Transcript End-Of-Life Directives - Indiana Osteopathic Association

Challenges in End-of-Life Care
A Case Based Discussion - Brian H. Black D.O. (11-11-12 update)

IU Bloomington Undergrad – B.S. Biology

COM - Des Monies University

Internship - Union Hospital

Residency - Richard Lugar Center for Rural Health
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Board - Family Medicine
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Board - Hospice & Palliative Care

Medical Director for Great Lakes Caring Hospice
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IOA Board of Trustee Member

I am proud to support Marian University’s new COM
Lecture Overview

Case based introduction:

Hospice History

Epidemiology

End-of-Life Directives

But Doctor, Morphine Kills People!

The Principle of Double Effect

Delirium at the End-of-Life

What is Essential?
Lecture Overview

Hospice History & Epidemiology

Advanced Directives

But Doctor, Morphine Kills People

The Principle of Double Effect

Delirium at the End-of-Life

What is Essential?

Other Case Studies
History & Epidemiology
Traditional
Palliative
History & Epidemiology

Hospice /hos· pice / ˈhäspis / Latin: "hospitium”

Origins:

11th Century – location for the sick, wounded, & dying

1850s – “Sisters of Charity”
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1967 concept pioneered by UK’s Saunders to the U.S.
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1972 - Kubler-Ross “On Death and Dying”
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1982 - Hospice Benefit Established
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2011 – 1.65 Million pts on hospice, > 5000 companies
History & Epidemiology


Explosion in number of hospices

1984: 31
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2011: >5000
*The number of people using hospice is increasing

495,000 in 1997
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1,650,000 in 2011
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*333% increase during that period
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The population is aging

Increases in Hospice utilization are noted in all races
History & Epidemiology
“Core Services”

Attending

Med Director

Nursing

Psychosocial

Spiritual

Other
Patient
&
Family
History & Epidemiology
History & Epidemiology
History & Epidemiology
History & Epidemiology
History & Epidemiology

Some studies have showed patients who are on
hospice live on average 27 days longer than those
who do not have hospice

2009 Survey looked at cost averages:

Hospital inpatient charges per day in 2009 = $6200

Skilled Nursing facility changes per day =$662
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Hospice Charges per day = $135
Lecture Overview

History & Epidemiology

End-Of-Life Directives

But Doctor, Morphine Kills People!

The Principle of Double Effect

Dementia at the End-of-Life

Terms of Confusion

What is Essential Care?

Other case studies
End-of-Life Directives
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*Only ~5% of patients who require ACLS outside
the hospital & only ~15% of patients who require
ACLS while in the hospital survive

**Patients who are elderly, are living in nursing
homes, have multiple medical problems, or who have
advanced cancer are much less likely to survive.

*PMID 17174021^ Zoch TW, Desbiens NA, DeStefano F, Stueland DT, Layde PM (July 2000).

**"Short- and long-term survival after cardiopulmonary resuscitation". Arch. Intern. Med. 160 (13):
1969–73. doi:10.1001/archinte.160.13.1969. PMID 10888971.^ Ehlenbach WJ, Barnato AE, Curtis JR, et al.
(July 2009).
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**"Epidemiologic study of in-hospital cardiopulmonary resuscitation in the elderly". N. Engl. J. Med. 361 (1):
22–31. doi:10.1056/NEJMoa0810245. PMC 2917337. PMID 19571280.
End-of-Life Directives

John a 78 yo BM presents to the hospital with
pneumonia. He has a living will. He is admitted in poor
overall condition to the ICU.

You are paged and notified that John had a bout of
chest pain  abnormal rhythm  poor pulse. Nursing
calls floor to inform you they are not going to call a
code because he has a living will.

Discussion: It this ok? Should we call a code? What do
you ask? What do you do? Should we defibrillate? Give
a med? CRP? Call Hospice? Call next of kin? Call a
“full code”, chastise staff, & advise nursing education?
End-of-Life Directives
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A recent study showed that *78% of physicians
misinterpreted living wills as DNRs
*as published Oct 29th, 2012 in American Medical
News – www.amednews.com

Who here reads American Medical News?

