End of Life Care PDF

End of Life Kelsey Noble, DO Board Certified Family Physician Hospice & Palliative Medicine Fellow Objectives Begin thinking about prognostication and work on developing prognostic awareness Identify common signs and symptoms patients may exhibit at end of life Know a few basic tools for management...

End of Life Kelsey Noble, DO Board Certified Family Physician Hospice & Palliative Medicine Fellow Objectives Begin thinking about prognostication and work on developing prognostic awareness Identify common signs and symptoms patients may exhibit at end of life Know a few basic tools for management of these symptoms Be able to compassionately and knowledgably support caregivers of dying patients Dying in the United States of America “It’s so hard to die here!” In 1950, over 50% of people died in their home First ventilators used outside of the operating room: August 1952 CardioPulmonary Resuscitation- developed in the 1960s as a treatment for sudden cardiac death Ebell MH, Jang W, Shen Y, Geocadin RG, for the Get With the Guidelines–Resuscitation Investigators. Development and Validation of the Good Outcome Following Attempted Resuscitation (GO-FAR) Score to Predict Neurologically Intact Survival After InHospital Cardiopulmonary Resuscitation. JAMA Intern Med. 2013;173(20):1872–1878. doi:10.1001/jamainternmed.2013.10037 “Being mortal is about the struggle to cope with the constraints of our biology, with the limits set by genes and cells and flesh and bone. Medical science has given us the remarkable power to push against these limits, and the potential value of this power was a central reason I became a doctor. But again and again, I have seen the damage we in medicine do when we fail to acknowledge that such power is finite and always will be. -Atul Gawande, Being Mortal Dying in the United States of America Remember that dying is a natural process, an integral and inevitable part of life. It is the EXPECTED outcome of living and should not be considered a failure. We provide medical care to people for the duration of life and palliative care is about ensuring we deliver the RIGHT care at the RIGHT time. “It’s so hard to die here!” Dying in the United States of America The percentage of deaths from all causes that occurred in a hospital decreased from 48.0% in 2000 to 35.1% “It’s so hard to die here!” in 2018. During that period, the percentage of deaths that occurred in the decedent’s home increased from 22.7% to 31.4%, and the percentage that occurred in a long-term care facility (hospice, nursing home, longterm care) increased from 22.9% to 26.8%. Source: National Vital Statistics System. Underlying cause of death data, 2000– 2018. https://wonder.cdc.gov/ucd-icd10.html. Murray, et al. Illness Trajectories and Palliative Care. BMJ 2015. bmj33001007.p df (nih.gov) Murray, et al. Illness Trajectories and Palliative Care. BMJ 2015. bmj33001007.pdf (nih.gov) What is Hospice? Medical care for people with an anticipated life expectancy of 6 months or less, when cure isn’t an option, and the focus shifts to symptom management and quality of life. An interdisciplinary team of professionals trained to address physical, psychosocial, and spiritual needs of the person; the team also supports family members and other caregivers. Provided primarily where a person lives, whether that is a private residence, nursing home, or community living arrangement, allowing the patient to be with important objects, memories, and family. Care that includes periodic visits to the patient and family caregivers by hospice team members. Hospice providers are available 24 hours a day, 7 days a week to respond if patient or caregiver concerns arise. The only medical care that includes bereavement care, which is available during the illness and for more than a year after the death for the family/intimate network. A Medicare benefit; to which all Medicare enrollees have a right. Hospice care also is covered by most private health insurance at varying levels, and in almost every state, by Medicaid. What is Hospice NOT? Focused on curative therapies or medical intervention designed to prolong life. A replacement for nursing home care or other residential care. Stopping all medications Care that hastens death. Reserved for homebound/bedbound patients. What does the hospice benefit include? Care team, including: hospice physician, RN, social worker, counselor/chaplain Medical supplies like oxygen, catheters, bandages, briefs Short-term Inpatient Care (when adequate symptom control cannot be achieved in the home setting) Medication for symptom control Medical equipment like a hospital bed, wheelchair, walker PT/OT, SLP, dietician* (Access on a case by case basis) Any other Medicare covered services needed to manage pain and other symptoms related to the terminal illness, as recommended by the hospice team Short-term respite care (relief for family caregivers) Grief and loss counseling for patient and loved ones, leading up to and for 13 months after a death Hospice Regulations and Notices | CMS When is Hospice appropriate? THE ONLY DEFINITIVE CRITERIA: Prognosis