Download Palliative care, hospice and dementia

Palliative care, hospice and dementia:
Are we providing the right care at the right time?
Jean Jaoude, MD, MHA, CMD
Medical director
UnityPoint Hospice and Palliative care
[email protected]
Participants will be able to:
• Describe the differences and similarities of
hospice and palliative care
• Identify the aging changes effect on end-of-life
geriatric care
• List the Do's and Don'ts in advanced dementia
and end-of-life care
Case 1
84 y.o. patient with metastatic lung cancer decides
to forgo further treatment after failing several
chemotherapy trials. He reports he is weak and
unable to enjoy his hobbies of fishing and traveling
anymore. He spends most of his time in his recliner.
His wife helps him with dressing which is every 3
days now . Bathing is limited to once a week. With
assistance of his wife and his walker, he takes
couple of steps only and needs to sit down due to
shortness of breath and fatigue. He reports no
appetite and a weight loss of 40 pounds over the
past 2 months.
Case 1(cont’d)
He wishes to focus on his quality of life and have his pain
and dyspnea under better control. He asks for your
opinion in regards to hospice referral. you should:
1- Refer to palliative care since this is a must step prior to
hospice referral
2- Disagree with him and encourage enrollment in a new
research chemotherapy trial
3- Counsel him about hospice care and proceed with the
referral
4- Explain to him that once he chooses to enroll, he
cannot revoke hospice care
Case 2
91 y.o. patient with Alzheimer’s dementia lives at
home with his daughter. She has been taking care of
him for the past 5 years. Over the past 6 months
she noticed he has been spending most of his time
in bed. He has been unable to bear any weight and
is non-ambulatory. He is dependent on his daughter
for bathing, dressing, and feeding. He is incontinent
of urine. He does not interact with family or
surrounding. Over the past 2 months, he has been
taking only bites of his meals and sips of his fluids
with occasional cough episodes.
Case 2(Cont’d)
Daughter is concerned about weight loss and
dehydration. she asks for your opinion. you counsel her
and recommend to:
1- Admit patient to the hospital and start IV fluids
2- Insert PEG tube and start feeding
3- Offer oral assisted feedings
4- Place PICC line and start TPN indefinitely
Aging Population
Aging Population
millions
90
80
70
60
50
85+
40
75-84
65-74
30
20
10
0
2010
2020
2030
Source : Us census Bureau 2008
2040
Aging Population
•
•
•
•
•
Higher comorbidities
Complex medical problems
Increased Rate of dementia
Stress on the healthcare system
Questionable model of care(i.e. acute care
model)
Baby Boomers
Aging and
physiologic changes
Renal:
• Renal mass decreases 25-30%
• Number of nephrons decreases(kidney adapts
to loss of nephrons by compensatory hyperfiltration and/or increasing solute and water
reabsorption in the remaining nephrons)
• Serum creatinine is unchanged
• Creatinine clearance decreases
Aging and
physiologic changes
Renal(continued):
Age
CrCl
Aging and
physiologic changes
Cardiovascular:
• Maximum heart rate declines(220-age in
males)
• Maximum cardiac output declines(At rest,
cardiac output tends to be normal. It declines
with stress)
• Increase in systolic BP(not age-related only)
Aging and
physiologic changes
Nervous system:
• Decrease in brain volume(20%)
• Asymmetric loss of neurons
Vision:
• Decrease in light adaptation(when walking in
dark room)
• Lacrimal gland function decreases
• More sensitive to glare because of light
dispersion in the lens
Aging and
physiologic changes
Hearing:
• High frequency hearing loss
Respiratory:
• Lung elasticity and elastic recoil decreased
• Decreased FEV1
Musculoskeletal:
• Muscle mass decreases
• Bone mass/density decreases
Aging and
physiological changes
Hematopoietic:
• Hct and WCC are unchanged (WCC may not be
elevated during an infection)
• T-cell function is decreased (immunological
response to vaccine is reduced)
Digestive:
• Decreased function of the GE junction(thus more
reflux prone)
• Decreased bowel transit time (thus more
constipation prone)
Aging and
physiological changes
Liver:
• Liver mass decreases by 25-35% and blood flow
by as much as 40% by age 90. Thus:
• Diminished first-pass metabolism
Increased
drug serum concentration(i.e. nitrates, Bblockers, CCB etc.)
• Diminished metabolic pathways(Cytochrome
P450-Phase 1 reaction)
Decreased oxidation,
hydroxylation, demethylation
Increase in
drug half-life(i.e. diazepam, alprazolam, NOT
Lorazepam-Phase 2)
Impact on caring for
the elderly
• Adjust medication dose(Renal and liver changes)
• Greater degree of illness and debility like
dehydration and quicker acute renal failure(renal
and cardiac changes)
• Less physiologic reserve thus myocardial
infarction and congestive heart failure prone(
cardiac changes)
• Patients more prone to confusion(Brain changes)
• More prone to reflux thus prone to aspiration
even if PEG use(GI changes)
Dementia
Projected number (in millions) of people age 65
and older in the U.S. population with Alzheimer’s
Disease , 2010 to 2050
16
14
12
10
85+
8
65-84
6
4
2
0
2005
2015
2025
2035
2045
Created from data from hebert et al. – 2013 Alzheimer’s disease facts and figures
Average annual per-person payments for health care services
provided to Medicare beneficiaries age 65 and older
Beneficiaries with
Alzheimer’s and other
dementias
Beneficiaries without
Alzheimer’s and other
dementias
Inpatient hospital
$ 10,293
$ 4,138
Medical provider
$ 6,095
$ 4,041
Skilled nursing facility
$ 3,955
$ 466
Hospice
$ 1,821
$ 178
Home health
$ 1,460
$ 471
Prescriptions medications
$ 2,787
$ 2,840
Created from data from the Medicare current beneficiary survey for 2008
Percentage changes in selected causes
of death (all ages) between 2000-2010
100%
80%
68%
60%
40%
20%
0%
Alzheimer
Stroke
Heart disease
Breast cancer
-20%
-40%
Data from the National Center for health statistics
-2%
-16%
-23%
What is palliative care?
