him warded
in an acute Hospital. On admission, she told the
ward staff that she would bring food to her
father, and asked them not to tube feed the
patient. It was the post SARS period when
restricted visiting was observed. When her father
was transferred to the convalescent hospital,
she noted that her father was already put on
tube feeding. This was done without her
knowledge. She noted that her fathers sad and
fearful face. Her father died in early January
2004, two more months after tube feeding
commenced. Ms A was still in grief at the
interview, which took place in September 2005.
She could not forgive herself and the healthcare
providers For the pain that had inflicted on her
father in the last two months of his life.
No Peace of Mind
46
Dying can be a peaceful event or a great agony
when it is inappropriately sustained by support
Dr Roger Bone, 1997
47
Appropriate Interventions at EOL(Mayo Clin Proc
2005 80(11) 1411-1413)
  • Inappropriate death is unnatural longevity
  • Soul Dignified

48
The System of Geriatric Care
Problems and Changes Comprehensive geriatric
assessment vsSpecialized Medicine
49
Geriatric consultation is there a future?(Age
and Ageing 2007361-2)
  • Frail older patients will represent an
    increasing proportion of hospital caseloads in
    future. Hospitals inevitably will respond to this
    phenomenon. There is a continuing need to explore
    practice models which will deliver geriatric
    specialist expertise to general ward settings
  • YES

50
The Future of Geriatrics(J Nut, Health Ageing
2006 10(4) 245)
  • The times they are a-changing
  • Bob Dylan
  • Geriatric care should integrate into health care
    systems following geriatric patients
  • From preventive, primary to home care and
    palliative care
  • Move with the flowing water

51
Purpose-Driven Geriatrics (2008)
Community dwelling elders P Support CNS in elder
care S Community / Homes
Successful Ageing 2030 P Preventive health at
mid-age S Community FM Clinics
Geriatric Medicine P Comprehensive Geriatric
Assessment
Residential P Onsite medical care, avoid
admission, EOL care S Old age homes
Family Medicine P Transfer skills S FM clinic
Geriatric session 1/wk
Skills follow clientele Shared care Hospitalist
approach Outreach within the hospital
Education Consultation
Non acute hospital P Reconditioning
rehabilitation S Convalescence ward ,
SpecialRehab ward eg. Stroke / Neuro-surgical
Geriatric Consultations P Geriatric
interventions eg. Perioperative optimization
for frail elder patients (gt75 yrs) S
Non-medical wards eg. surgical
AED P Avoid admission and recurrent
attendances S Emergency ward, general AED
Ortho-Geriatrics P Perioperative optimisation
to facilitate early surgery and
rehabilitation S Orthogeriatric ward
Acute Medical wards P Shorten DOS, minimize
functional decline, geriatric diagnoes,
arrange post-discharge support S Acute
medical / admission wards
SOPD P Shared care S Geriatric clinic, dementia
clinic, fragility clinic
52
Soul of Elder CareA River
53
A New Generation of Physicians( Acad Med 2007
82(4) 321-323)
  • Medical ethics is the foundation of clinical
    medicine
  • Values hold a central place in clinical decision
    making
  • The ethos of humane care must be cultivated
  • Admission committees should seek medical students
    who possess both cognitive and emphatic skills
  • Transmit knowledge of clinical science coupled
    with humane care

54
The Soul of MedicineMark G KuczewskiPersp in
Bio and Med 2007 50(3) 410-20)
  • Medical Humanities
  • Ethical and spiritual text
  • Narrative, Reflection

55
Nun Study
56
Ageing in Grace
57
Impaired walking
  • TN, F/ 81, OAH resident
  • gt10years of impaired walking further
    deteriorating 1 week
  • Washing wolfram ore 10 days after 1st child
    birth, slipped and fell.

