End of Life Care Touro University College of Osteopathic Medicine - CA Gold Humanism Honor Society Class of 2013 Cohort's Group Project
Goals of Presentation History Changing of death in America Introduction & definitions Recognize deficiencies in end of life care How palliative care can address these Realistic expectations Osteopathic Manipulative Medicine in End of Life Care
Not just Education for the family, but also for Residents and the Physicians Resident Rank-Order Listing of Palliative Care Topics (n 49) Domain Pain control Discussing prognosis Delivering bad news Discussing code status Including children in discussions Treatment of nausea Rank Mean SD 1 2.6 2.3 2 3.9 2.1 3 4.3 3.1 4 4.6 2.4 5 5.4 2.5 6 5.7 2.6
History The concept of hospice has been evolving since the 11th century Originally a place of hospitality for the sick, wounded, or dying, as well as those for travelers and pilgrims Many of the foundational principles by which modern hospice services operate were pioneered in the 1950s by Dame Cicely Saunders
History Continued Hospice in the United States has grown from a volunteer-led movement to a significant part of the health care system Last 10 years: 47% growth in number of hospice programs and 74% increase in number of persons served by hospice As of 2009, there were 3400 programs
Changing patterns in the way we die
End of Life Trajectories http://www.nhslothian.scot.nhs.uk/publichealth/2008-09/img/fig-04-04-01.gif
Advanced Directives Legal documents: convey your decisions about end-of-life care ahead of time Communicates your wishes to family, friends, and healthcare professionals Living will tells how you feel about care intended to save life: dialysis breathing machines tube feeding organ donation Durable power of attorney documents your healthcare proxy State-specific living wills and advanced directives
Hospice vs. Palliative Care Hospice: Compassionate care for people facing a lifelimiting illness/injury, involving a team-oriented approach to medical care, pain management and emotional and spiritual support. Focus on caring, not curing, and death with dignity, in most cases, at home. Palliative Care: Treatment that enhances comfort and improves the quality of an individual's life. It focuses on providing patients with relief from the symptoms, pain, and stress of a serious illness. No specific therapy is excluded from consideration in either hospice/pc. www.nhpco.org
Hospice vs. Palliative Care Hospice Usually given in the home with caregiver and visiting home hospice nurse Generally patient must be considered to be terminal or within six months of death to be eligible for most hospice programs or to receive hospice benefits from his/her insurance Most programs concentrate on comfort rather than aggressive disease abatement Palliative Care More common in the hospital, extended care facility, or nursing home that is associated with a palliative care team Can be received by patients at any time, at any stage of illness whether it be terminal or not No expectation that lifeprolonging therapies will be avoided *Palliative care is part of hospice care, but you don't have to be dying to receive palliative care.
http://dx.doi.org/10.1016/j.blre.2012.07.001
5 Emotional Stages of Dying Elisabeth Kubler-Ross (University of Chicago School of Medicine) described the dying patient Fluid state of five emotional changes Acknowledging these stages is important to support our patients even though they may be accusatory and/or belligerent. 1) Denial and isolation 2) Anger 3) Bargaining 4) Depression 5) Acceptance
Begin with the patient What is the patient's view of 'good' end of life care? 5 domains found to be important: Receiving adequate pain and symptom management Avoiding inappropriate prolongation of dying Achieving a sense of control Relieving burden Strengthening relationships with loved ones Singer et al, JAMA, 1999
Problems of the Unknown Without advanced care planning, wishes of the patient are unknown and sustainability of life becomes the only goal Advance care planning: improves end of life care enhances patient and family satisfaction reduces stress, anxiety, & depression in surviving relatives Detering et al., BMJ 2010; 340, 1345
Problems with Care Nearly half of patients studied received unwanted medical treatments For 50% of conscious patients that died in the hospital, family members reported moderate to severe pain at least half of the time 38% of those who died spent >10 days in the ICU Connors et al., JAMA,1995; 274, 1591-1598
Financial Burden on Family 34% of patients required major caregiving assistance from the family In 20%, a family member quit work or made a major life change to provide care to the patient 31% lost most or all of the family savings; 29% lost the major source of income Covinsky JAMA 1994; 272; 1839
