Transcript Chapters 24 and 11 Multisystem Problems and Care at the End of

The Frail Older Adult
Care at the End of Life
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Weight loss of >5% of baseline
Poor appetite and nutrition
Dehydration
Immobility
Depression
Impaired immune function
Low cholesterol levels
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Presence of 3 or more of the following:
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Unplanned weight loss (10 lb in past year)
Weakness
Poor endurance and energy
Slowness
Low activity
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Progressive physiological decline
Chronic illness
Loss of organ function
Recurrent acute illness
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Dependency
Institutionalization
Mortality
Frailty
Slow recovery
Hospitalization
Falls
Injuries
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Poverty
Social isolation
Functional decline
Cognitive decline
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CVD
CAD
HTN
Diabetes
Frailty
and
Disability
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Frailty
Acute illness
Worsened chronic
condition
Stress of care
provided
Poor treatment
outcome or death
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Diagnose all vague symptoms and complaints accurately
Treat all relevant diseases
Assess effect of current changes in health status
Consider effect of acute
illness on chronic disease
• Prevent complications of
hospitalization
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• Trajectory: the path of a moving object through space
• Also applies as a model for understanding the eventual course
of one’s health status throughout time until death
This is the way the world ends
This is the way the world ends
This is the way the world ends
Not with a bang but a whimper.
—T.S.Eliot, The Hollow Men (1925)
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Direct Influences
• Genetics
• Environment
• Wear and tear
• Nutrition
• Stress
• Disease
Indirect Influences
• Social relationships
• Education
• Finances
• Response to age-related changes
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• More than 50% of persons over 40 years of age have at least
1 chronic condition
• More than 80% of non-institutionalized persons over 65 years
of age have at least 1 chronic condition
• Therefore, health care for the elderly should be oriented
toward care of chronic disease regardless of the person’s age
• Health care should emphasize:
• Improving function
• Postponing deterioration and disability
• Preventing complications
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• Maintain or improve self care
capacity
• Effective disease management
• Enhance body’s healing abilities
• Prevent complications
• Delay deterioration and decline
• Promote highest possible quality of
life
• Ensure death with dignity
and comfort
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• After each acute episode, patients are left with greater
functional deficit or increased problems.
• The episodes become increasingly frequent and refractory to
treatment as the patient nears the end of life.
• Recognition of a pattern enables those at risk of imminent death
to be managed more appropriately.
• The patient will then have the chance that most (but not all)
patients prefer…
to plan and prepare for death, together with their
families.
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• Use short term goals that are evaluated throughout the
trajectory of the disease
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• Each disease, be it acute or chronic, has its own trajectory
• The disease trajectory influences the individual’s health
trajectory
HEALTH
DISEASE
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• Evaluation occurs at
each point of change
in the trajectory
• Goals and interventions
are modified to permit
change in patient
baseline status
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Preferences of patient, preferences of family
Minimize burden to patient if chance of success is reasonable
Allocation of resources to those most likely to benefit
Should not be delivered to alleviate guilt or distress of family
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What are our goals of care?
How will we achieve those goals?
Agreement among patient and family members
Agreement on code status
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• Aggressive care
• Patient has high functioning, satisfactory quality of life
• Goal: extension of life
• Modified care
• Frailty or comorbidities, but likely to respond to treatment
• Goal: extension of life considering burden of treatment
• Palliative care
• Can be delivered with aggressive or modified care or by itself
• Goal: patient comfort and quality of life
• Life extension is secondary
• Hospice care
• A type of palliative care for final months or weeks
• Patient has life expectancy of 6 months or less
• Goal: comfortable death
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• Focuses on relieving and preventing the patient’s suffering
• Appropriate for patients in all disease stages:
• Patients undergoing treatment for curable illnesses
• Patients living with chronic diseases
• Patients nearing the end of life
• Uses a multidisciplinary approach to
patient care
• Addresses the physical, emotional,
spiritual, and social concerns of
advanced illness
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• Dying is an inevitable part of living
• Helping the dying patient and family find comfort and meaning
in the dying experience is often more important than correcting
physiological problems
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• Allow patient and family to maintain control
• Encourage participation in end-of-life care
• Prevent and relieve distress
• Physical
• Emotional
• Spiritual
• Know local laws and institutional
policies
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Living wills
Durable power of attorney
Resuscitation
Specific treatment
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Maintain communication among patient, family, staff
Display sensitivity to specific beliefs
Alleviate pain, promote comfort
Manage psychological, social,
and spiritual concerns
• Continuous collaboration
• Promote access to palliative
and hospice care
• Respect right to refuse care
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• Value of quantity of life over quality
• Acceptance of pain or disfigurement
• Is there perceived value in curative, rehabilitative or preventive
care?