Perhaps that’s just the M.D.’s? Lets take a quiz and
we will see…
End-of-Life Directives
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What is a living will?

A.) A medical order that enables a family member or
surrogate to speak for the patient if the patient is
incapacitated.
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B.) A legal document that addresses life-sustaining
treatments if a patient is terminally ill or in a
permanently unconscious state.

C.) A legally recognized written or oral statement
directing medical treatment during a life-threatening
emergency.
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D.) A made-up term started by the IOA Board
End-of-Life Directives
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What categories best define a “DNR”?
 A.) a medical document
 B.) a legal document
 C.) both a medical & legal document
End-of-Life Directives
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What is contained in a “DNR Order”?
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A. No intubation or Ventilation
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B. No artificial nutrition
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C. No Medications
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D. No CPR
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E. No Life Support
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F. No Surgeries
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G. Comfort Care Only
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H. A specific combination of the above
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I. All of the Above
End-of-Life Directives
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In the U.S. documentation is complicated in that
each state accepts different forms

Advanced directives and living wills are NOT
accepted by EMS as legally valid forms

“CODE ORDERS” in the hospital however are often more
convoluted with “Code A” / Code “B” / Code “C” options


check lists to expressly ALLOW intubation, meds,
CPR, or some other combination of “Code Skills”.
Only the “state sponsored form” that is co-signed by
a physician is valid legally
End-of-Life Directives

An advance directives name a patient spokesperson
for the patient

A.) True

B.) False
End-of-Life Directives
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Some advanced directives appoint a person to speak
on a patient’s behalf

However, the provision is not required in order to
enact the remainder of the directives
End-of-Life Directives

What is the proper term for the appointment of a
person who can speak on a patient’s behalf ?

A.) Health Care Power of Attorney
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B.) Health Care Proxy
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C.) An Informatics Surrogate
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D.) The Agent
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E.) All of the above
End-of-Life Directives
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One essential component of a living will is
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A.) Pt is unconscious and needs treatment
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B.) Pt is critically ill despite initial emergency treatment
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C.) Pt is terminally ill despite sound medical treatment
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D.) Unable to breathe on own and requires intubation
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E.) All of the above
End-of-Life Directives
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The majority of living wills say not to treat a patient
after a “terminal condition”, despite sound medical
treatment OR if the patient remains in a permanently
unconscious state.

A living will can be written to accept or refuse
specific life-saving medical care during such an event,
including mechanical respiration, antibiotics, or
feeding tube insertion.
End-of-Life Directives
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What is necessary for a health care power of
attorney to begin making health care choices for the
patient?





A. ) One doctor must determine that the patient is
unable to communicate to make health care decisions
B.) Two physicians must determine that the patient is
unable to communicate to make health care decisions
C.) A physician and nurse can deem a patient unfit
D.) A doctor and the patients family must agree that the
patient requires a health care power of attorney.
E.) It depends on the state
End-of-Life Directives
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When is an advance directive enacted
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A.) When the patient is dying.
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B.) When the patient or a family member asks that it be
enacted.
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C.) When triggers outlined in the directive are present.
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D.) When the patient no longer can communicate.
End-of-Life Directives
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Advanced directives are activated based on the
details within the document

The language of the directives have to be read closely
to determine if the patient’s circumstances call for
the directives to be triggered

This can be a source of conflict and confusion,
especially in a critical situation.

The better we help prepare patients ahead of time the
easier this process is to follow. That is until the
daughter from California arrives…
End-of-Life Directives

Back to John: Chest pain  Abnormal Rhythm 
poor pulse. Nursing calls floor to inform you they are
not going to call a code because he has a living will.
It reads:

“If a situation should arise in which there is no
reasonable expectation of my recovery from
extreme physical or mental disability, I direct that I
be allowed to die and not be kept alive by
medications, artificial means or "heroic
measures”.
End-of-Life Directives

Advance Directive - A general term describing both
living wills and the medical power of attorney. These
documents allow you to give instructions about future
medical care and appoint a person to make healthcare
decisions if the pt is unable.