58
(No Transcript)
59
Soul Resurrected
Medical Grand Round on Ethics I want to
eatand drink
22 October, 2008
60
On Humanity and Old Age
61
On Humanity
  • Humanity means to restrain oneself and observe
    the rites. Once one does this, the whole world
    will be embraced in ones humane mind

?????????????,?????
62
Humanity relational
  • Helping others to be established ??????
  • Imposing nothing undesirable on others
  • ????,????
  • Loving and understanding others?????
  • Only the humane can love others??????
  • Sacrificing ones life to achieve Humanity
  • ????
  • Finding peace in Humanity????

63
Soul in Humanity
  • The Humane live
  • long lives

??? Longevity can be a Blessing
64
?? ????????(Education) ????(Occupation) ?????
(Life style) ??????(Restore Reserve) ?????(Social
Engagement) ???????,??? Successful Ageing
65
?????? ????, ????, ????, ????????
Pursuit of Knowledge
66
Take Home Message
  • Frailty and illness in old age puts an elder
    personhood at risk
  • Clinicians should seek to preserve and restore
    the dignity of the persons at end of life
  • Dialogue with family members offers more
    appropriate EOL care based on ethics, narration
    and palliative approach
  • Soul of elder care rests on the understanding of
    humanity especially in the Chinese context

67
End of Life and Human Dignity
68
2033
Soul in Celebration
69
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70
The Humanity Riddle
71
?? Brain Health Boosters
Social interaction Physical exercise Dancing Si
nging Model making Pottery Cooking Travel Stres
s reduction
Multiple Intelligences
?? Intrapersonal ? Interpersonal Musical
? Visual spatial
? Kinesthetic ? Linguistic
? Logic-mathematical
? (Naturalistic) ???
Education Life-long Education Music
playing Idea exchange Art / Painting Calligraph
y Word puzzles
72
Your Eighties is determined when you were Three
?????
73
Shalom
74
Functional decline and improvement(AJ Epid 1997
145 935-47)N386, agegt 75yrs, community
dwelling, followed for 2 yrs
  • Stable autonomy
  • Functional decline
  • 11.9/yr
  • Recovery
  • 6.2
  • Mortality
  • 3.4
  • Lost autonomy in previous yr
  • Functional decline
  • 15
  • Recovery
  • 32.2 in following yr
  • Mortality
  • 9.1

????
75
????
  • ??????
  • ????
  • ????
  • ????/????
  • ????
  • ????

??, ??
76
Prehabilitation
Curr Opin Clin Nutr Metab Care 823-32
77
Functional Decline and Hospitalisation(J Geron
202, 57A(9) M 567-568)
  • Death rate increases
  • 15 with 1 IADL
  • 21 2 IADLs
  • 37 5-6 IADLs
  • Predicts subsequent acute illness and OAH
    placement
  • Delirium during hospitalisation predicts
    functional decline

78
A Comprehensive Construct of Elder Care
Ageing
Social primary prevention
Social vulnerability
Physiological Biological Vulnerability
Impairments
Disability
Handicap
Death
Stressors
Limited Activities
Limited Social Participation
Diseases
End of Life issues
Frailty
Palliative (Compression of disability and
morbidity)
Organisation of support Social oriented with
medical input
Restorative (Functional assessment, Reverse
decline
Knowledge Preventive (Targeted, Universal)
Therapeutic (Targeted conditions, CGAMulti-site
s Eg. AED, Acute, Rehab OAH, Community
79
Functional Decline Syndrome???????
  • Characteristics
  • Non-specific
  • Atypical presentation
  • Insidious course
  • Mix of physical, psychological, social and
    functional manifestations

??????
80
?
Quality Safety
EQ
IQ
Professional Skills Standards
Clinical Practice
Risk Management
Ethical Legal Perspectives
Communication Empathy
Patient and Staff Relations
MQ
SQ
Social Responsibility
To Err is Human, To Heal is even more Human
81
Predictors of mortality of NHAP in demented
elders( J Clin Epid 2006 59(9) 970-979)
  • 14 day mortality
  • Eating dependency
  • ?pulse
  • ? resp rate
  • ?fluid intake
  • Male
  • Pressure sores
  • Clinical judgement (Med Dec Making 200525(2)
    210-221)

