Intensive Care Unit END OF LIFE CARE FOR THE FRAIL ELDERLY Ken Hillman Interface of Palliative Care and ICU/Critical Care. Palliative Care South Australia. 19 March 2018. Adelaide.
THE CHALLENGE Increasing number of aged people Increasing number of aged people coming into EDs via ambulance Increasing number of aged patients in ED Increasing number of aged patients in hospitals The Lancet 2016;387:2145
Proportion of deaths in hospital by agegroup and sex, 2014-15 Australia
Proportion of deaths in hospital that involved an ICU stay by age-group and sex, 2014-15 Australia
MYTH Hospitals are good places to die 9/0628
DYING SAFELY IN HOSPITALS The management of end-of-life care in hospitals is dangerous: Patients at the end-of-life are not recognised Management is inappropriate, resulting in inappropriate care and suffering for patients Inter J Cl Practice 2009; 63: 508
MYTH Doctors know how to diagnose dying and understand the limits of modern medicine 9/0629
DIFFICULTY DIAGNOSING DYING Multicentre, international study One-third of all emergency calls in hospitals are for previously not addressed end-of-life issues CCM 2012;40:98-103 9/0673
INEFFECTIVE / INAPPROPRIATE / FUTILE INTERVENTIONS AT THE END-OF-LIFE UP TO ONE-THIRD OF ALL INTERVENTIONS Int J Qual Health Care 2016;28(4):456-469
DELAYED DIAGNOSIS OF DYING UNTIL THE VERY END J Palliat Med 2005;8:1042
PNEUMONIA USED TO BE THE OLD PERSON S FRIEND
Nelson Mandela died of old age and frailty (labelled pneumonia) Of all the people in the world who has the courage, acceptance and dignity to face this, it is Nelson Mandela 9/0670
MANY DEATHS ARE PRECEEDED BY A SURGE IN TREATMENT
THE FACTS In Australia, a dying person will have: 8 hospital admissions in the last year 2 ED visits A 60 70% chance of dying in hospital MJA 2011;194:1-4
CO-MORBIDITIES or CHRONIC HEALTH CONDITIONS Normal and predictable age-related conditions Irreversible and progressive Associated with increasing frailty, infections and falls These are MARKERS of nearing the endof-life, not necessarily treatable conditions
DIAGNOSIS OBSESSED Training Dialogue and communication DRGs billing and performance indicator Dictates how we die with a label 9/0672
THE SINGLE DISEASE PATHWAY From a different medical era - no longer relevant
DIFFERENT POPULATION SAME SYSTEM The majority of hospitalised patients are now >60 years of age The sum of the chronic conditions predispose to the acute reason for admission and the seriousness of it Specialists are not appropriate for this new population of patients
OVER DIAGNOSIS AND OVER TREATMENT Doctors do not recognise the frail aged as terminal No discussion with patient/carer until last few hours/days of life
MOST HOSPITALISED PATIENTS >85 YEARS OLD HAVE DIED BY 12 MONTHS
OUTCOMES IN THE ELDERLY FRAIL Not just short or even long-term mortality: Quality of life Post-traumatic stress syndrome FUTURE RESEARCH - Would I go through this again?
USING ELECTRONIC HEALTH RECORD (EHR) TO PREVENT OVER-USE Delivering the most up-to-date Evidence Based Medicine (EBM) to elderly frail patients is over-use JAMA 2017; 317: 257
FRAIL AGED - TERMINAL CONDITION MEDICINE SEES IT AS A DISEASE To be cured or delayed or controlled
ZEUS GRANTED TITHONUS Immortality but not Eternal youth Similar to todays ageing population
FRAILTY PREVALENCE IN HOSPITALS 42% in >65 year olds 50% elective surgery 80% medicine 100% in geriatrics in >75 year olds J Am Coll Surg 2010;210:901 Int J Nurs Pract 2010;16:14
A NEW APPROACH
RECOGNITION Need a more accurate way Need a different and more realistic approach not tied to traditional diagnosis The CriSTAL tool BMJ Supp and Pall Care 2014; 4: 263 9/0410
A TOOL TO MINIMISE UNCERTAINTY AROUND END-OF-LIFE IN THE ELDERLY FRAIL 5 countries 14 hospitals 3000 patients
MODIFED CriSTAL TOOL Age Co-morbidities Disseminated cancer FRAILTY are important
FRAILTY Age-associated Decreased functionality Decreased biological reserves Physiological dysregulation Increased vulnerability Associated with poor outcomes The Lancet 2015;385.