Do-Not-Resuscitate Order (DNR) - A DNR order
is a physician's written order instructing healthcare providers
not to attempt cardiopulmonary resuscitation (CPR) in case
of arrest. A person with a valid DNR order will not be given
CPR. Although the DNR order is written at the request of a
patient or family, it must be signed by a physician to be valid.
End-of-Life Directives

Life-Sustaining Treatment - Medical procedures that
replace or support an essential bodily function. Include
cardiopulmonary resuscitation, mechanical ventilation,
artificial nutrition and hydration, dialysis, and certain other
treatments.

Capacity – In relation to end-of-life decision-making, a patient
has medical decision making capacity if he or she has the ability
to understand the medical problem and the risks and benefits of
the available treatment options. The patient’s ability to understand
other unrelated concepts is not relevant. The term is frequently
used interchangeably with competency but is not the same.

Competency - is a legal status imposed by the court.
End-of-Life Directives
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Allow Natural Death 
Advocated as alternative terminology to DNR

Explicitly only applied to a terminal patient. AND
orders ensure that only comfort measures are taken.

This would include withholding or discontinuing
resuscitation, artificial feedings, fluids, and other
measures that would prolong a natural death.

The term is evolving and lacks the specificity of a
physician signed “DNR Order”.
End-of-Life Directives
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Physicians and other health care professionals need
to understand the values and preferences of their
patients

You need to understand the terminology, but most
importantly it the need to understand the patient
and help them state their goals using this defined
language

If not you, then who?
End-of-Life Directives
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Other good places to start a conversation:
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The One Slide Project (engagewithgrace.org)
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The Five Wishes Program (agingwithdignity.org)
End-of-Life Directives
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5 Wishes (agingwithdignity.org)
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Wish 1: The Person I Want to Make Decisions When I
Can't
Wish 2: The Kind of Medical Treatment I Want or Don’t
Want
Wish 3: How Comfortable I Want to Be
Wish 4: How I Want People to Treat Me
Wish 5: What I Want My Loved Ones to Know

Very specific, nearly comprehensive, & “plain
language”

Not legal as advanced directives in the State of Indiana

Preset pharases
End-of-Life Directives
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POLST PROJECT (http://www.polst.org)
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Started in Oregon in 1991

“…translates values expressed in advance directives into
immediately active medical orders which do not require
interpretation or further activation”
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Provide continuity of care across all settings (e.g. ER,
ICU, hospice, long-term care, and home) which is
transferred with the patient

Its better but not perfect. Especially if not initiated!

Please, go the the website, review, and get involved
End-of-Life Directives
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Barriers to the POLST program in Indiana

State Statute IC 16-35-5, which contains language
which is in compatible with POLST using the term
“terminal” which may exclude some people who would
like to limit interventions when the burdens of tx
outweigh the benefits.

Currently, out of hospital DNR forms require 2
signatures from unrelated witnesses (can’t be employees)
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Confusion regarding hierarchy of “decision makers” in
the event the patient can not speak on their own
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Questions regarding who can enact them (mid-levels?)
End-of-Life Directives
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Indiana:

www.in.gov/isdh/advanceddirectives.pdf

Legally only state approved forms can be used, but the
state of Indiana does not currently support “POLST
forms” nor “5 Wishes” as official advanced directives

Need to have support from physicians on this important
issue immediately

Contact for further information and to get support:

IU Nurse: Susan Hickman
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[email protected]
Lecture Overview

Hospice History & Epidemiology

Advanced Directives

But Doctor, Morphine Kills People!

The Principle of Double Effect

Terms of Confusion at the End-of-Life

What is Essential?

Case Studies
But Doctor,
Morphine Kills People!

A will known 57 yo Caucasian
plant manager of your practice
becomes hospitalized due to severe
abdominal pain which has been
worsening despite OTC treatment

Subsequently found stage IV
pancreatic CA mets to liver & lung

As this patients Family Physician,
what do you suggest for him?

P.S. I hope you did encourage him to
get 5-wishes packet filled out and
have conversations with his family
prior to this rights?
But Doctor,
MoreFine Kills People!