82
?????
Stressors and Decline
83
Elder Abuse
16 (US, 1980)
Health care Personnel Under report Unaware Fear
of litigation
  • Elders
  • Hide, cultural
  • background
  • Isolated
  • Abuser control
  • Access
  • Fear for
  • institutionalisation
  • Mx Health care
  • visits

Elder Abuse
Know the Red Flags ??
84
(No Transcript)
85
(No Transcript)
86
(No Transcript)
87
Red Flags
  • ELDERS
  • 1) live with others
  • 2)physically/financially dependent
  • 3) physical/mental impairment
  • 4)depressed/stressed
  • 5) BPSD(aggression, wandering, verbal outburst,
    embarrassing acts)
  • 6) falls, dehydration, failing self-care
  • ABUSER
  • financial/emotional dependence on victim
  • Underlying legal or financial difficulties
  • Alcohol/drug dependence
  • Psychiatric illness
  • Family violence

88
A C P Discussions
Hospital
Outpatient
Residential
Home
???????
89
Setting / Circumstance
Chronic illness
Medical team
Client/ Family members
Advance Care plan
Advance directive
Advance Proxy care plan
Healthcare Provider
Regular Review
The Process of Advance Care Planning
90
Chinese culture
  • Japanese no CPR
  • Chinese full CPR ( JAGS 2000 48 554-4557)
  • Confucian culture
  • Xiao
  • Family autonomy Chinese Self is a relational
    one

91
Family
  • The family decision may not be in the
    patients best interest and may not reflect what
    the patient would have wanted if competent
  • (Tse, Tao J Med Phil 200429(2) 207-223)

92
3 Standards(Hastings Center Report, 1995)
  • No one should , in the modern world, have to live
    longer in the advanced stages of dementia than he
    would have in a pre-technological era
  • The more advanced the damage of dementia, the
    more legitimate it is to overturn the usual bias
    in favour of treatment
  • Whoever is making the decision has as strong an
    obligation to prevent a painful and degrading
    death as to promote health and life

93
Withholding and Withdrawing( Clin Geri Med 2005
21223-238)
  • Legally neither homicide nor suicide, but a
    permitted removal of medical artifice allow a
    patient to die is a recognized part of ethical
    medical practice
  • Ethically equivalent
  • Intuitively different withholding is thought to
    be less morally troubling than withdrawal once
    begun (abandonment)

94
(No Transcript)
95
  • 7.Communication and Managing Disagreement
  • 8.Artificial Nutrition and Hydration
  • 9.Recording Reviewing the Decision
  • 10.Providing Care and Support

96
Madam SIU Y
  • F/90, OAHR, speaks ???, understands cantonese
  • Premorbid walks a few steps with frame,
    self-feeding, assisted dressing
  • PMH
  • Hypertension, bp?
  • Chronic renal failure Cr 300-400 USG bilateral
    small kidneys and renal parenchymal
    disease/nephrotic syndrome (not for renal biopsy
    in view of old age), repeated admission for fluid
    overload
  • Anaemia of chronic illness, repeated transfusion
  • Gout
  • Osteoarthritis of knees
  • Fracture right neck of femur with operation done

97
Usual Medications
  • Special note in summary Poor compliance to
    med and often spit out the tablets
  • Tried different antihypertensives
  • Aldomet, Betaloc, Zanidip
  • Lasix, Aldactone

98
This Admission
  • decrease GC, refused oral feeding and
    medications
  • Found dehydrated with acute on CRF Cr 550,
    symptomatic anaemia Hb 6.8
  • Rehydrated and transfused
  • Refused oral feeding and all medications

