End of Life Care and Assessment Tools

• definitions

  • Palliative care -- focuses on QOL and alleviation of symptoms in pts w/ serious illness
  • Aim is to consider all facets to maintain hope, dignity, and autonomy
  • Offered simultaneously w/ other medical treatment
  • Hospice care -- provided when a pt is terminally ill
  • < 6 months to live [confirmed by 2 physicians]
  • Specific type of comfort care
• definitions (cont.)

  • DNR -- Do-Not-Resuscitate
  • Life sustaining treatment  -- any tx that serves to prolong life w/o reversing underlying medical condition (mechanical ventilation, dialysis, chemo, antibiotics, artificial nutrition, hydration)
  • Medical Power of Attorney (POA)
  • Legal form -- person who makes your medical care decisions ONLY if you're unable to make your decisions
• advanced directives

  • "Do you have a written plan stating what health care txs you would or would not want if you could not speak for yourself?"
  • Whys is it important?
  • Allows wishes to be known
  • Only used if unable to express decisions
  • Can happen at any age
  • Peace of mind -- you and your loved ones
  • Caveats
  • Can be overridden by treating MD
  • Does not immediately translate to MD order
• treatment limitations -- palliative care

  • No limitations in treatment
  • May include curative of life-prolonging measures if they help pt achieve goals
  • Compensated like any other specialty service
• treatment limitations -- hospice care

  • Limitations on treatment
  • May NOT include curative treatment
  • Goal is NOT to cure, but to provide comfort
  • Receives fixed per diem rate for all services
• From Vitas Healthcare

  Palliative Care Eligibility

  • Is begun at the discretion of the physician and pt at any time, at any stage of illness, terminal or not

   

  Palliative Services

  • Paid by insurance, self
  • Any stage of disease
  • Same time as curative treatment
  • Typically happens in hospital
  • Cost can vary
• From Vistas Healthcare (cont.)

  In Common between Palliative and Hospice Services

  • Comfort care
  • Reduce stress
  • Offer complex symptom relief related to serious illness
  • Physical and psychosocial relief
• From Vistas Healthcare (cont.)

  Hospice Eligibility

  • Requires that 2 physicians certify that the pt has less than 6 months to live if disease follows its usual course
  • If you qualify, it's 100% covered

   

  Hospice Services

  • Paid by Medicare, Medicaid, Insurance 
  • Prognosis 6 months or less
  • Excludes curative treatment
  • Wherever pt calls home
• Common Complications in EOL Care -- Pain Management

  • Do NOT overmedication but don't be afraid to treat
  • Expect changes in doses to be needed
  • As pt declines, s/sxs of pain change, become harder to identify
• Common Complications in EOL Care -- Constipation

  • Causes:
  • Opioids
  • Immobility
  • Poor nutrition
  • Hydration status
  • Treatment: prophylactic laxatives (stool softeners and stimulants)

  --> osmotic laxatives (caution!)

  --> enema (if ineffective in ~4 days)
• Common Complications in EOL Care -- Nausea and Vomiting

  • Treated based on causes when possible
  • Dopamine antagonist/Prokinetic agents (metoclopramide), serotonergic antagonists (ondansetron)
  • Motility agents (metoclopramide), serotonin antagonists, antihistamines, scopolamine, meclizine
• Common Complications in EOL Care -- Anorexia/Cachexia

  Anorexia

  • Described loss of appetite and/or an aversion to food

  
  

  Cachexia

  • Refers to loss of body mass in the setting of a disease state, in this case cancer
  • Including lean body mass and fat
  • Its that look where you know they are anorexic
  • Almost universal among terminally ill

  --> do NOT treat if actively dying

  
  

  Associated with Anorexia and Cachexia

  • Treat symptoms (dry month, lips, skin)
  • Encourage to eat what appeals, w/o restrictions
  • Watch albumin levels
  • < 2 g/dL very dangerous, poor healing
• Common Complications in EOL Care -- Delirium

  • Common and distressing
  • Find causes if possible (infection, impaction, pain, hypoxia, changes to scenery)
• Common Complications in EOL Care -- Dyspnea

  • Self-report is the only reliable measure
  • Treat but don't delay symptom management
  • BZD -- can help w/ anxiety but not true dyspnea
  • Remember: opioids decrease respiratory drive
• Medications in Hospice

  • Indications are not always expected
  • Many are off-label
  • Often referred to a "comfort pack"
  • Requires careful, coordinated care
• Medications in Hospice (cont.)

  • Acetaminophen --> pain or relief
  • Laxatives --> constipation
  • Senna, Dulcolax, Fleet enema
  • Promethazine --> N/V
  • Ondansetron --> N/V
  • Prochlorperazine --> N/V
  • Often used in oncology, pregnancy, post-op N/V and for rescue N/V
  • Phenobarbital --> agitation or seizures
  • Diphenhydramine --> insomnia
• Medications in Hospice (cont.)