ED visits near end of life More than half of older adults who died used the emergency department in the last month of life 77% seen in last month of life were admitted to hospital; 68% died there Repeat visits were common Hospice enrollees rarely went to the ED Smith Health Affairs 2012; 31: 1277
Hospice & the ED- guidelines Step-wise Approach to Initiating hospice referral in the ED Guidelines for ED Patients on Hospice Step 1:Assess Eligibility Is patient expected to live 6mos or less if the disease runs its normal course? Step 2:Assess whether Patient/surrogate goals are consistent with the Hospice Philosophy Ask, "if we could ensure taht you will be taken care of comfortable at home, with good support and an attempt to treat what is easily reversible, what would you say?" Step 3: Discuss Hospice as a disposition with Primary Physician The emegency provides should sicuss with the primary physician the prognosis and referral to coordinate care. Because the team si interdisciplinary, it is a matter of professional courtesy and ensures support for the hospice care plan once initiated, decreasing conflicts in plans of care. Step 4:Introduce Hospice as Plan of Care to Patient & Surrogates Address any concerns and clarify misconceptions. Code status may be discussed but is not necessary for placement Step 5:Make a Referral; Write holding orders Anyone on the ED team may initiate a cal to a local hospice. The patient or caregivers may have an agency that they would prefer. The ED attending physician would need to write an initial prognostic statement. Anticipate questions such as, Is there a caregiver? Does the patient need 24-hrs care? Does the patient need special equipment such as home oxygen? Step 6:Ensure Understanding and Secure the Plan Communicate wiht patient/surrgogate about what to expect next: an inpatient hospice bed, hospital admission until referral, or a discharge home with early hospice contact. 1. Treat distressing signs and symptoms. Provide physical and emotional support to the patient/caregivers. Maintain a supportive, patient-centered approach to care. 2. If deterioration is imminent, ascertain resuscitation status and the desire for life-extending therapy such as mechanical ventilation. (It is not necessary to have a DNR order to be under hospice care.) 3. Notify hospice of the patient's transfer to the ED. 4. May need to delay laboratory tests or other diagnostic studies until discussed with hospice nurse/physician. Follow patient's already determined goals of care. 5. Ascertain the pain level and medications for pain currently in use; maintain the baseline dosages despite seemingly high and continue ion ED until disposition. 6. Avoid the initiation of invasive treatments, including IV lines, unless discussed with hospice nurse/physician and family; the patient may appear dehydrated because patients frequently stop drinking as death approaches, but is normal and expected. 7. If the patient is actively dying, try to give the family privacy; involve the chaplain on family request. 8. Symptom-directed therapy for relaxation and gagitation as needed; oxygen by nasal cannula may be freely given. 9. Do not admit to the hospital without discussion with hospice nurse/physician because an alternate disposition may be possible. 10. If the patient is admitted, consult inpatient palliative care Source: Annals of Emergency Medicine 2011; 57:282-290 (DOI:10.1016/j.annemergmed.2010.06.569 )
Patient Preference for Place of Death Of the 81% who preferred to die at home, 55% died in the hospital Of the 19% who preferred to die in the hospital, 46% died in the hospital Major factor was availability of hospital beds and hospice/nursing homes in area J Am Geriatr Soc. 1998: 46, 1242
End of Life Discussions and Quality of Life End of Life discussions associated with: Reduced rates of ventilation Reduced rates of resuscitation Reduced rates of ICU admission Earlier hospice enrollment More aggressive medical care may lead to: Worse patient quality of life (QOL) Increased risk of major depressive disorder in bereaved caregiver Longer hospice stays lead to better patient QOL which was associated with better caregiver QOL JAMA. 2008;300(14):1665-1673
Palliative Care Goals Comfort care: pain and symptom management Shared decision making Psychosocial and spiritual support for patient and family Home care and other alternatives to the acute care hospital
Difference between Adults and Children Approach Adult: discussion more focused on end of life Pediatrics: Does not focus on end of life. More of a delicate, supportive discussion about making the patient comfortable and working with the family for all of their needs.