99
What will you do?
  • Forced feeding
  • Insert a nasogastric tube for nutrition and
    medications ( to preserve life )
  • Consult psychiatrist
  • Talk to the patient
  • Arrange SH for rehabilitation

100
(No Transcript)
101
I / O Chart in PWH
102
I / O Chart in PWH
103
(No Transcript)
104
(No Transcript)
105
(No Transcript)
106
Consult SH x rehab
107
I/O Chart in SH
108
I/O Chart in SH
109
Cognitive status
  • MMSE

110
She still refused all medication
  • Preference for food over meds
  • When asked why she refused meds, she answered
    ??? !
  • Changed to daily dose, minimal essential
    medication
  • Explained to her the importance of meds, she said
    ????!
  • Nurse tried to mix crushed meds into food but
    patient still spit it out because of the bitter
    taste

111
(No Transcript)
112
General Ethical approach
113
Ethical concerns approach
  • Autonomy and the 4 Pillars of Clinical Ethics
  • Mental competence and evaluation
  • Can we administer medications with the patients
    consent?
  • Family members view and narrative ethics

114
Autonomy
  • The patient has the right to choose
  • The mode of treatment
  • The institution providing treatment
  • To refuse treatment
  • (We have no right, nor power, to detain a patient
    against his/her won wishes)

115
Beneficence/Non-maleficence
  • The medical team should seek to
  • Explore the patients motive for refusal,
  • Correct any mis-understanding
  • Advise the patient of the risks of non-treatment,
    and
  • Offer other treatment options, if appropriate.

116
Beneficence/Non-maleficence
  • Should the patient choose to seek treatment or
    second opinion elsewhere, we should provide the
    following resources, where appropriate, to enable
    the patient to exercise his right
  • Referral documents,
  • Essential medications,
  • Transport arrangement, and
  • Loan of medical equipment for use during the
    transfer.

117
Justice
  • The old DAMA form is a weak legal document
  • 1. the wording may be viewed as offensive and
    intimidating.
  • 2. without a duplicate copy of the document, the
    doctors signature could be inserted many hours
    after the patient left,
  • 3.there may not have been any explanation given
    to the patient
  • 4. the patient can argue that he/she was made to
    sign the form under duress
  • 5. the witness is not a neutral party, but one
    with vested interest on the side of the hospital.

118
A Model of competency testing
  • Assess the problem
  • How complex is it?
  • What are its consequences?
  • What qualitative aspects require consideration?
  • 2. Assess the patients decision
  • If it appears rational, accept it.
  • If the decision does not appear rational, or if
    it is unclear and the
  • Consequences are great
  • Identify (where possible) the cognitive factors
    involved in the decision
  • Identify the patients broader cognitive state,
    paying particular attention
  • to the factors in (a)
  • 3. If the patients broader cognitive state, and
    the cognitive factors required
  • for the decision are adequate, accept the
    decision. If they are not adequate
  • Defuse the decision if possible by changing the
    complexity or
  • consequences of the decision
  • b) Otherwise consider overriding the patients
    decision to protect his or her

119
Optimising Cognitive Function during
testing(Curr Anesth Critic Care 2002, 13
221-227)
  • Create a non-intimidating, friendly atmosphere
    with sensitivity for the patient
  • Careful introduction to the assessor and
    neuropsychological assessment with explanations
    about the reasons for testing
  • Recognise the patients fear and maintain
    diginity and respect
  • Encourage to try ones best
  • Minimize anxiety

120
Improving Capacity(Prim Care Update Ob/Gyns
2002 9 71-75)
  • Optimize activities of daily living( bowels,
    sleep, safety, continence)
  • Treat depression and optimize BPSD
  • Reduce unnecessary medications
  • Treat coexisting medical conditions( heart
    failure, infections, pain)
  • Correct sensory deficits and enhance
    communication
  • Encourage proper nutrition
  • Manage crisis

