Geriatric Grand Rounds

Transcription

1 Geriatric Grand Rounds Tuesday, April 15, :00 noon Dr. Bill Black Auditorium Glenrose Rehabilitation Hospital Visit web sites: for handouts, poster, schedule, subscription: for on-demand archive of previous presentations: Death One, Medicine: No Score Goals of care and Survival prognosis Elisa Mori-Torres MD CCFP. CoE April 2008 Objectives Goals of care and survival prognosis Tools to assess survival Tips for EOL care discussions EPEC Protocol Life is life is like getting into a small boat that s just about to sail out to sea and sink Shunryu Suzuki Roshi Death in Everyday Life: Trungpa Rinpoche 1

2 EoLC Informal Questionnaire Prognosis of life expectancy Communication with patients Communication with families Conflict Management : patients, family, health professionals What is available in OUR community Future plans to address the problem Knowledge of guidelines DX time of death 15% No discusion:icd deactivation 87% Use of inotropes: 68% Knew when to refer to hospice 45% Decision affected by pte. acceptance 45% ALL want an instrument 2

3 Age 75.8 (9943) Multiple co-morbidities Competing risk of death Newly admitted for CHF Five risk categories 3

4 Median survival 2.4yrs High risk: 8mths Very high risk: 3mths Only 5% had a DNR order Increase in survival if alive after 3mths Patient preference are influenced by prob. EB Medications underused LVF echo: 42% Unclear value for patients with repeated hospitalizations University of Washington The Seattle Heart Failure Model Check Upstream Home Press Release Media contact:craig Degginger, (206) mailto:craigd@u.washington.edu March 16th, 2006 For immediate release: Seattle Heart Failure Model is able to accurately predict survival and the impact of medications and devices for patients with heart failure A new model developed at the University of Washington provides an accurate estimate of one-, two-, and three-year survival rates and average years of survival for patients with heart failure. The model incorporates medications and devices that are used to treat heart failure and how altering these affect survival. The Seattle Heart Failure Model was created by Dr. Wayne C. Levy, associate professor of medicine in the Division of Cardiology at the UW, in collaboration with 13 co-authors. It is now available online at and will be published March 21 in the journal Circulation. Heart failure has a mortality rate that can range from 5 percent to 75 percent per year. Patients and clinicians have not had an easy way to estimate survival. The Seattle Heart Failure Model was developed using very simple clinical and laboratory variables that are available to any health care provider. Some of these include age, gender, blood pressure, weight, heart failure medications/devices, and simple laboratory variables like hemoglobin, cholesterol, uric acid, and serum sodium. The model was derived by examining 1,125 heart failure patients, and validated in five additional groups, totaling 9,942 patients. The accuracy of the model was excellent. What is unique about this model is that one can estimate the change in an individual patient s survival by adding medications or devices used to treat heart failure, Levy said. For example, a heart failure patient treated with only digoxin and diuretic therapy with a 20 percent annual mortality rate will live about four years on average. But according to the Seattle Heart Failure Model, if you add an ACE inhibitor the patient will live five years, and if you add an ACE inhibitor and a beta blocker the patient will live six and a half years. If you use an ACE inhibitor, beta blocker and an aldosterone blocker, the patient makes it to eight years, or double the original life span, Levy said. And if you add an implantable cardiovertor defibrillator (ICD) you would make it to nine and a half years. Heart failure medications are proven to be effective and are relatively inexpensive, as many are available in a generic formulation. However, in ADHERE, a 65,000-patient registry of heart failure patients admitted to the hospital, only 41 percent were taking an ACE inhibitor, and only 45 percent were on beta blockers. The question we are asking is: Why aren t they on these proven life-saving heart failure medicines? Levy said. This model will actually illustrate why patients need to take them. The same applies to cardiac devices, such as biventricular pacemakers, implantable cardiovertor defibrillators, or left-ventricular assist devices. We are trying to encourage patients and physicians to use the medications and devices that we know will work in our heart failure patients, he said. The model may also be valuable in determining who should receive a heart transplant. Unlike other organs, there is no score for either listing patients for a heart transplant or to allocate who receives an organ, Levy said. This model could help determine who should be listed for a heart transplant and to allocate the heart to the highest-risk patient on the waiting list. Dr. David T. Linker, an associate professor of medicine in the Division of Cardiology at the UW and co-author of the paper, has developed a Web-based application to make this interactive model available to health care providers at 4

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7 PPS Benefits of Prognosis Identify persons at greatest risk of death Prompt all involved to re-assess goals of care Re-define medically necessary treatments Focus on symptom control Address physical, spiritual and social issues Prompts PC referral The Bad News Address identified need May assist in expenditure allocation Redefine usefulness of medical tx Allow comparison of health outcomes Allow risk adjustment Best Tool To Date Would I be surprised if this patient died in six months? 7

8 Preparation BEFORE the discussion Review the medical record Review what you know about the pte/fam Consider your own feelings: Anxiety or guilt Ensure that all appropriate clinicians are consulted about their opinions about prognosis 8

9 Goals of Care Communication about Dx. Prognosis and alternative tx plans Sx. Management Decision making consistent with pte/fam. Preferences Addressing existential and spiritual concerns Completion of life tasks Continuity and coordination of services Support for family and caregivers Do Not Forget caregivers Caregiving is a 24/7 work It is often stressful Must meet daily needs of pte and cope their own It is expensive and access to funding cumbersome 9

10 The Project to Educate Physicians on End-oflife Care Supported by the American Medical Association and the Robert Wood Johnson Foundation Module 7 Goals of Care Objectives... Understand the different goals and how they interrelate and change Understand how to use the 7-step protocol to negotiate goals of care Be able to communicate prognosis and its uncertainty Understand how to tell the truth and identify reasonable hope... Objectives Be able to use language effectively Be able to set limits on unreasonable goals Be able to adjust care and communication according to culture Understand how to identify goals when patients lack capacity 10

11 Potential goals of care Cure of disease Avoidance of premature death Maintenance or improvement in function Prolongation of life Relief of suffering Quality of life Staying in control A good death Support for families and loved ones Multiple goals of care Multiple goals often apply simultaneously Goals are often contradictory Certain goals may take priority over others Goals may change Some take precedence over others The shift in focus of care is gradual is an expected part of the continuum of medical care... Palliative care: expanding the options Any life-threatening diagnosis Anytime during illness Whenever patient / family prepared to accept it May be combined with curative therapies May be focus of care 11

12 7-step protocol to negotiate goals of care step protocol to negotiate goals of care 1. Create the right setting 2. Determine what the patient and family know 3. Explore what they are expecting or hoping for 4. Suggest realistic goals 5. Respond empathically 6. Make a plan and follow-through 7. Review and revise periodically, as appropriate Language with unintended consequences Do you want us to do everything possible? Will you agree to discontinue care? It s time we talk about pulling back I think we should stop aggressive therapy I m going to make it so he won t suffer Language to describe the goals of care... I want to give the best care possible until the day you die We will concentrate on improving the quality of your child s life We want to help you live meaningfully in the time that you have 12

13 Language to describe the goals of care Language to describe the goals of care I ll do everything I can to help you maintain your independence I want to ensure that your father receives the kind of treatment he wants Your child s comfort and dignity will be my top priority I will focus my efforts on treating your symptoms Let s discuss what we can do to fulfill your wish to stay at home Let s discuss what we can do to have your child die at home 13