What would you recommend?




A.) Heavy Sedation
B.) A referral to
 Oncologist
 Inpatient Palliative care team
 Surgery
 Outpatient hospice group
 Chaplin
 Pain management
C.) Further imaging to define lesions
D.) A frank discussion with pt & family
But Doctor,
Morphine Kills People!

Pts pain gets worse and the hospice medical director
suggests starting morphine for pain control, but the
family is reluctant stating quote:

“ Dr. I Googled ‘Morphine and Hospice’ and it says
that the double effect and will kill him, & anyway
everyone knows opiates are addictive! We don’t want
him to start them”
But Doctor,
Morphine Kills People!

Which of the following is true regarding Morphine
and the family’s concerns?

A.) Morphine has an unusually high risk of addiction

B.) Morphine is likely to cause respiratory depression as
an early effect, especially in the frail and elderly

C.) The principle of double effect does not apply

D.) Using morphine for patients with cancer or at the
end-of-life is likely to trigger an immediate DEA
investigation

E.) None of the above
Double Effect

The principle of “double effect” refers to the ethical
construct where a treatment is given, for an ethical
intended effect where the potential outcome is good
(eg, relief of a symptom), knowing that there will
certainly be an undesired secondary effect (such as
death)

A Medical example of double effect: Separating
conjoined twins who will die without a surgery, but
yet for which also, one will die if the surgery takes
place at all
Double Effect

Many physicians inappropriately call the risk of a
potentially adverse event, a double effect but

it is in fact a secondary & unintended consequence

Patients receiving palliative care whose pain can be
adequately treated with opioid drugs may well value
quality additional days, hours, or minutes of life

It is therefore unjustified to assume that the
hastening of death is itself a form of merciful relief
for patients with terminal illnesses and not a
regrettable side effect to be minimized
Double Effect

Although this principle of “double effect” is
commonly cited with morphine, it does not apply, as
the secondary adverse consequences are unlikely

Morphine-related toxicity will be evident in
sequential development of drowsiness, confusion, &
loss of consciousness well before respiratory drive is
significantly compromised

In Hospice pts, it is common to titrate to effect and
only hold doses if pts respiratory rate drops below set
parameters set 8-10 breaths per minute
Side Effect

All of the following have potential good effects and
potential bad side effects leading up to even death,
but none of them would be considered a “double
effect” in most settings:

TPN

Pain Medications

Chemotherapy

Radiation treatment

Surgery
Lecture Overview

Hospice History & Epidemiology

Advanced Directives

But Doctor, Morphine Kills People!

The Principle of Double Effect

Terms of Confusion at the End-of-Life

What is Essential Care?

Case Studies
Terms of Confusion

Mr. Stevens is a 79 yo new hospice c Alzheimer’s. At
2am a page from the ECF nurse, “confused and
agitated worse than usual”

What do you suggest to to aid this normally pleasant
patient? Testing? Do you suggest medications? What
kind? Do you want to ask questions first? What
testing do you want to do? Send to the ER? Get a
CT scan? Get his wife in there to calm him down?
Terms of Confusion

Confusion is not a helpful or accurate term



Delirium is common


Do you mean delirium, dementia, psychosis,
obtundation, or other disease?
work to find a cause
complaints require a good history and exam
A good validated mental status equivalent needed



helps to understand the baseline
helps to chart pt course / changes
Aids in understanding appropriateness for hospice
Terms of Confusion

Which of the following are considered validated
assessment tools for dementia?

A.) Mod Mini-Mental Status (Modified-MMSE = 3MS)

B.) Alzheimer’s Disease Assessment Scale (ADAS-Cog)

C.) Practitioner Assessment of Cognition (GPCOG)

D.) Psychogeriatric Assessment Scale (PAS)

E.) All of the above
Terms of Confusion

MMSE is very familiar / easy. Updated M-MMSE is
a better test


http://www.dementiaassessment.com.au/cognitive/index.html
The GPCOG is very similar / quick. Added benefit
of interviewing optional observer

http://www.gpcog.com.au
Terms of Confusion

Delirium –


is a sudden and severe loss of brain function that occurs
with physical or mental illness. Often caused by a
temporary and reversible factors.
Dementia Disorders–

