A Primer in Palliative Care for the Stroke Team
description
Transcript of A Primer in Palliative Care for the Stroke Team
![Page 1: A Primer in Palliative Care for the Stroke Team](https://reader038.fdocuments.net/reader038/viewer/2022110102/568139bb550346895da15f07/html5/thumbnails/1.jpg)
A Primer in Palliative Care for the Stroke
Team
Mohana Karlekar, MD, FACPMedical Director Palliative
Vanderbilt UniversityMay 15th 2013
![Page 2: A Primer in Palliative Care for the Stroke Team](https://reader038.fdocuments.net/reader038/viewer/2022110102/568139bb550346895da15f07/html5/thumbnails/2.jpg)
DisclosureO I have a disclosureO I am on advisory board for Hospice
Compassus
![Page 3: A Primer in Palliative Care for the Stroke Team](https://reader038.fdocuments.net/reader038/viewer/2022110102/568139bb550346895da15f07/html5/thumbnails/3.jpg)
ObjectivesO Differentiate hospice and palliative
careO List, understand and apply basic
advance care directives available in Tennessee
O List steps in initiating a conversation on advance care directives
![Page 4: A Primer in Palliative Care for the Stroke Team](https://reader038.fdocuments.net/reader038/viewer/2022110102/568139bb550346895da15f07/html5/thumbnails/4.jpg)
Old Model of Palliative Care
aka…Hospice
![Page 5: A Primer in Palliative Care for the Stroke Team](https://reader038.fdocuments.net/reader038/viewer/2022110102/568139bb550346895da15f07/html5/thumbnails/5.jpg)
Hospice CertificationO 2 MDs certify life expectancy < 6
monthsO If disease runs its natural course
O Treatments are for palliationO Do not have to be DNRO Can revoke at any time
![Page 6: A Primer in Palliative Care for the Stroke Team](https://reader038.fdocuments.net/reader038/viewer/2022110102/568139bb550346895da15f07/html5/thumbnails/6.jpg)
Services ProvidedO Nursing Care O MDT Team
O Chaplain, SW, volunteers…O Covers cost of medications related to
terminal illnessO DMEO Bereavement CareO Respite
![Page 7: A Primer in Palliative Care for the Stroke Team](https://reader038.fdocuments.net/reader038/viewer/2022110102/568139bb550346895da15f07/html5/thumbnails/7.jpg)
Hospice LocationsO Home
O Assisted livingO Nursing home
O Inpatient HospiceO General Inpatient Status
![Page 8: A Primer in Palliative Care for the Stroke Team](https://reader038.fdocuments.net/reader038/viewer/2022110102/568139bb550346895da15f07/html5/thumbnails/8.jpg)
Current Model of Palliative Care
![Page 9: A Primer in Palliative Care for the Stroke Team](https://reader038.fdocuments.net/reader038/viewer/2022110102/568139bb550346895da15f07/html5/thumbnails/9.jpg)
Palliative CareO Multidisciplinary careO Appropriate for all patients facing
serious illnessO Not just for end of lifeO Appropriate to offer while hoping for
cure/prolongation of lifeO Available inpatient and outpatient
settings
![Page 10: A Primer in Palliative Care for the Stroke Team](https://reader038.fdocuments.net/reader038/viewer/2022110102/568139bb550346895da15f07/html5/thumbnails/10.jpg)
Palliative Care O VUMC
O Outpatient clinics at 100 OaksO Inpatient Palliative Care UnitO Consultation Service
O CommunityO Hospices often offer palliative care
services at home or at nursing homes/skilled facilities/rehabilitation centers
![Page 11: A Primer in Palliative Care for the Stroke Team](https://reader038.fdocuments.net/reader038/viewer/2022110102/568139bb550346895da15f07/html5/thumbnails/11.jpg)
Hospice Vs. Palliative Care
Hospice Palliative CareO Defined life
expectancyO Pt must forego life
prolonging therapies/curative intent
O More support in the home setting (equipment, MDT)
O No defined life expectancy
O Can continue curative/life prolonging measures
O Little to no support in the home
![Page 12: A Primer in Palliative Care for the Stroke Team](https://reader038.fdocuments.net/reader038/viewer/2022110102/568139bb550346895da15f07/html5/thumbnails/12.jpg)
O When should I call Palliative Care?O How do I explain this to my patient
and family?O Will they think I am giving up?O Have we called them too earlyO Will patients opt out of treatments
that may potentially help them?
