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Decision Making in Palliative Care


Decision Making in Palliative Care Mike Harlos MD, CCFP, FCFP Professor and Section Head, Palliative Medicine, University of Manitoba Medical Director, WRHA Adult and ... – PowerPoint PPT presentation

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Title: Decision Making in Palliative Care

Decision Making in Palliative Care
Mike Harlos MD, CCFP, FCFP
Professor and Section Head, Palliative Medicine,
University of Manitoba Medical Director, WRHA
Adult and Pediatric Palliative Care
The presenter has no conflicts of interest to
  • To consider the roles that the patients,
    families, and the health care team have in
  • To consider the role of effective communication
    in reviewing helath care options
  • To explore an approach to health care

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Case 1
  • 35 yo woman with metastatic CA cervix
  • ongoing bleeding, requiring 1-2 transfusions per
  • transferred to palliative care unit for comfort
    care after her health care team decided that no
    further transfusions would be given, as they were

Case 2
  • 7 month old infant with severe anoxic brain
    injury due to balloon aspiration
  • life-sustaining treatment in the PICU withdrawn,
    was being transferred ward for palliative care
  • as he was being wheeled out of his ICU room in
    his bed, his father noticed that he no longer had
    an intravenous line
  • Where is his IV line? How is he going to get

Case 3
  • 65 yo man with esophageal CA, extensive mets to
    liver, cachexia
  • difficulty swallowing
  • Asking about a feeding tube

Case 4
  • 75 yo woman with widely metastatic CA lung
  • brought in near death to ED by ambulance
  • unresponsive, mottled, resps congested and
    irregular, pulse rapid and barely palpable
  • IV started, fluids and cefuroxime administered
    for presumed pneumonia
  • 2 daughters both realize mom is dying and do not
    want CPR, however
  • one wants all meds and fluids discontinued
  • one wants possible pneumonia treated and
    hydration provided if this is not done, she will
    never speak to her sister again

Anatomy of Decision Making
  • Information is the foundation on which decisions
    are made
  • Clinical information facts, numbers the
  • Values / belief systems / ethical framework the
  • Patient / family
  • Health care team
  • Goals are the focus of decisions dialogue
    around health care decision (or any decision, for
    that matter) should be framed in terms of the
    hoped-for goals
  • Communication is the means by which information
    is shared and discussion of goals takes place

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Preemptive Decisions
  • The clinical course at end of a progressive
    illness tends to be predictable... some issues
    are predictably unpredictable (such as when
    death will occur)
  • Many concerns can be readily anticipated
  • Preemptively address communications issues
  • food/fluid intake
  • sleeping too much
  • are medications causing the decline?
  • how do we know he/she is comfortable?
  • can he/she hear us?
  • dont want to miss being there at time of death
  • how long can this go on? what will things look

  • functional decline occurs
  • food/fluid intake decr.
  • oral medication route lost
  • symptoms develop
  • dyspnea, congestion,delirium
  • family will need support information

Some Problems Are Easily Predictable
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Preemptive Discussions
You might be wondering Or At some point soon
you will likely wonder about
  • Food / fluid intake
  • Meds or illness to blame for being weaker / tired
    / sleepy /dying?

Introducing the Topic
  • One of the biggest barriers to difficult
    conversations is how to start them
  • Health care professionals may avoid such
    conversations, not wanting to frighten the
    patient/family or lead them to think there is an
    ominous problem that they are not being open
  • Discussions around goals of care can be
    introduced as an important and normal component
    of any relationship between patients and their
    health care team

Starting the Conversation Sample Scripts 1
  • Id like to talk to you about how things are
    going with your condition, and about some of the
    treatments that were doing or might be
    available. It would be very helpful for us to
    know your understanding of how things are with
    your health, and to know what is important to you
    in your care what your hopes and expectations
    are, and what you are concerned about. Can we
    talk about that now?
  • (assuming the answer is yes)
  • Many people who are living with an illness such
    as yours have thought about what they would want
    done if fill in the scenario were to happen,
    and how they would want their health care team to
    approach that. Have you thought about this for

Patient/Family Understanding and Expectations
Health Care Teams Assessment and Expectations
Starting the Conversation Sample Scripts 2
  • I know its been a difficult time recently, with
    a lot happening. I realize youre hoping that
    whats being done will turn this around, and
    things will start to improve were hoping for
    the same thing, and doing everything we can to
    make that happen.
  • Many people in such situations find that although
    they are hoping for a good outcome, at times
    their mind wanders to some scary what-if
    thoughts, such as what if the treatments dont
    have the effect that we hoped?
  • Is this something youve experienced? Can we
    talk about that now?

The Unbearable Choice
  • Usually in substituted judgment scenarios
  • Misplaced burden of decision
  • Eg
  • Person imminently dying from pneumonia
    complicating CA lung unresponsive
  • Family may be presented with option of trying to
    treat which they are told will prolong
    suffering or letting nature take its course, in
    which case he will soon die

Prolong Suffering
Let Die
Helping Family And Other Substitute Decision
  • Rather than asking family what they would want
    done for their loved one, ask what their loved
    one would want for themselves if they were able
    to say
  • This off-loads family of a very difficult
    responsibility, by placing the ownership of the
    decision where it should be with the patient.
  • The family is the messenger of the patients
    wishes, through their intimate knowledge of
    him/her. They are merely conveying what they feel
    the patient would say rather than deciding about
    their care

  • If he could come to the bedside as healthy as he
    was a month ago, and look at the situation for
    himself now, what would he tell us to do?
  • Or
  • If you had in your pocket a note from him
    telling you that to do under these circumstances,
    what would it say?

Life and Death Decisions?
  • when asked about common end-of-life choices,
    families may feel as though they are being asked
    to decide whether their loved one lives or dies
  • It may help to remind them that the underlying
    illness itself is not survivable no decision can
    change that
  • I know that youre being asked to make some
    very difficult choices about care, and it must
    feel that youre having to make life-and-death
    decisions. You must remember that this is not a
    survivable condition, and none of the choices
    that you make can change that outcome. We are
    asking for guidance about how we can ensure that
    we provide the kind of care that he would have
    wanted at this time.

The three ACP levels are simply starting points
for conversations about goals of care when a
change occurs
Goal-Focused Approach To Decision Making
  • Regarding effectiveness in achieving its goals,
    there are 3 main categories of potential
  • Those that will work Essentially certain to be
    effective in achieving intended physiological
    goals (as determined by the health care team) or
    experiential goals (as determined by the patient)
    goals, and consistent with standard of medical
  • Those that wont work Virtually certain to be
    ineffective in achieving intended physiological
    goals (such as CPR in the context of relentless
    and progressive multisystem failure) or
    experiential goals (such as helping someone feel
    stronger, more energetic), or inconsistent with
    standard of medical care
  • Those that might work (or might not) Uncertainty
    about the potential to achieve physiological
    goals, or the hoped-for goals are not
    physiological/clinical but are experiential

Goal-Focused Approach To Decisions
Revisiting The Cases
Case 1 75 yo woman with metastatic CA cervix, question about the role of transfusions
Case 2 7 month old infant with severe anoxic brain injury, question about hydration
Case 3 65 yo man with esophageal CA, wondering about feeding tube
Case 4 75 yo woman with widely metastatic CA lung, conflict between daughters