• Palliative care is specialized medical care for
people of any age with serious illnesses. It is
focused on providing patients with relief from
the symptoms, pain and stress of a serious
illness, whatever the diagnosis.
• The goal is to improve quality of life for both
the patient and the family.
Who is palliative care appropriate for?
• Palliative Medicine is appropriate at any age and
at any stage in a serious illness, and can be
provided together with curative treatment.
• Life limiting disease like(not limited):
– COPD
– CHF
– Cancer
– Dementia
– Parkinson
Palliative Care
Services
•
•
•
•
Goal clarification
IPOST development
Symptom management
Education/ chronic
disease management
• Coordination of care
• Medical director
• Nurse
practitioners/Physicians
• Social workers
• Nurses
• Bereavement/chaplain
you may be mistaken for …
Communication
• Communication with patients, families,
providers, multidisciplinary team
• Family conferences
• Tips for communication
“Family wants everything done”
Goal clarification
• Considering the patient’s disease process,
what is the patient’s goal?
• Goal clarification is key
• End of life wishes
• Advanced directives
• IPOST
– Iowa Physician Orders for Scope of Treatment
Coordinate
• Coordinate care of patients among various
agencies
• Coordinate and share plans of care
• Access resources
• IDT
Support
•
•
•
•
•
Facilitation of family conferences
Community Resources
Financial Assessment
Transfer to new setting
Advance Directives
Symptom management
• Collaborating with others to provide symptom
relief
• Physical symptoms
• Emotional symptoms
• Spiritual symptoms
Hospice
• Care designed to give supportive care to
people in the final phase of a terminal illness
and focus on comfort and quality of life,
rather than cure.
• The goal is to improve quality of life for both
the patient and the family.
END-of-Life care
Services
• Case Management
• Symptoms management
• Social and emotional
support
• Spiritual care
• Assistance with ADL’s
• Volunteers
• Medications
• Supplies/equipment
•
•
•
•
•
•
•
Medical director
Nurses
Social Workers
Chaplain
Volunteers
Certified Nursing Aides
Music, pet and massage
therapy
Medicare Hospice Benefit
•
•
•
•
Professional services
Medical equipment/ supplies
Medications
4 Levels of care
– Routine home care
– Continuous care
– Short term inpatient care
– Respite care
End-of-Life
•
•
•
•
Hospitals major site for end-of-life care
Rate of hospital death is 30% *
Setting goals at the end of life
Discussing values, preferences and goals with
patients
• CMS approved reimbursement for providers
discussing advance care planning
* JAMA, January 2016
End-of-life
Guidelines for discussions
1. Begin conversations early in the illness
2. Ask about their understanding of current medical
condition
3. Assess patient’s and family’s information-sharing
preferences
4. Answer clearly with jargon’s-free information about
patient’s condition, prognosis and options
5. Ask about unacceptable states
6. Inquire about patient’s concerns
7. Recommend a plan for end-of-life care
Comfort care for patients dying in the hospital
Craig D Blinderman, MD and J. Andrew Billings, MD
N Engl J Med, December 24, 2015
The conversation
Do’s and Don’ts in advanced dementia
and end-of-life care (Choosing Wisely)
Do
• Screen for dementia in your
clinic(USPSTF- Evidence
Insufficient to assess the
balance of benefits and
harms of screening for
cognitive impairment)
• Start the conversation
early(NEJM).
Don’t
• Don’t delay palliative care for a
patient with serious illness
who has physical,
psychological, social, or
spiritual distress because they
are pursuing disease-directed
treatment(HPM).
• Don’t delay engaging available
palliative and hospice care
services in the emergency
department for patients likely
to benefit(ER).
Do’s and Don’ts in advanced dementia
and end-of-life care (Choosing Wisely)
Do
• Avoid prescribing appetite
stimulants and high calorie
nutritional supplements in
elderly with anorexia and
cachexia(AGS).
• Discontinue medications that
may interfere with eating.
Provide appealing food,
feeding assistance, measures
for optimizing social supports,
and means to clarify patient
goals and expectations(AGS).
Don’t
• Don’t recommend
percutaneous feeding tubes
in patients with advanced
dementia; instead, offer
oral assisted feeding(HPM,
AGS, AMDA).
Do’s and Don’ts in advanced dementia
and end-of-life care (Choosing Wisely)
• Don’t leave an implantable cardioverterdefibrillator (ICD) activated when it is inconsistent
with the patient/family goals of care (HPM).
• Don’t routinely prescribe lipid-lowering
medications in individuals with a limited life
expectancy (AMDA).
• Don’t recommend aggressive or hospital-level
care for a frail elder without a clear
understanding of the individual’s goals of care
and the possible benefits and burdens (AMDA).
Thank you