Duties at The End of Life Care

The End of Life Care
Objectives
■ Address issues surrounding end-of-life

care and vulnerable older adults
- definition of palliative care
- logistics of end-of life-care
- surrogate decision making and advance
directives
- symptom management
WHAT IS PALLIATIVE CARE?
◆ Interdisciplinary
◆ Goal :
◆ to prevent and alleviate suffering
◆ assist towards the best possible quality of life
◆ optimize function
◆ assist with decision making for patients with serious
illness and their families.
Can be the main focus of care or offered

◆
concurrently with all other life - prolonging

medical treatment.
END-OF-LIFE DEMOGRAPHICS
◆ The majority of deaths occur in elderly adults
◆ Very ill patients may spend much of their final

time at home, but…
◆ Hospitals or nursing homes are actual location

most deaths
◆ There is regional/ geographic variability in

location of deaths (home vs. institution)
Adapted from Geriatrics Review Syllabus, Sixth

Edition
END-OF-LIFE (EOL) IN THE U.S.
◆ For elderly, death is typically slow and
associated with chronic disease
◆ Patients experience increased dependency in
their care needs
◆ EOL care can be complicated by family stress,
poor symptom control, and discontinuity of
care
◆ In this age of technology, commonly decisions
need to be made about the use of these
agents
Adapted from Geriatrics Review Syllabus, Sixth Edition

Curative / Life Prolonging
Presentatio Deat
n h
Sx Control /
Adapted from Institute of Medicine Palliative Care
Historical trajectories of care pathways

WHAT IS “HOSPICE”?
◆ Location
⧫ Place for the care of dying patients
◆ Group
⧫ Organization that provides care for the dying patient
◆ Approach to care
⧫ Philosophy of care for the dying patient
◆ A Medicare benefit
Adapted from Geriatrics Review Syllabus, Sixth Edition

PROGNOSIS
■ More straightforward for cancer diagnosis
■ Often unpredictable for chronic disease
COPD
Alzheimer’s Disease
Heart disease
Failure to Thrive/ Debility
PROGNOSIS
■ In general:
Patient’s condition is life limiting, and pt/ family
are aware
Pt/ family have elected relief of sx treatment
goals rather than curative goals
Pt has either documented clinical progression of
disease or documented recent impaired nutritional
status related to the terminal process
DELIVERING BAD NEWS
◆ Prepare
⧫ Plan an agenda
⧫ Ensure availability of all medical facts
⧫ Pick an appropriate setting
⧫ Minimize interruptions
◆ What does the patient understand? What does the
patient want to know?
◆ Deliver the news
⧫ Be straightforward, avoiding medical jargon
⧫ Provide a “warning shot”
◆ Allow time for discussion
◆ Create a plan and organize for follow-up
DECISION MAKING
■ Autonomous choices are voluntary,

adequately informed and based on
reasoning
◆ Does the patient have the ability to
choose?
◆ Does the patient understand pertinent
information?
◆ Does the patient appreciate the clinical
situation/ choices/ consequences?
◆ Can the patient reason through choices?
The patient identifies the goal(s).
The plan follows the goal.
SURROGATE DECISION MAKING
■ May be required with both younger and older

adults
■ Specific surrogate may be identified via a
DPOA (durable power of attorney) for health
care
■ Goal of surrogate is to advocate for patient
based on what they know of patient’s wishes
- based on prior discussions, advance directives/
living wills
SOME DEFINITIONS
■ Durable Power of Attorney for Health Care

◆ Appointing someone to make medical decisions for you if
you cannot make them yourself
■ Living Will
◆ Description of wishes about life sustaining medical treatments if
one is terminally ill
■ Advance directives
◆ Instructions / guidance for for health care should one become
incapacitated
◆ Can name an “agent” to make decisions for them
◆ Wishes stated must be honored by surrogate unless court orders
otherwise
◆ Can be revoked at any time
Adapted from University of New Mexico SoM

DECISION MAKING
■ If a patient cannot make their medical

decision and has not identified a surrogate
decision maker, does not have an advance
directive, or has not made their wishes
known, a surrogate may have to be identified.
◆ Some states have an automatic order of priority for
identifying surrogates
OTHER PALLIATIVE CARE ISSUES
■ Symptom management
■ Cross-cultural issues
■ Spiritual concerns
■ Psychosocial issues
See recommended readings for further information

SYMPTOM MANAGEMENT
■ Multiple symptoms of concern near the end of life
- Pain
- Dyspnea
- Constipation
- Nausea
- Anxiety
- Delirium
- Fatigue
- Anorexia
PAIN
■ Treatment based on assessment
- severity
- nociceptive vs. neuropathic
- step-wise approach
■ Potential modalities
- Non-opioid
acetominophen
NSAIDs/ COX-2 –I
- Opioid (s2 number)
- Adjunctive
Anti-convulsants
Steroids
TCAs
Opioids
■ IV- morphine, hydromorphone, fentanyl
■ PO- morphine (LA & SA), oxycodone (LA & SA),
hydromorphone, methadone, fentanyl, hydrocodone
■ Transdermal- fentanyl
■ Initial decisions based on
- route of administration
- need for continuous vs. intermittent dosing
- severity of pain
LA= long acting
SA= short acting
Opioids-Pharmacology
■ All water soluble opioids behave similarly:
■ Cmax is 60-90 minutes after PO dose
30 minutes after SQ or IM
6-10 minutes after IV dose
■ All are conjugated in liver and 90% excreted via
the kidney
■ With normal renal fx, all have ½ life of 3-4 hours,
reach steady state in 4-5 ½ lives
Potential opioid side effects
■ Nausea
■ CNS depression/ sedation
■ Pruritis
■ Constipation
■ Delirium
■ Endocrine dysfunction with long term use
DYSPNEA
■ Subjective symptom
■ Pathophysiology can reflect disorder in
regulation or act of breathing
■ Treatment directed at underlying cause
- Most common reversible causes
bronchospasm, hypoxia, anemia
- Both non-pharmacologic and non-pharmacologic
treatments can be helpful
- Opioids used for sx relief when more directed
therapy doesn’t reverse the dypsnea
NAUSEA
■ Potentially debilitating symptoms near the end

of life
■ Treatment based on source
- Brain chemoreceptor trigger zone, cerebral cortex,
vestibular apparatus
- GI tract obstruction, motility, mucosal irritation
DELIRIUM
■ Common near the end of life

- geriatric patients with multiple risk factors for
development
■ Large number of cases can be reversible
■ Control of delirium may be important for both
patient and family
- pharmacologic and non-pharmacologic means
Thank you!
■ Good luck sa Midterms…..
Love,
Sir Gilbeys

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The End of Life Care

■ Address issues surrounding end-of-life

Can be the main focus of care or offered

concurrently with all other life - prolonging

◆ Very ill patients may spend much of their final

◆ Hospitals or nursing homes are actual location

◆ There is regional/ geographic variability in

Adapted from Geriatrics Review Syllabus, Sixth

Adapted from Geriatrics Review Syllabus, Sixth Edition

Historical trajectories of care pathways

Adapted from Geriatrics Review Syllabus, Sixth Edition

■ Autonomous choices are voluntary,

■ May be required with both younger and older

■ Durable Power of Attorney for Health Care

Adapted from University of New Mexico SoM

■ If a patient cannot make their medical

See recommended readings for further information

■ Potentially debilitating symptoms near the end

■ Common near the end of life

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