What to Expect in the Process Weakness/fatigue Reduced intake Decreased communication Confusion/delirium Breathing changes Loss of bowel/bladder control Eyes won't close Poor circulation
Common Medications/ The "Comfort Kit" Morphine liquid - used to treat pain and shortness of breath Lorazepam - can be used to treat anxiety, nausea or insomnia Atropine drops - used to treat wet respirations, also known as the death rattle Haloperidol- can treat agitation and terminal restlessness Prochlorperazine - in either pill or rectal suppository form, this medication is used to treat nausea and vomiting Promethazine - an anti-emetic like compazine, phenergen is used to treat nausea and vomiting Dulcolax suppositories- rectal suppositories to treat constipation Senna - a plant-based laxative used to treat constipation
Osteopathic Manipulative Treatment and the Dying Patient
Osteopathic Manipulative Treatment and the Dying Patient Principles of Osteopathy are no different in its application to the dying patient as in any other stage of life 1) The body is a unit: an integrated unit of mind, body, and spirit. 2) The body possesses self-regulatory mechanisms, having the inherent capacity to defend, repair, and remodel itself. 3) Structure and function are reciprocally interrelated. 4) Rational therapy is based on consideration of the first 3 principles.
Osteopathic Manipulative Treatment and the Dying Patient End-of-life problems that can be addressed with osteopathy include: Pain Gastrointestinal dysfunction (nausea, vomiting, ileus, and constipation) Cardiopulmonary problems (shortness of breath, central and peripheral edema)
Somatic Dysfunction Impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial, and myofascial structures, and related vascular, lymphatic, and neural elements
Myofascial and Visceral Pain Entering the final stage of life is often associated with fear of pain and suffering Appropriate use of OMT, medications, nerve blocks, neurostimulation, biofeedback, and physical therapy can alleviate discomfort Soft tissue stretching, gentle articulatory procedures, rib raising, counterstrain, and lymphatic pump are some options that may be implemented in the care of the dying patient Caution should be taken with patients with fragile bone strength and it is best to err in the direct of less aggressive procedures
Gastrointestinal Problems May include nausea, vomiting, diminished peristalsis, constipation, and malabsorption of nutrients Peristalsis may be compromised due to the loss of intrinsic gut motility or external effect of physical activity. Transabdominal OMT can be used to increase peristalsis. Frequent application of transabdominal OMT is recommended and can safely be taught to the patient, family members, and other caretakers Can alleviate passive congestion of blood/lymph with mechanical stimulation of the organs as well as the diaphragm and lymphatic structures
Gastrointestinal Problems Optimize parasympathetic tone to the GI tract by focusing treatments to the vagus and pelvic splanchnic nerves Vagal reflexes can be addressed by treating occiput, C1 and C2 somatic dysfunction and primarily result in right-sided reactions in the pancreas, liver, gallbladder, small intestine and ascending colon, and right side of the transverse colon. Left-sided reactions occur in the esophagus, stomach, and duodenum. Sacral parasympathetic reflexes via S2-S4 typically result in left-sided reactions of the left side of the transverse colon, descending colon, sigmoid colon, and rectum.
Cardiopulmonary CHF and pulmonary failure are frequently encountered at end of life and often occur together Peripheral and pulmonary edema can be relieved with lymphatic drainage Lymphatic pump techniques mobilize fluids and significantly impact the homeostasis of the patient Thoracic inlet, thoracic spine, ribs, thoracoabdominal diaphragm must be evaluated to optimize the mechanics of respiration C3, C4 and C5 somatic dysfunction treatments optimize phrenic nerve function, further improving diaphragmatic function
Osteopathic Manipulative Therapy and the Dying Patient Ultimately, OMT can correct somatic dysfunctions and provide an overall positive effect on the patient It makes the patient feel worthwhile and allows them to live until the end of life without feeling burdensome Zal, A.J., (2007). Chapter 13 The Patient at the End of Life. in Nelson, K.E. & Glonek, T. (Eds.), Somatic Dysfunction in Osteopathic Family Medicine (pp. 181-196). Baltimore, MD: Lippincott Williams & Wilkins.
Resources http://theconversationproject.org/ http://www.aahpm.org/ http://www.eperc.mcw.edu/eperc