121
Narrative ethics
  • Telling and knowing
  • Narratives of the witnesses
  • Narratives of the patient
  • Narratives of the doctor

122
Differences between principlism and narrative
ethics
  • Principlism clear, systematic approach, method
    of decision making that adheres rules from
    different cultural backgrounds
  • Narrative ethics individualized, respect
    individual values and stories, emphasis on
    professional/patient relationship, fosters skills
    of interpretation and communication

123
Narrative skills
  • Interpretive
  • Communicative
  • Interpersonal and empathetic

124
Relationship-building
  • Partnership
  • Empathy
  • Apology
  • Respect
  • Legitimization
  • Support

125
  • To read in the fullest sense students must have
    mastered certain basic skills of literary
    analysis. The same questions that they learn to
    ask about a literary text who is the narrator?
    is the narrator reliable? from which angle of
    vision does the narrator tell the story? what
    has been left out of the narrative? whose voice
    is not being heard and why?

126
A Model for Ethical Decision-Making1) Clearly
state the problem Context Ethical problems
medical, social, cultural, linguistic and
legal issues. Value laden terms, eg
futility, quality of life.2) Obtain the
facts History, examination and relevant
investigations. Patients narrative and
understand their personal and cultural
biography.
127
3)Consider the fundamental ethical
principles Autonomy Beneficence Non-maleficenc
e Justice how are the interests of different
parties to be balanced? Confidentiality Veracity
4)Consider how the problem would look from a
different perspective or using a different
theory Who are the relevant stakeholders?
What is their interest and how salient?
What do they have to lose? How powerful
are they? How legitimate are they? How urgent are
they? How would the problem look like from an
alternative ethical position? For example,
consequentialist, rights-based, virtue-based,
feminist, care-based.
128
5)Identify ethical conflicts Explain why the
conflicts occur and how they may be
resolved.6)Consider the law Identify
relevant legal concepts and relationship with
clinical-ethical decision. 7)Making the
ethical decision State the clinical ethical
decision and justify it Specifying how guiding
principles were balanced and why Take
responsibility for the decision Communicate the
decision and assist relevant stakeholders
determine an action plan Document the
decision Evaluate the decision.
129
According to her son(Narrative Ethics)
  • She is all along very stubborn
  • I have explained to her that she needs the
    medication and what would happen if she does not
    take meds
  • No need R/T insertion for meds, I respect her
    choice. After all, she has survived for 20years
    without taking meds when first noted to have
    hypertension!
  • She is satisfied with this age, and we choose
    full comfort care
  • We are psychologically prepared that she may
    pass away anytime

130
Do Not ResuscitateandEnd Of Life Care
  • DNR and EOL
  • Allow oral feeding as tolerated, no restriction
    (she likes Coca Cola and moon cake)
  • Further deterioration of renal function,
    developed metabolic acidosis and right hemiplegic
    stroke
  • Died comfortably with family at bedside

131
End of Life Care
132
End-of-life care
  • End-of-life care is the term used to describe the
    support and medical care given during the time
    surrounding death.
  • ?difference between palliative care, EOL care,
    hospice
  • Good symptom control ongoing commitment to serve
    the patient and family, physical psychological,
    spiritual support

133
Clincial Ethical Decision Making
  • Clinical decision making should be paralleled by
    and ethical considerations
  • Ethical decisions should be communicated to
    patient and family members

