Next Month

1. Next Month • Live Conference is on FRIDAY June 5 • Millard Fillmore Gates/Suburban will replay session for Monday Grand Rounds Meg Campbell, PhD, RN Recognizing patients who can benefit from palliative care consultation

2. CME Disclosure • NO commercial relationships of any kind • Some off-label uses may be discussed—they will be identified as such

3. Managing Death:Diagnosing Dying,Setting Goals Jack P. Freer, MD Professor of Medicine University at Buffalo

4. Learning Objectives • Be able to recognize the dying patient in institutional settings

5. Learning Objectives • Be able to recognize the dying patient in institutional settings • Help clarify and prioritize the goals of care most relevant to the dying patient

6. Learning Objectives • Be able to recognize the dying patient in institutional settings • Help clarify and prioritize the goals of care most relevant to the dying patient • avoid burdensome diagnostic and therapeutic modalities that are unlikely to further the goals of care

7. Learning Objectives • Be able to recognize the dying patient in institutional settings • Help clarify and prioritize the goals of care most relevant to the dying patient • avoid burdensome diagnostic and therapeutic modalities that are unlikely to further the goals of care • Help family and staff understand clinical signs and symptoms that are likely to occur

8. Learning Objectives • Be able to recognize the dying patient in institutional settings

12. Diagnosing “Dying” Some patients are clearly dying • They die, no matter how intensely we try to prevent death. • They die, no matter how superb the medical care they receive. • If we “successfully treat” one potential cause of death, they still “die of something else.”

13. Diagnosing “Dying” Dying patients may be maddeningly difficult to distinguish from those who are simply sick. • Frail old people sometimes get pneumonia or an MI. • High quality medical care sometimes restores them to baseline.

14. Diagnosing “Dying” More often than not, modern medicine treats dying patients like they are simply sick. • Fits with our forensic reductionist medical model (people die of something). • In uncertain situations, we avoid the path that will cause us the most chagrin.

15. Chagrin Factor Feinstein AR. The 'chagrin factor' and qualitative decision analysis. Archives of Internal Medicine. 145(7):1257-9, 1985 Jul. • Medical decisions produce specific results • Each “wrong result” follows from a particular decision “...a customary clinical strategy is to choose the option whose wrong result will cause the least chagrin.”

17. Prognosticating in Cancer Patient • Advanced metastatic cancer is fatal • Trajectory is predictable • Performance predicts survival

18. Karnofsky Performance Status

23. Prognosticating in CHF/COPD • Diseases are potentially fatal • Trajectory is less predictable • Treatment decisions have significant effect (ventilator)

25. Prognosticating in Dementia, Frailty • Alzheimer’s is fatal (not widely recognized) • Trajectory is very unpredictable • Treatment decisions have significant effect (PEG)

26. Learning Objectives • Be able to recognize the dying patient in institutional settings • Help clarify and prioritize the goals of care most relevant to the dying patient • avoid burdensome diagnostic and therapeutic modalities that are unlikely to further the goals of care • Help family and staff understand clinical signs and symptoms that are likely to occur

27. Goals of Care? • Complete cure

28. Goals of Care? • Complete cure • Longevity/survival

29. Goals of Care? • Complete cure • Longevity/survival • Comfort/avoidsuffering

30. Goals of Care? • Complete cure • Longevity/survival • Comfort/avoidsuffering • Independence

31. Goals of Care? • Complete cure • Longevity/survival • Comfort/avoidsuffering • Independence • Remain in familiar environment

32. Goals of Care? • Complete cure • Longevity/survival • Comfort/avoidsuffering • Independence • Remain in familiar environment • …

33. Goals of Care • Goals not explicitly articulated • Single goal often presumed • Failure to attain that goal devastating

34. Goals of Care • Multiple goals • Goals differ in priority • Goals differ in attainability • Goals conflict with each other • Dynamic—changes with time

35. Goals of Care? • Complete cure • Longevity/survival • Comfort/avoidsuffering • Independence • Remain in familiar environment • …

36. Goals of Care? • Longevity/survival • Comfort/avoidsuffering • Remain in familiar environment

37. Goals of Care? • Longevity/survival • Comfort/avoidsuffering

38. Goals of Care? • Comfort/avoidsuffering • Remain in familiar environment

39. Learning Objectives • Be able to recognize the dying patient in institutional settings • Help clarify and prioritize the goals of care most relevant to the dying patient • avoid burdensome diagnostic and therapeutic modalities that are unlikely to further the goals of care • Help family and staff understand clinical signs and symptoms that are likely to occur

40. “Futility” vs. Goals of Care • Aggressive treatments in dying patients sometimes discounted as “futile” • Futility really means totally ineffective

41. “Futility” vs. Goals of Care • Real reason: the treatment is incapable of furthering any realistic goals of care • Dialysis, ventilator, PEG tubes etc • Diagnostic tests: scans, biopsies, blood tests • Vital signs, pulse oximetry

42. Learning Objectives • Be able to recognize the dying patient in institutional settings • Help clarify and prioritize the goals of care most relevant to the dying patient • avoid burdensome diagnostic and therapeutic modalities that are unlikely to further the goals of care • Help family and staff understand clinical signs and symptoms that are likely to occur

43. Death in Days—Weeks • Bedridden • Profound weakness • Little interest in food / drink • Difficulty swallowing • Increasingly somnolent Palliative Medicine, Declan Walsh, MD, Ed. 2009 by Saunders/Elsevier

44. Death in Hours—Days • Cold skin • Clammy skin • Cyanosis of extremities / mouth • Decreased urine output • Diminished level of consciousness Palliative Medicine, Declan Walsh, MD, Ed. 2009 by Saunders/Elsevier

45. Death in Hours—Days • Breathing may “rattle” • Respiration: irregular / shallow / Cheyne-Stokes • Waxen face • Relaxed facial muscles • Prominent nose Palliative Medicine, Declan Walsh, MD, Ed. 2009 by Saunders/Elsevier

46. Summary • Diagnose Dying • Clarify and Prioritize Goals • Start Early • Engage Patient & Family • Review, Revise, Discuss • Trust the Process • Communication: Start with Positive Treatments (not “Do Not….”) • Location, Location, Location