Mod 7B: Palliative & End of Life Care

ars moriendi's good death

frames the final hours of life as a spiritual battle between angels and demons for a person's soul

death in america in the early 1900s characteristics (4)

- high childhood mortality

- death from inf & accidents -> no antibiotics

- care & comfort focused medication

- sick were cared for at home

avg life expectancy in america in the 1900s

about 50 yrs -> adults lived into their 60s

avg life expectency in america in the 1970s

climbed to 71.1 yrs

technological advancements in the 1970's increasing life expectancy (3)

- resuscitation

- implantable's

- transplantation

end of life care in america in the 1970s (3)

- hospitals avoided effective painkillers to avoid addiction

- pts w cancer weren't told of their sickness

- poor quality of dying

normal visiting hours in america in the 1970s (2)

- 1 hr on 3 afternoons/week

- 30 mins on 4 evenings/week

shift trends over 2000-2015 for location of death

hospital deaths & nursing home deaths both decreased

when do a majority of hospital deaths occur?

after a decision to withhold or withdraw life sustaining tx

avg life expectancy in america in 2019

78.79 yrs

death characteristics in america in 2019 (3)

- living longer w chronic disease & dying more slowly

- look to tech & organ transplantation to avoid dying

- ppl are demanding right to die

active euthanasia

someone takes active means to bring abt death -> lethal inj or meds

passive euthanasia

individuals choose not to intervene to prevent someone's death

voluntary euthanasia

individual chooses action

non-voluntary euthanasia

surrogates chose the action based on substituted judgement or best interest standard

- pt isnt able to consent

involuntary euthanasia

action is chosen by others

- pt is able to consent but is euthanized against their will

medical aid in dying (MAID)

meds are prescribed by physician, but is self adm by pt

- differs from euthanasia where clinician administers death causing medical care

euthanasia tourism

the practice of individuals traveling to another state or country to access legal voluntary euthanasia

negative right to die

others may not interfere when refusing life saving medical tx

positive right to die

individual is entitled to help from the state or healthcare system to end their life

balancing benefit & burden in context of autonomy when determining euthanasia (2)

- will tx achieve pt defined goals -> beneficence

- does tx impose undo burden -> nonmaleficence

criteria used in surrogate decision making when wishes are not explicitly documented (3)

- of low value -> futile or inappropriate

- excessively burdensome -> little benefit

- outcome not consistent w pt values

types of advanced directives to protect autonomy (4)

- living will

- durable medical power of attorney (DPOA)

- physician orders for life sustaining tx (POLST)

- medical orders for life sustaining tx (MOLST)

limitations of ADs

- details never disclosed -< person doesn't know they're DPOA

- not specific to situation

- based on tx not outcomes

3 competencies of end of life discussion (3)

- ethics, law, regulatory knowledge

- clinical knowledge

- communication skills (culturally congruent)

what does clinical knowledge in EOL discussion include?

- knowledge abt EOL care

- knowledge abt pts condition

ways to start a hard convo (4)

- what have they told you abt their condition?

- what are your concerns?

- what questions do you have?

- what are you hoping we can do for them?

some ways to achieve shared decision making (6)

- establish trust

- assess their understanding of situation

- highlight theres a choice

- elicit goals

- offer recommendation

- validate their efforts

common misconception of comfort care

doesn't mean no care

comfort care

foregoing disease directed tx -> assure non-abandonment

common clinical issues w comfort care (4)

- nutrition

- hydration

- pain meds

- terminal sedation

issues w nutrition during comfort care (2)

- situations where food & water no longer attain intended goals

- organ failure & cannot absorb nutrition

comfort feeding (2)

- favorites or culturally significant foods

- minimize risk if concerns for dysphagia