134
Case Vignettes
135
Mr B lived with his widowed mother for more than
30 years before she received institutional care.
The mother had dementia in her 80s. She also had
hypertension, atrial fibrillation and diabetes
mellitus. She had two episodes of fall that
rendered her bed-ridden due to fractured femur
and deterioration of general condition. In
August 2000, the patient was first put on tube
feeding. However, the patient was very resistive
and had successfully pulled that tube out many
times despite of restraints. The doctor suggested
to place a PEG for long term tube feeding.
In view of the patients resistive behaviour, the
family decided to try oral feeding. special
hand-feeding techniques were eventually
instituted to keep the patient on natural
feeding. The whole family, including Mr. Bs wife
and children, took turn to feed the patient. In
August 2002, the patient suffered an episode of
chest infection. Her infection was actively
treated with intravenous antibiotics, and
tube feeding was resumed. The patient died in a
weeks time. On interviewing Mr.B, he regretted
that his mother had to suffer such treatment
burdens in the last week. Mr. Bs mother died in
her age of 88.
136
Ms Cs mother was put on tube feeding during the
episode of stroke in October 2000. On recovering
from the stroke attack, Ms C tried to oral feed
her mother with baby food and puree despite the
presence of the nasogastric tube and the medical
order of NPO (nil per oral). She did so by
wheeling her mother to the garden outside
the ward. However, her act was discovered by the
ward nurse, who seriously warned her that she was
endangering her mothers life by suffocating her.
Ms C was compliant since then by learning how to
tube feed her mother. Her mother was eventually
discharged home with the tube. She was readmitted
several times into the hospital because of acute
illness. As Ms Cs mother became more frail and
weak, she was admitted for long term care. The
patient died because of recurrent and unresolved
chest infection in October 2002. On interview
with Ms C, she grieved that her mother had
suffered from aggressive medical treatments more
than anything else over the past two years. She
was doubtful whether it was the right decision
then to put her mother on long term tube feeding.
Ms Cs mother died in her age of 79.
137
yl pln
138
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Quality Safety
EQ
IQ
Professional Skills Standards
Clinical Practice
Risk Management
Ethical Legal Perspectives
Communication Empathy
Patient and Staff Relations
MQ
SQ
Community awareness
To Err is Human, To Heal is even more Human
139
??? Practice ??? Ethics ??? Compassion ??? Art
Driving Force Specialists and WMs/ NOs
140
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141
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142
Rectangularisation of Age Pyramid ???????
143
Bioethical aspects of EOL care( Eur J Anaes
2008 25 (suppl 42) 51-57)
  • More than 5 Cs competence, collegiality,
    communication, continuity of care, compassion
  • Deliberative approach inclusion of all the
    different subjects involved in the decision
    making (patient, family, doctors, nurses, other
    carers)
  • Best possible decision in a specific situation

144
3 issuesethical, moral, policy
  • How aggressive should medical treatment be for
    persons who have advanced Alzheimers disease and
    other dementias?
  • What is the appropriate division of public and
    private responsibility for long-term care of the
    functionally dependent elderly?
  • Should healthcare for elderly persons be rationed?

145
Common risk factors
  • OAH resident (????)
  • Delirium (????)
  • Worsening cognition and IADLs (????)
  • Functional impairment at home (????)
  • Longer hospitalization (????)

146
Frailty
Incontinence
  • Social
  • Activity

Mobility
? Function
Stroke
Fall
Osteopenia
Hospitalization
Hip Fracture
Institutionalization
Fear of Falling
Death
147
  • In the acute hospital
  • ( Psy 2006 35 187-9)
  • Invasive procedures limited
  • More blood gases
  • Fewer referrals to specialist palliative care and
    palliative medications
  • Inappropriate use of neuroleptics
  • Negative attitudes
  • Recording of dementia not adequate
  • Spiritual needs not addressed

148
National Service Framework for Older PeopleDept
of Health, London 2001
  • Standard 2
  • Use of better EOL care for older people
  • Many older people and their carers have found
    that palliative care services have not been
    available for them

149
The attitudes of Chinese family caregivers of
older people with dementia toward LST( J Ad
Nursing 2007 58(3) 256-262)
  • Chinese family caregivers displayed poor
    knowledge about LST but were reluctant to forgo
  • Chinese caregivers relied on their own views
    rather than the perceived wishes of their
    relatives, they were reluctant to take
    responsibility for such decisions tendency for
    collective decisions
  • Information about outcomes of CPR and tube
    feeding helped caregivers make decisions to forgo

150
The Doctor Role(Chest 2002 121(3) 683-686)
  • We do our best to help our patients overcome
    the obstacles during this journey that are posed
    by various illnesses and accidentsThe intent at
    that time ( end of this journey) is not to cure,
    but to palliate .to be a sensitive and
    compassionate physician who respects the dignity
    of the patient and family, and their right to
    refuse treatment.