  • Lorazepam --> nausea, insomnia, seizures, anxiety, SOB
  • Opioids (morphine, oxycodone, fentanyl) --> pain
  • Usually concentrated oral liquid form --> swallow/sublingual
  • May present as SOB, agitation
  • Haloperidol --> confusion/agitation, terminal restlessness
  • Oral solution
  • Anticholinergics --> terminal secretions (gurgling)
  • Scopolamine, hyoscyamine, atropine (eye drops, given orally)
  • Tranexamic acid --> excessive bleeding
• Geriatric Patient Assessment -- Geriatric Assessment

  • General
  • Comprehensive Geriatric Assessment
• Geriatric Patient Assessment

  • Can help identify geriatric syndromes
  • Fatigue
  • Cognitive impairment
  • Delirium
  • Incontinence
  • Malnutrition
  • Falls risk
  • Gait disorder
  • Pressure ulcers
  • Sleep disorders
  • Sensory deficits
  • Dizziness
• Comprehensive Geriatric Assessment (CGA)

  • [def] multidisciplinary diagnostic and treatment process that identified medical, psychosocial, and functional capabilities of an older adult in order to develop a coordinated plan to maximize overall health w/ aging
  • Typically done by multidisciplinary team
  • Includes identification and management of geriatric syndromes
  • Medical, psychosocial, functional limitations (physical, cognitive, affective, social, financial, environmental, and spiritual components that influence health)
• Comprehensive Geriatric Assessment (CGA) (cont.)

  • Usually initiated through referral -- content varies based on setting w/ the overall same goal
  • Complications: time, coordination, reimbursement
  • Based on premise that a systemic evaluation of frail older adults by a team may identify treatable/preventable health problems leading to better health outcomes
  • Indications: right acuity to derive benefits
  • Not well defined
• Comprehensive Geriatric Assessment (CGA) (cont.)

  • Those that might not derive benefit: "too healthy" or "too sick" [explained by premise of CGA]
  • Terminal illness
  • Cancer or advanced HF
  • Severe, advanced dementia, falls, or functional disability
  • Change in living (independent --> assisted living, etc.)
  • High healthcare utilization (part or present)* -- research cause
• Comprehensive Geriatric Assessment (CGA) (cont.)

  Assessment Team

  • Clinical
  • Nurse
  • Social worker

  + (PLUS)

  • PT and OT
  • Dietician
  • Pharmacist
  • Psychiatrist
  • Psychologist
  • Dentist
  • Audiology
  • Podiatrist
  • Optometrist

  -->

  Conduct Review

  • Gather the data
  • Discuss
  • Implement
  • Monitor
  • Revise
• Comprehensive Geriatric Assessment (CGA) (cont.)

  Major Components of a CGA

  • Functional capacity
  • Fall risk
  • Cognition
  • Mood
  • Polypharmacy
  • Social support
  • Financial concerns
  • Goals of care
  • Advance care preferences

  + (PLUS)

  Additional Components

  • Nutrition/weight change
  • Urinary continence
  • Sexual function
  • Vision/hearing
  • Dentition
  • Living situation
  • Spiritually
• Types of CGA -- House Assessment

  • Usually followed for 1 yr
  • Primarily preventative (rather than rehabilitative)
  • Reduce functional decline and overall mortality
  • Did not significantly prevent nursing home admissions
• Types of CGA -- Inpatient Consultation

  • Co-management of pt
  • Benefit for short term survival only
  • No change in functional status, readmission, or length of stay
• Types of CGA -- Inpatient Consultation

  • Largely only found in VA in US -- seldom in academic and private sector
  • Primarily rehabilitation drive
  • Acute Care of Elderly [ACE] units
  • More acute care focused -- traditional, more common
  • Detailed education
  • Improve med compliance
  • Intensive discharge planning
  • Leads to increased independence in ADL
  • Greater independence
  • Decrease nursing home admission
  • Shorter and less costly hospital admission
  • Decrease 30-day readmission rates
• Types of CGA -- Inpatient Consultation (cont.)

  • Geriatric Evaluation and Management Units [GEMUs]
  • Driven and run by group -- more consistent and effective
  • PCP usually works in unit -- recommend --> implementation
  • Reduced nursing home admissions up to a year after hospital admission
  • No difference in dependence or cognitive status
• Types of CGA -- Outpatient Consultation

  • When coupled w/ adherence interventions show better results
  • Very inconsistent/variable results
• Types of CGA -- Specialized Team Management

  • Combines home-based and long-term care CGA

  --> Geriatric Resources for Assessment and care of Elders (GRACE) interventions

  • NP and social worker collaborate to bring pertinent players
  • Owed better health-related QOL
  • Decreased ED visits
  • Decrease admission rate
  • Guided Care
  • Specifically trained nurse as PCP
  • Decrease healthcare utilization
  • Lower cost of care in short term
  • Practice redesign
  • Screening, structured visits, delegation of office staff, outreach

  --> focuses on specific conditions at a time

  • Improved quality of care
• CGA Examples -- Mood Disorders

  • "during the past month, have you been bothered by feeling down, depressed, or hopeless?"
  • "during the past month, have you been bothered by little interest or pleasure in doing things?"
  • If yes to both --> PHQ-9
• CGA Examples -- Gait

  • TUG test
  • Linked to survival
  • Functional decline predicator
  • Identifies those in need of additional assessment
• CGA Examples -- Falls Risk

  • Previous falls/balance issues
  • Increase risk of another fall
  • Increase risk for loss of independence
• CGA Examples -- Cognitive Assessment

  • MMSE
  • Clock draw test
  • Mini-cog and Memory impairment screening
• Take Home Message

  • Patience is key
  • Can't and shouldn't treat everything w/o reason to do so
  • Balance --> might be in the best interested of all parties
  • How to approach a geriatric pt plan of care
  • Need --> goal --> guidelines --> beers criteria --> STOPP/START
  • Go slow --> monitor --> reassess --> reevaluate
  • Benefits must outweigh the risk -- and must remain so
  • Evaluate that balance (of benefits and risks) often
  • Let guidelines guide you, let guidance steer you
  • Geriatrics is complicated -- you cannot treat w/o basics
  • Remember to treat the person, not just the sxs