Describes a family of gradual progressive
neruodegenerative brain disorders of enough severity to
interfere with normal activities of daily living and
multiple categories of higher cortical function, lasting
more than six months, not present since birth, and not
associated with a loss or alteration of consciousness.
Terms of Confusion

Delirium can be hypoactive OR hyperactive

Key feature is an ACUTE CHANGE in the level of
arousal

may also feature

a change in the sleep wake cycle

mumbling speech

disturbance of memory

and even delusions & hallucinations.
Terms of Confusion

Most common causes of delirium is drugs



Anti-cholinergics (anti-secretion, anti-emetic, antihistamine, TCA, etc…)
Sedative-Hypnotics (Benzos especially)
Opiates

Infection also common

CNS pathology should be considered

Drug / EtOH withdraw

Any new medications are suspect
Terms of Confusion

Consider the environment:





Reduce sensory stimulation as needed
Ask family to stay to calm the patient
Increase nursing care
Frequent reminders of time and place
Treatment of choice:

Major Tranquilizer. Superior to benzos in sx control and SE profile

Haldol can be used in escalating doses. Start 0.5-1mg po q1 hr and titrate

Quetiapine (Seroquel) is atypical with less extraparmidal risk. Especially
useful if longer term use. Also more sedating than other atypicals.

Documentation is essential (as is informed consent) when using these agents
Terms of Confusion

Back to Mr. Stevens

79 yo debility pt confused and agitated at 2am

Further questions revealed he was started on ativan
recently for bouts of confusion and also benadryl to
help sleep

A CBC and temp ordered to identify possible infection

A BMP was ordered to identify metabolic causes (quick
finger stick helpful in diabetics)

O2 sat taken to rule out hypoxia

Lastly ,we verified he had not hx of EtOH so withdraw
was not expected to be a concern
Terms of Confusion

Benadryl was stopped

Ativan was stopped

Pt did very well with 1mg of haldol which was
repeated in 4 hours x 1. A week later he required
repeated haldol doses x 2

Pt eventually started on Seroquel at a low dose 50mg
po bid, then titrated to a full dose at 300mg po bid.
He did not have over-sedation and functioned well
until his demise over 2 months later
Lecture Overview

Hospice History & Epidemiology

Advanced Directives

But Doctor, Morphine Kills People!

The Principle of Double Effect

Terms of Confusion at the End-of-Life

What is Essential Care?

Case Studies
What is Essential

What % of patients in the U.S. die in the hospital?

What % of Medicare dollars are spent on the last
year of life for a patient?
What is Essential?

Walter is a 62 yo in ER. Chest pain &
SOB. Multiple recent prior admissions
for CHF. Has pacemaker/defibrillator.
Pale. Anorexic. Fatigued.

Meds in his bag include: Coumadin,
Amoxil, Norvasc, Nitroglycerin spray,
Synthroid, Valsartan, Lasix, Plavix,
Iron, Folic Acid, Ambien, Vicodin,
Paxil, Lyrica, St. John’s Wart, Lipitor,
Blond psyllium, CoQ10, MVI, &
Nexium

What do we do now????
What is Essential?

Information returns:






Albumin was 2.1 (3.4 - 5.4)
Hgb was 7.2 (12.4-15.3)
INR was 5.2 (2.3-2.9)
EF was estimated at 10-15% 3 weeks ago (Normal range 50-60%)
Pacer/defib was placed hospital last visit
What do we do now?






Feeding tube?
Blood Transfusion?
Vitamin K, FFP, Platelets?
Transplant list?
Hospice Consult?
Turn off defib?
What is Essential?

Communication re med & tx essential at every
patient encounter

It is vital questions are appropriately answered

Goals of care & personal philosophy is key

Med list needs to be trimmed

Realistic expectations

Advanced directives are underutilized at best
What is Essential?

Meds list was trimmed down: Coumadin stopped. ISMO started.
Morphine started as prn.

