BEST PRACTICES IN CARE OF THE DYING

1
BEST PRACTICESINCARE OF THE DYING
In Search of

• James Hallenbeck, MD
• Hospice Medical Director
• VA Palo Alto HCS

2
OverviewBest Practices
A conceptual framework

• Various groups working on guidelines
• AMA
• ABIM
• National Cancer Care Network
• Position papers/policies
• Last Acts Precepts of Palliative Care
• VA policy on Pain as the Fifth Vital Sign

Among others
3
Domains of EOL Care
Pain Management Non-pain Symptom
Management Communication Ethics Psychosocial,
Spiritual Care System issues
4
Pain ManagementStandards of Care

• Patient Centered
• Standardized assessment tools
• Pain as the Fifth Vital Sign
• Monitoring is incorporated into quality
  management
• Specific prescribing guidelines
• Ex. For chronic pain, rely on long-acting oral
  opioids with short-acting breakthrough doses

5
Pain Management Controversies

• Generalist vs. specialist
• Palliative Care specialist vs. Pain Management
  specialist
• In Geriatrics- traditional vs. palliative
  approach
• Polypharmacy vs. mult-modality therapy
• Emphasis on functional status vs. relief of
  suffering

6
Non-pain Symptom Management
What symptoms are we talking about?

• Constipation
• Dyspnea
• Nausea and vomiting
• Dry mouth
• Plus approximately 50 more...

7
Non-pain Symptom ManagementStandards of Care

• Overall- emphasis on tailoring drug therapy to
  specific cause(s) of symptoms
• Constipation
• start treatment when starting opioids
• more patient/nurse autonomy in treatment
• Dyspnea
• central role of opioids, benzodiazepines
• Nausea and vomiting
• dopamine antagonists for opioid related nausea

8
Non-pain Symptom ManagementControversies

• Role of antibiotics in certain infections
• Role of artificial hydration/nutrition
• Use of newer, often more expensive palliative
  medicines
• Ex. 5HT3 antagonists for nausea
• Overlap/differences between traditional and
  palliative care for certain symptoms

9
CommunicationStandards of Care

• Active Listening
• Assessment of patient preferences
• Current as well as advance directives
• Sharing of bad news
• How to pronounce a patient
• Patient/family education
• Prognosis, care options, goals of therapy, normal
  changes of dying

10
CommunicationControversies

• Who should communicate what?
• Time and money involved in good communication
• Cultural factors
• Attending physician role in modeling/teaching
  communication skills
• Much EOL communication part of resident
  sub-culture

11
EthicsControversies

• Physician Assisted Suicide (PAS)
• Voluntary Euthanasia (VE)
• Terminal Sedation (TS)
• Voluntary Self-discontinuation of Eating and
  Drinking (VSED)
• Futility
• Who pays for what? (Issues of justice)
• Cultural factors

12
EthicsStandards of Care

• Discussion and documentation of current and
  advance directives
• Non-abandonment
• Respect for patient, family, healthcare worker
  values
• Importance of cultural competency
• Availability of ethics consultation

13
Psychosocial, Spiritual CareStandards of Care

• Recognition/treatment of depression
• Recognition of the family as the unit of care
• Appreciation for economics of EOL care
• Importance of addressing patient/family spiritual
  needs
• Bereavement support

14
Psychosocial, Spiritual CareControversies

• Treatment of terminal delirium
• Role of the physician in this area, esp.
  addressing spiritual suffering
• Are we at risk of forcing our notion of a good
  death onto others?
• Reimbursement for this care
• In Geriatrics- Independence vs. Interdependence

15
System IssuesStandards of Care

• Universal access to appropriate EOL care
• Coordination of care across venues
• Treatment of patients in the venue of care
  desired to the extent possible
• Interdisciplinary approach to care
• Incorporation of monitors into quality management
  structure and accreditation

16
System IssuesControversies

• ? Right to EOL care
• Hospice vs. Palliative care
• Role of managed care
• Proper reimbursement structure (taking into
  account)
• different dying trajectories (problems with
  prognosis)
• different patient/family preferences for care
• differences in case-mix

17
Summary

• Standards of care are beginning to evolve
• Large gaps between best practices and current
  level of practice
• Major controversies exist as to what constitute
  best practices