• Supportive care may be only realistic choice
• Plan of care does not terminate
• Account for
• Patient’s goals
• Limits imposed by illness
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• Physical and mental distress commonly experienced by patients
with terminal illness
• Fear that discomfort cannot be controlled
• Relief of discomfort and reassurance that effective treatment is
available
• Enables living life as fully as possible
• Able to focus on unique issues associated with the approach of death
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• Symptoms can have many causes
• Patients respond differently as deterioration progresses
• Altered drug metabolism likely to occur
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• About half of patients dying of cancer have severe pain
• About half of these receive adequate relief
• Often pain is due to:
Misconceptions on parts of physicians and patients
regarding:
• Pain
• Drugs used to control pain
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Patients perceive pain differently
Fatigue
Insomnia
Anxiety
Depression
Nausea
Supportive environment
can help control pain
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What is most available?
Least invasive route
Depends on pain intensity
Analgesics should be given
routinely rather than as needed
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• Controlling pain after it occurs is more difficult than preventing
it
• Pain generates anxiety
• In hospice situations, nurses, patients and family members can
become competent at making dosing or scheduling adjustments
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Hypnosis
Guided mental imaging
Counseling for stress and anxiety
Relaxation methods
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• One of the most feared and most distressing symptoms
• Cause should be treated
• Dyspnea symptoms are suppressed when physiologic cause
cannot be relieved
• Demerol (less frequently)
• Morphine
• Oxygen may be psychologically
comforting to patient and family
even when not physiologically
beneficial
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Opioid can slow respirations
Relieve mild chronic symptoms
Allows more comfortable sleep
Morphine 2.5 mg IV
every 2 to 4 hours
• Morphine may be given
by continuous drip or
bolus
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• Usually more distressing to family members
• Counseling may be necessary for family members to accept
anorexia
• The patient has “more important things to do”
• Tube feedings, parenteral nutrition likely futile
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Small portions if full tray is overwhelming
Specially prepared foods
Flexible meal schedule
Small amount of alcoholic beverage 30 minutes before meals
Foods with strong flavors or smells
Medications
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Corticosteroids (dexamethasone)
Antidepressants
Metochlopramide
Megace (progestin)
Marinol (cannabinoid)
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Used rarely
Discontinuation may be difficult to accept
Food and fluid symbolize nurturing and caring
Inform family members that dying patient may be more
comfortable without artificial administration of food and water
• Easy-to-swallow foods may be more
appropriate:
• Sherbet
• Gelatin
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• Supportive care imperative
• Good oral hygiene
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Brushing teeth
Swabbing oral cavity
Applying lip salve
Ice chips for dry mouth
• Physically and psychologically
comforting care for family to provide
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Potential causes
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Constipation
Reduced gastric emptying
Bowel obstruction
Central opioid effects
Increased intracranial pressure (ICP)
Gastritis
Peptic ulcer
Hypercalcemia
Uremia
Toxic drug effects
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• Phenothiazines act on chemoreceptor zone in the medulla, e.g.,
prochlorperazine (also an anxiolytic, trade Compazine, et al.)
• Metochlopromide (Trade Reglan)
• If near death, conservative treatment
without relief of obstruction
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Often underestimated by physicians
Give stool softener first
Should give laxatives prophylactically
Stimulant/laxative should be given if patient is being given
opioids
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• Common causes
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Drug therapy
Hypoxia
Metabolic disturbances
Intrinsic CNS disease
• Confusion is treated if cause can
be determined
• Withholding treatment for confusion may be preferable if
• Patient is comfortable
• Patient less aware of surroundings
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• Sedatives (benzodiazepines, e.g., Librium, Valium, Xanax)
• Risperdone (trade Risperdal)—produces changes in chemicals in
the brain, generally used for schizophrenia, bipolar disease,
autism in children)
• Olnazapine (trade Zyprexa)—
generally useful in schizophrenia
and bipolar disease
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Symptom, not a diagnosis
Depression and anxiety are the leading causes
Also:
Trazodone 25 to 50 mg at bedtime (antidepressant)
Hypnotic (zolpidem [Ambien]) at bedtime
May also try: meditation, relaxation techniques, deep
breathing exercises, relaxation tapes
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• Most medical actions perceived as hastening death are based
on the need for relieving pain
• Physician must inform patient and family that such actions may
shorten life
• Should be clear that treatment is for pain and symptom relief
and not for causing death
• Myth: “Good pain management rarely shortens life and may
extend it.”
• Assisting with suicide is a criminal
act in most states…including
California.
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Should be made by a physician
Sometimes made by Nurses in the absence of a physician
Determination should be made as soon as possible
Ensure psychological and spiritual needs of family are met
Comfortable environment
Arranging for someone to be with body when family visit can
be helpful
• Notify clergy or funeral home
• Reassure family patient was comfortable
• Contact family a few weeks later for follow up
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