151
Geriatric medicine remain a specialty? (BMJ
2008 337a515)
  • Increasing problems attracting trainees to
    geriatric medicine renewed impetus to increase
    the number of generalists in hospitals advocacy,
    innovation, and teaching of health care for
    elderly people needs enthusiastic supporters.

152
A Comprehensive Construct of Elder Care
Ageing
Social primary prevention
Social vulnerability
Physiological Biological Vulnerability
Impairments
Disability
Handicap
Death
??
????
??
????
Stressors
Limited Activities
Limited Social Participation
Diseases
End of Life issues
Frailty
Palliative (Compression of disability and
morbidity)
Organisation of support Social oriented with
medical input
Restorative (Functional assessment, Reverse
decline
Knowledge Preventive (Targeted, Universal)
Therapeutic (Targeted conditions, CGAMulti-site
s Eg. AED, Acute, Rehab OAH, Community
153
Humanity
  • History making
  • The Elder personal and sickness history

154
??????1The naturalness of dying(JAMA
1995,2731039-1043)
  • The progressive move of the dying out of the home
    and into acute and LTC facilities suggests that
    medicalization may be an irreversible process.
  • Viewing dying as an independent diagnosis in
    patients who are obviously undergoing terminal
    declines from aging and chronic diseases can
    facilitate communication about spiritual and
    palliative care needs, which tend to be neglected
    in the medicalized view of dying.

155
???? Functional Decline Vulnerability Frailty
156
Exhaustion of Reserve to 30
????
157
Medical Management at End of Life (Advanced
Dementia)
Dying in Hospital
Antibiotics LST (AHN, Tubes)
Withholding / Withdrawing of LST
Palliative Care Model of care
Advance care planning Advance directive
Surrogate decision
Decision making Competence, Law, Ethics
158
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Quality Safety
EQ
IQ
Professional Skills Standards
Clinical Practice
Risk Management
Ethical Legal Perspectives
Communication Empathy
Patient and Staff Relations
MQ
SQ
Social Responsibility
To Err is Human To Heal,even more Human To
Forgive, Divine
159
??? Practice ??? Ethics ??? Compassion ??? Art

160
Advanced Dementia need Palliation
  • Not viewed as a terminal disease by carers and
    professionals
  • ( McCarthy, 1997 Balderesdi, 1999)
  • Mortality risk of mild/moderate dementia is 3.61
    vs 2.01 for neoplastic disease ( Baslereschi,
    1999)
  • In older women, dementia carries a relative risk
    of death greater than that of carcinoma of GI
    tract ( Agvarsson, 1996)

161
Dying in the old age home
  • Not perceived as being a terminal condition and
    most do not receive optimal palliative care
  • (Arch Int Med 2004 164 321-326)
  • Dying at Home NO WAY

162
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163
Advanced Dementia need Palliation
  • Not viewed as a terminal disease by carers and
    professionals
  • ( McCarthy, 1997 Balderesdi, 1999)
  • Mortality risk of mild/moderate dementia is 3.61
    vs 2.01 for neoplastic disease ( Baslereschi,
    1999)
  • In older women, dementia carries a relative risk
    of death greater than that of carcinoma of GI
    tract ( Agvarsson, 1996)

164
Dying in the old age home
  • Not perceived as being a terminal condition and
    most do not receive optimal palliative care
  • (Arch Int Med 2004 164 321-326)
  • Dying at Home NO WAY

165
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