DNR written. Advanced directives discussed

Defib turned off

Symptom management

Pt discharged to a residential hospice
What is Essential Care?

Betty is an unfortunate 42 yo type I diabetic pt
with pancreatic cancer living in an ECF. She is
now 112 lbs (down from 146 six months ago).
You are covering call for Betty’s PCP.

Hospice calls to inform you that Betty’s BS is
450 and she has nausea and vomited, but lets
you know “I don’t really worry about the blood
sugars in dying diabetics” so this is more of
“just an FYI” based on protocols.

What targets should you give the nurse? Tx?

Would your advice vary in DM II?
What is Essential Care?

Hospice DM Tips:


Tight glycemic control prevents long term complications
Hospice Goals” minimizing symptomatic episodes

Hypoglycemia  panic, tremors, weakness, and
seizures.

Hyperglycemia (days)  dehydration, thirst, and
polyuria, lethargy, & coma

Type I DM - risk of rapid DKA  acidosis, abdominal
pain, & nausea/vomiting
What is Essential Care?

Hospice DM tips:

In hospice pts, relax tight BS control

There is no role for an A1c

Continue insulin to prevent DKA (DM I)

Decrease glucose checks unless symptomatic

Decrease pill burden

Frame family discussion with therapeutic goals

Clarify stopping meds  pt safety
Lecture Overview

Hospice History & Epidemiology

Advanced Directives

But Doctor, Morphine Kills People

The Principle of Double Effect

Delirium at the End-of-Life

What is Essential?

Other Case Studies
Other Case Studies

Other case studies to be discussed will be reviewed
during the course of the lecture
Hospice Tips

If you believe that a patient with an advanced,
“progressive illness” is likely to die within a year,
hospice may be an excellent option.

Any “terminal diagnosis” likely meets criteria

Prognoses do not have to be certain, as some endstage conditions have unpredictable courses

Patients may initially improve in hospice

Patients may be in hospice longer than six months
Hospice Tips

Patients with cancer and non-cancer diagnoses
benefit from hospice services and should be referred
when their prognosis is still longer than two months

The most effective length of stay with hospice is
debated, but most estimates say at least two to three
months; very short stays have been associated with
increased caregiver morbidity and depression
Hospice Tips

Discussions with patients and families about hospice
should take place as early as possible

Approach in the context of the larger goals of care

Late referrals are associated with decreased family
satisfaction with services and increased caregiver
morbidity
Hospice Tips

Switch essential medications to non-pill route

Stop unnecessary meds / procedures / monitoring

Don’t forget to approach
Biologic
Psychologic
Socio & Spiritual aspects of patient care
Family
Others on the team
Resources and References

EPERC: End of Life/Palliative Education Resource Center
Delivering Bad News-Part 1 | Delivering Bad News - Part 2
Discussing Hospice

National Hospice and Palliative Care Organization
Talking About Treatment Options and Palliative Care: A Guide for Clinicians

American Family Physician
End-of-Life Care: Guidelines for Patient-Centered Communication
1/15/08

JAMA Commentary
Communicating With Seriously Ill Patients (Better Words to Say)
JAMA. 2009;301(12):1279-1281. doi: 10.1001/jama.2009.396

British Medical Journal
Spotlight: Palliative Care Beyond Cancer
Having the difficult conversations about the end of life
9/16/10
Resources and References

Journal of Clinical Oncology
American Society of Clinical Oncology Statement: Toward Individualized Care for Patients
With Advanced Cancer
1/24/11

Journal of Clinical Oncology
Faculty Development to Change the Paradigm of Communication Skills Teaching in Oncology
3/1/09

CA: A Cancer Journal for Clinicians
Making Difficult Discussions Easier: Using Prognosis to Facilitate Transitions to Hospice
6/17/09

Medscape Today (free registration required)
Communicating Diagnosis and Prognosis to Patients with Cancer: Guidance for Healthcare
Professionals
1/07/11

Canadian Medical Association Journal
What people want at the end of life
CMAJ - November 9, 2010; 182 (16).
Resources and References