Clinical Frailty Scale 1. Very Fit 5. Mildly Frail 2. Well 6. Moderately Frail 7. Severely Frail 3. Managing Well 8. Very Severely Frail 4. Vulnerable 9. Terminally Ill
Age-Related Frailty Is Not Curable
HAVE WE ASKED THE ELDERLY FRAIL ATTENDING HOSPITALS: IS THIS WHAT YOU WANT?
RESPONSE UNCERTAINTY inherent in clinical practice FLAG not a precise number
It is easier to write ten volumes of philosophy than to put one principle into practice Stephan Zweig 1847
TURNING POLICY INTO PRACTICE - SWEDEN Almost no awareness at any level of any organisation about any end-of-life policies Recommend tying policy to implementation and evaluating the policy by its implementation Health Policy 2017; 121: 1194
RESPONSE Honest and empathetic discussion with patient/carer Empowering patient/carer to construct own Goals of Care Connecting with appropriate resources to achieve those Goals 9/0495
RESPONSE HONEST AND EMPATHETIC DISCUSSION Trialing with dedicated and specifically trained person Eventually hoping to train and embed this approach as part of normal practice in hospitals and community
RESPONSE GENERIC RESPONSE On admission to the emergency department At the time of a rapid response call (1/3 for end-of-life issues) On admission to the ICU At the pre-operative clinic GPs Other community settings
RESPONSE Connect with community alternatives General practitioner Support in the home Aged care and other institutions
Over-treatment of 50 year olds is mostly a matter of inconvenience and waste, whereas over-treatment of 80 year olds borders on assault James Goodwin NEJM 1999;340:1283
I am writing about a 94 year old patient, AS, who was recently an inpatient under my care. Mrs Scordino was admitted from a nursing home with a L1 fracture post fall, and delirium on top of mixed dementia. She had a background history of right sided stroke with left sided weakness and hypertension I suggest that prazosin should not be used in older people and would be grateful if you could pass this on to the ICU registrars. Mrs Scordino subsequently improved and was discharged alive (justifying the decision to admit and treat).
GERIATRICS ABOUT INEVITABILITY OF AGEING Preventability Modification Intervention But also acceptance and social support
WHAT IS IMPORTANT TO PATIENTS Control where they die Close to friends/family Company Assistance with personal care Meals Clean surroundings Needs of the elderly near the end-of-life social not medical
End-of-life care in the elderly is NOT NECESSARILY: geriatrics and medical palliative care It is a widespread social and community support Most frail elderly do not want repeated hospital admissions at the end-of-life
THE ROLE OF GPs IN THE CARE OF THE ELDERLY FRAIL Be aware of what hospitals can and can t do Ageing and frailty are irreversible and untreatable Honest and empathetic engagement with the elderly/carers Future medical care and ACDs are based on the same beliefs
WHAT IS THE ROLE OF PALLIATIVE CARE IN THE LAST YEAR OF LIFE IN THE ELDERLY FRAIL?
REFORMS Public discussion about the limitations of modern health care Personal choices encouraged and formally stated Ensure system complies with wishes Reorientate current health services to comply with society s wishes MJA 2015;202:10 9/0495
REFORMS Better recognition of the dying needs to become everyone s business Palliative care may not have the resources to deal with all dying patients in hospital and the community The needs of elderly frail patients near the end-of-life are more a social construct
COST Community Palliative Care package for last 3 months of life total cost $6000 Cost of an ICU bed - $4000/patient/day Swerrissen H, Duckett S. Dying Well. Grattan Institute. 2014. http://grattan.edu.au/wp-content/uploads/2014/09/815- dying-well.pdf
Medical crescendo occurs by default, not as a result of personal choice based on prognosis The Economist 2017
DYING GRADUAL DETERIORATION Boundaries between being old, sick and dying have been obscured by us.