michael nisco md mba - · pdf filemichael nisco md mba ... i hope you get better, but i want...
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9/28/2012
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Michael Nisco MD MBACh i NHPCO E hi C iChair, NHPCO Ethics Committee
Director, UCSF Palliative Medicine Fellowship, Fresno
Medical Director, SAMC Hospice & Palliative Care Services
• Understanding the evolution of our approach to life sustaining treatments, and the role of DNR orders such as POLST
• Appreciate the importance of different perspectives in the decision making process.
• Learn skills to have a better conversation with patients and families about their end of life wishes.
• Consider how your hospice can better adapt to the expanding hospice continuum of care and develop plans of care to honor patients’ treatment preferences.
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80 YEAR OLD WOMAN WITH METASTATIC COLON CANCER IN RESPIRATORY DISTRESS. HER DAUGHTER IS PRESENT. THE NURSE ASKS THE DAUGHTER:
“WOULD YOU LIKE US TO DO EVERYTHING?”WOULD YOU LIKE US TO DO EVERYTHING?
WHAT IS WRONG WITH THIS QUESTION?
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DementiaDementiaTrauma, InfectionTrauma, Infection
COPD, CHFCOPD, CHF
InfectionInfection
CancerCancer
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Positive pressure mechanical ventilation via endotracheal intubation.
Nutrition via tube gastrostomy
Cardiopulmonary Resuscitation
Once each LST entered common use, it was deemed unethical to withhold it and particularly to withdraw it.
With experience, LSTs found to have not only benefits but also serious burdens.
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Code: Code:
An Alarm
Resuscitation:
Attempts to revive a pulseless patient with CPR/ACLS.
DNR:
Not attempting to revive a pulseless patient with CPR/ACLS.Not attempting to revive a pulseless patient with CPR/ACLS.
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Goals
Comfort
Prolong Life
Treatments
CPR
Intubation
Cure
Preserve Function
Preserve Dignity
Die at home
Religious goals
l l
Ventilation
Noninvasive ventilation
Vasopressors
“ACLS Medication”
Chest compressions
Cardioversion Family goals Survive to the birth of a
baby, visit of a relative, etc.
Cardioversion
Antibiotics
Artificial Nutrition
Etc….
Goals of care Comfort
Prolong Life
Cure
Preserve Function
P Di i
vs. Treatment choices CPR
Intubation
Ventilation
Noninvasive ventilation
Vasopressors Preserve Dignity
Die at home
Religious goals
Family goals
p
“ACLS Medication”
Chest compressions
Cardioversion
Antibiotics
Artificial Nutrition
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POSITION:
I want my mom to have CPR!
INTERESTS:
I hope my mom can survive until my brother gets here.
I want my mom to be comfortable I want my mom to be comfortable
I don’t want to be accused of giving up on mom.
I think my mom will get better and walk out of here!
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Conversations along the way…
From the patient/family: p y Hopes and expectations
Quality of Life assessment
Define the parameters of “beneficial vs. burdensome” care.
From the health care team:From the health care team: Diagnosis, prognosis, treatment options and
expected outcomes.
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Prior To Death When Death Occurs
A. Cure Disease A. Attempt Resuscitation
B Maintain best health B Allow a Natural DeathB. Maintain best health B. Allow a Natural Death
possible
C. Maximize Comfort
Prior To Death When Death Occurs
A. Full Treatment A. Full Code
B Limited Treatments B DNR / A N DB. Limited Treatments B. DNR / A.N.D.
C. Comfort Measures
Only
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ILLNESS:
60 y/o College Professor
with Stage IV Colon Cancer
30 y/o Professional Athlete
1. Diagnosis
2. Prognosis
3. Mental Capacity
4. Decision Maker / Process
G l f C5. Goals of Care
6. Code Status
7. Treatment Preferences
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80 YEAR OLD WOMAN WITH METASTATIC COLON CANCER IN RESPIRATORY DISTRESS. HER DAUGHTER IS PRESENT. THE NURSE ASKS THE DAUGHTER:
“WOULD YOU LIKE US TO DO EVERYTHING?”WOULD YOU LIKE US TO DO EVERYTHING?
WHAT IS WRONG WITH THIS QUESTION?
Lacks medical information. Alternatives? Expected outcomes?
Insensitively delivery
Improperly worded. Lack of understanding of surrogate decision making & substituted surrogate decision making & substituted judgment.
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“I have bad news. Your mother’s condition is deteriorating, and she likely will die soon. Many people in your mother’s condition do not improve much with intensive care, CPR and breathing machines. Has she ever spoken to you about what she would want in this situation?”
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“It is only by waiting and listening that we can gain an idea of what we should be saying.”
“Silences and gaps are often more revealing than words as we try to learn what a patient is facing along the constantly changing journey of his ill ”illness….”
Dame Cicely Saunders
St. Christopher’s Hospice
It’s not your job to “talk people into” making the wisest decisions!
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“Is there any hope I’ll get better?”
I hope you get better, but I want to help you prepare in case it doesn’t happen…
Plurality of Hope:
If you don’t get better,
what else are you hoping for?
“Nothing to prolong life or hasten dying”
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1. Understanding the evolution of our approach to life t i i t t t d th l f DNR d h sustaining treatments, and the role of DNR orders such
as POLST
2. Appreciate the importance of different perspectives in the decision making process.
3. Learn skills to have a better conversation with patients and families about their end of life wishes.
4. Consider how your hospice can better adapt to the expanding hospice continuum of care and develop plans of care to honor patients’ treatment preferences
Emanuel LL, von Gunten CF, Ferris FD. (1999) The Education for Physicians on End‐of‐Life Care (EPEC) curriculum. American Medical Association, Chicago.
Krakauer, E.L. 2008. Just palliative care: Responding responsibly to the suffering of the poor. Journal of Pain and Symptom Management, 36(5), 505–12.
N.A. Christakis, Death Foretold: Prophecy and Prognosis in Medical Care, Chicago: University of Chicago Press, 1999.
Lamont EB, Christakis NA.. Complexities in prognostication in advanced cancer. JAMA. 2003; 290:98‐104.
Aitkin PV. Incorporating advance care planning into family practice. American Family Physician. 1999; 59(3):605‐14, 617‐20.
The SUPPPORT Principal Investigators. A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). JAMA. 1995; 274:1591‐1598.( ) 995; 74 59 59
Weissman DE. Decision making at a time of crisis near the end of life. JAMA. 2004; 292: 1738‐1743.
Quill TE. Initiating end‐of‐life discussions with seriously ill patients. JAMA. 2000; 284: 2502‐2507.
Von Gunten CF, Weissman DE. Discussing DNR Orders – Part 1 & 2, 2nd Edition. Fast Facts and Concepts. July 2005; 23.
Emanuel LL, Ferris FD, von Gunten CF, Von Roenn J. EPEC‐O: Education in Palliative and End‐of‐life Care for Oncology. © The EPEC Project,™ Chicago, IL, 2005. ISBN: 0‐9714180‐9‐8