Fast Facts from the University of Wisconsin

The book GONE FROM MY SIGHT

The book THE 36 HOUR DAY

Grief Share Program
Resources and References

ERERC: End of life / Palliative Resource Center
Delivering Bad News-Part 1 | Delivering Bad News Part 2
Discussing Hospice

National Hospice and Palliative Care Organization
Talking About Treatment Options and Palliative
Care: A Guide for Clinicians

American Family Physician
End-of-Life Care: Guidelines for Patient-Centered
Communication1/15/08
Resources and References

JAMA Commentary
Communicating With Seriously Ill Patients (Better
Words to Say)
JAMA. 2009;301(12):1279-1281. doi:
10.1001/jama.2009.396

British Medical Journal
Spotlight: Palliative Care Beyond Cancer
Having the difficult conversations about the end of
life 9/16/10
Resources and References

Yennaurjalingam S et al. Pain and terminal delirium research in the elderly. Clin
Geriatr Med. 2005;21(1):93-119.

Lawlor PG, et al. Occurrence, causes and outcome of delirium in patients with
advanced cancer. Arch Int Med. 2000;160:786-794.

Brietbart W, Marotta R, Platt M, et al. A double blind trial of Haloperidol,
Chlorpromazine and Lorazepam in the treatment of delirium. Am J Psych.
1996; 153:231-237.

Breitbart W, Alici Y. Agitation and delirium at the end of life. “We couldn’t
manage him.” JAMA 2008; 300(24):2898-2910.

Cummings, J.L., et al., Guidelines for managing Alzheimer’s disease:part I.
Assemment and Part II. Treatment. American Family Physician, 2002. 65(11):
p. 2263-72, American Academy of Family Physicians
Resources and References

Susan E. Hickman, Bernard J. Hammes, Alvin H. Moss, and Susan
W. Tolle, “Hope for the Future: Achieving the Original Intent of
Advance Directives,” Improving End of Life Care: Why Has It Been
So Difficult? Hastings Center Report Special Report 35, no. 6
(2005): S26-S30.
Resources and References

^ Seymour, J. E; D. Clark, M. Winslow (2004). "Morphine use in
cancer pain: from 'last resort' to 'gold standard'. Poster
presentation at the Third research Forum of the European
Association of Palliative Care". Palliative Medicine 18 (4): 378.^ a b
Center to Advance Palliative Care, www.capc.org^

Joanne Lynn (2004). Sick to death and not going to take it anymore!:
reforming health care for the last years of life. Berkeley: University of
California Press. p. 72. ISBN 0-520-24300-5.^ "WHO Definition of
Palliative Care". World Health Organization.
http://www.who.int/cancer/palliative/definition/en/. Retrieved
March 16, 2012.
Resources and References

Angelo M, Ruchalski C, Sproge BJ. An approach to diabetes mellitus in hospice and palliative
medicine.J Palliat Med. 2011; 14(1):83-7.Boyd K.

Diabetes mellitus in hospice patients: some guidelines. Palliat Med. 1993; 7(2):163-4.

Budge P. Management of diabetes in patients at the end of life. Nurs Stand. 2010;25(6):42-6.Ford-Dunn S,
Smith A, Quin J. Management of diabetes during the last days of life: attitudes of consultant diabetologists and
consultant palliative care physicians in the UK. Palliat Med. 2006; 20(3):197-203.

King EJ, Haboubi H, Evans D, et al. The management of diabetes in terminal illness related to cancer. QJM.
2012; 105:3-9.

McCoubrie R, Jeffrey D, Paton C, Dawes L. Managing diabetes mellitus in patients with advanced cancer: a
case note audit and guidelines. Eur J Cancer Care. 2005; 14(3):244-8.

Quinn K, Hudson P, Dunning T. Diabetes management in patients receiving palliative care. J Pain Symptom
Manage. 2006; 32(3):275-86.

Vandenhaute V. Palliative care and type II diabetes: A need for new guidelines? Am J Hosp Palliat Care. 2010;
27(7):444-5.
Thank you…

Thanks for your attention

Please contact me with questions

I welcome further discussion on
any interesting patients you have
(Hospice or otherwise)
[email protected]