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Introduction to Palliative Care and Hospice

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Title: Introduction to Palliative Care and Hospice


1
Introduction to Palliative Care and Hospice
  • VA Palo Alto
  • Inpatient Hospice

2
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.

4
Brief Overview of End-of-Life Care
  • How are we doing in end-of-life care (ELC) in
    this country?

5
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

6
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

7
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

8
Where We Die
9
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

10
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

11
Trajectory of Steady Decline
12
Other Dying Trajectories
13
Brainstorm
  • Implications of different trajectories of dying

14
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

15
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

16
Themes for a Good Death
  • Home
  • Comfort
  • Sense of completion (tasks accomplished)
  • Saying goodbye
  • Life-review
  • Love

17
Common Ideal Death Scenarios
  • Sudden death in sleep
  • Dying at home
  • Dying engaged in meaningful activity

18
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?

19
The Last 48 Hours
  • How do you know a person is dying?
  • What are some of the signs of imminent death?

20
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

21
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

22
Events of the Last 48 Hours
  • Orderly loss of the senses and desires
  • Hunger
  • Thirst (but persistent dry mouth)
  • Speech
  • Vision
  • Hearing and touch

23
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)

24
Loss of Thirst
  • Dry mouth is misinterpreted as thirst

25
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

26
Loss of Vision
  • Patient may appear to stare off in space, as if
    looking through people

27
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

28
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

29
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

30
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
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