![Page 13: A Primer in Palliative Care for the Stroke Team](https://reader038.fdocuments.net/reader038/viewer/2022110102/568139bb550346895da15f07/html5/thumbnails/13.jpg)
Advance Care Directives
How Do I Decide Which is Appropriate????
Living Will…Health Care Agent…
Advance Care Plan…POST…
![Page 14: A Primer in Palliative Care for the Stroke Team](https://reader038.fdocuments.net/reader038/viewer/2022110102/568139bb550346895da15f07/html5/thumbnails/14.jpg)
![Page 15: A Primer in Palliative Care for the Stroke Team](https://reader038.fdocuments.net/reader038/viewer/2022110102/568139bb550346895da15f07/html5/thumbnails/15.jpg)
Advance Care Directives
O Physician OrdersO DNR ordersO POST forms
O Advance Care DirectivesO Living willO Health Care Agent
O Court Appointed DocumentsO Conservator
![Page 16: A Primer in Palliative Care for the Stroke Team](https://reader038.fdocuments.net/reader038/viewer/2022110102/568139bb550346895da15f07/html5/thumbnails/16.jpg)
C0mpleting Advance Care Directives
O Do not need an attorneyO Do not need notaryO Must be witnessed by 2 individuals
not named in the document
![Page 17: A Primer in Palliative Care for the Stroke Team](https://reader038.fdocuments.net/reader038/viewer/2022110102/568139bb550346895da15f07/html5/thumbnails/17.jpg)
What If…One has no advance care
directive??O Tennessee Surrogate Decision Maker
ActO Physician may act as surrogate
decision makerO If no surrogate available or willing to
serve
![Page 18: A Primer in Palliative Care for the Stroke Team](https://reader038.fdocuments.net/reader038/viewer/2022110102/568139bb550346895da15f07/html5/thumbnails/18.jpg)
![Page 19: A Primer in Palliative Care for the Stroke Team](https://reader038.fdocuments.net/reader038/viewer/2022110102/568139bb550346895da15f07/html5/thumbnails/19.jpg)
![Page 20: A Primer in Palliative Care for the Stroke Team](https://reader038.fdocuments.net/reader038/viewer/2022110102/568139bb550346895da15f07/html5/thumbnails/20.jpg)
Initiating Conversations on Advance Care
Planning
![Page 21: A Primer in Palliative Care for the Stroke Team](https://reader038.fdocuments.net/reader038/viewer/2022110102/568139bb550346895da15f07/html5/thumbnails/21.jpg)
![Page 22: A Primer in Palliative Care for the Stroke Team](https://reader038.fdocuments.net/reader038/viewer/2022110102/568139bb550346895da15f07/html5/thumbnails/22.jpg)
Consider…
O Assess patient family readinessO Assess clinical relevancyO Determine who is best able to have
such a conversation
O Initiate conversations early!
![Page 23: A Primer in Palliative Care for the Stroke Team](https://reader038.fdocuments.net/reader038/viewer/2022110102/568139bb550346895da15f07/html5/thumbnails/23.jpg)
Decline Varies…
![Page 24: A Primer in Palliative Care for the Stroke Team](https://reader038.fdocuments.net/reader038/viewer/2022110102/568139bb550346895da15f07/html5/thumbnails/24.jpg)
We do not accurately prognosticate
![Page 25: A Primer in Palliative Care for the Stroke Team](https://reader038.fdocuments.net/reader038/viewer/2022110102/568139bb550346895da15f07/html5/thumbnails/25.jpg)
Physicians’ accuracy in estimating prognosis???
U. Chicago Medical Center Study: extent and determinants of error in prognostication.
Study participants:
O 343 physiciansO 468 terminally ill patients
Extent and determinants of error in doctors' prognoses in terminally ill prospective cohort study. .Christakis NA, Lamont EB.BMJ. 2000 Feb 19;320(7233):469-473.patients:
![Page 26: A Primer in Palliative Care for the Stroke Team](https://reader038.fdocuments.net/reader038/viewer/2022110102/568139bb550346895da15f07/html5/thumbnails/26.jpg)
ConclusionsO Median survival for patients 24 days
O 20% predictions were accurate (within 33% estimated survival time)
O 63% predictions were over optimistic
Extent and determinants of error in doctors' prognoses in terminally ill prospective cohort study. .Christakis NA, Lamont EB.BMJ. 2000 Feb 19;320(7233):469-473.patients:
![Page 27: A Primer in Palliative Care for the Stroke Team](https://reader038.fdocuments.net/reader038/viewer/2022110102/568139bb550346895da15f07/html5/thumbnails/27.jpg)
We do we may not feel comfortable disclosing true prognosis even if
when we know…
![Page 28: A Primer in Palliative Care for the Stroke Team](https://reader038.fdocuments.net/reader038/viewer/2022110102/568139bb550346895da15f07/html5/thumbnails/28.jpg)
Prognostic Disclosure to Patients
O Study:O 326 patientsO 258 physicians
O Physicians stated:O 37% of time they would provide frank
estimates O 63% of time, would provide no estimate or
either a conscious over/under estimate
Lamont E, Christakis, A. Prognostic Disclosure to Patients with Cancer near the end of life. Annals of Internal Medicine. Jun 2001. Vol134(12);1096-1105.
![Page 29: A Primer in Palliative Care for the Stroke Team](https://reader038.fdocuments.net/reader038/viewer/2022110102/568139bb550346895da15f07/html5/thumbnails/29.jpg)
![Page 30: A Primer in Palliative Care for the Stroke Team](https://reader038.fdocuments.net/reader038/viewer/2022110102/568139bb550346895da15f07/html5/thumbnails/30.jpg)
Steps to take…
![Page 31: A Primer in Palliative Care for the Stroke Team](https://reader038.fdocuments.net/reader038/viewer/2022110102/568139bb550346895da15f07/html5/thumbnails/31.jpg)
Assess Patient’s Readiness
![Page 32: A Primer in Palliative Care for the Stroke Team](https://reader038.fdocuments.net/reader038/viewer/2022110102/568139bb550346895da15f07/html5/thumbnails/32.jpg)
Discuss what “Better” means
![Page 33: A Primer in Palliative Care for the Stroke Team](https://reader038.fdocuments.net/reader038/viewer/2022110102/568139bb550346895da15f07/html5/thumbnails/33.jpg)
Language that can be helpful…
O “I hope that you will recover from this stroke, but it is important that we discuss all of the possibilities….”
O “I worry that this stroke may leave you with some disabilities…”
O “I want to be sure that I know what your goals are, what you are hoping for…”
![Page 34: A Primer in Palliative Care for the Stroke Team](https://reader038.fdocuments.net/reader038/viewer/2022110102/568139bb550346895da15f07/html5/thumbnails/34.jpg)
Message should…O Focus on quality of lifeO Life goals
O Language is less effective ifO Focused on individual interventions
O Lose the trees within the forest
![Page 35: A Primer in Palliative Care for the Stroke Team](https://reader038.fdocuments.net/reader038/viewer/2022110102/568139bb550346895da15f07/html5/thumbnails/35.jpg)
![Page 36: A Primer in Palliative Care for the Stroke Team](https://reader038.fdocuments.net/reader038/viewer/2022110102/568139bb550346895da15f07/html5/thumbnails/36.jpg)
How Doctors Die…Its not like the rest of us but it should
beBy Ken Murray
http://zocalopublicsquare.org/thepublicsquare/2011/11/30/how-doctors-die/read/nexus/
![Page 37: A Primer in Palliative Care for the Stroke Team](https://reader038.fdocuments.net/reader038/viewer/2022110102/568139bb550346895da15f07/html5/thumbnails/37.jpg)
It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.
![Page 38: A Primer in Palliative Care for the Stroke Team](https://reader038.fdocuments.net/reader038/viewer/2022110102/568139bb550346895da15f07/html5/thumbnails/38.jpg)
Of course, doctors don’t want to die; they want to live. But they know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most: dying in pain, and dying alone. They’ve talked about this with their families. They want to be sure, when the time comes, that no heroic measures will happen—that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with CPR (that’s what happens if CPR is done right).
![Page 39: A Primer in Palliative Care for the Stroke Team](https://reader038.fdocuments.net/reader038/viewer/2022110102/568139bb550346895da15f07/html5/thumbnails/39.jpg)
Questions???