Geriatrics + Anaesthesia

•G. A. S.

•S. A. G.

•F. A. S. T.

•F. A. R. T

F. A. R. T. Code•Green

•Yellow

•Red

Considerations of Care at End Of Life

Dr Carol Douglas

Perioperative SIG Meeting Noosa 2016

End of Life

End of Life is that undefined period of time starting with the recognition that a person has an advanced progressive incurable illness that ends in death.

Australian Context EOL

• In 2011 40 % died after the age of 85, largely of chronic disease

• 70% wanted death at home, 14% achieved.

– 54% die in Acute Care, 32% in RACF

• 59% Health care expenditure occurs last 3 yrsbefore death

(GRATTAN REPORT 2014)

AIHW REPORT 2014-15

AIHW 2014, Palliative care referrals

• 2011-12

• 73.8% of patients with primary diagnosis malignancy referred to Palliative Care

• cf 24% with a primary non-malignant diagnosis

Whole Person Care

Attributes of a good death(in order of frequency in literature)

• being comfortable• sense of closure• affirmation/value of the dying person recognised• trust in care providers• recognition of impending death• beliefs and values honoured• burden minimised• relationships optimised• leaving a legacy and family care

(Moving towards Peace: an analysis of the concept of a Good Death-Am J Hosp and Pall Med:2006;23;277)

Quality of Death

“I believe healthcare needs to be judged, not just by the lives saved, but by the quality of death for those they can’t save.” (Intensivist )

“patients should be able to trust the quality of care they receive at the end of life as much as they trust the care they receive during their life”

(Dr Barbara Hayes,Clinical Lead in Advance Care Planning, Northern Health,

Victoria)

• IDENTIFICATION EOL

Preoperative Markers for 6/12 Mortality & Institutionalisation

• Preoperative markers related to 6-month mortality included: impaired cognition, recent falls, lower albumin , greater anaemia, functional dependence , and increased comorbidities

• Strongest predictor(regression analysis) - any functional dependence

Redefining Geriatric preoperative assessment using frailty, disability and co-morbidity . Robinson TN et al. Annals of Surgery, Sept. 2009- bol250-Issue 3- pp 449-455

Identification Deteriorating Health & Dying

• Thomas K, the GSF Prognostic Indicator Guide. End Life C 2010;4

SPICT criteria(2 or more)

• Performance status poor or deteriorating , in bed 50% of time or more

• Dependent on others for care due to physical or mental health issues

• 2 or more unplanned admissions <6/12• Significant wt loss >10% over 3-6/12 and a low BMI• Persistent troublesome symptoms despite optimal

management of underlying disease• Patient asks for palliative/supportive care

Surprise Question

“Would you be surprised if this patient was to die in the next 6 months?”

Trajectories of Dying

Prevalence EOL

• Recent studies show 20-30% of adult patients die within 12mths of admission

• Manner and trajectory of death changing

• Determining dying phase difficult-Clinicians under recognise Pall Care needs

• Major role for Advance Care Planning

• Timely discussions goals of care and planning alleviate distress patient and family

ANZSPM 5 Key Goals of Care EOL

• Advance Care Planning- emphasis on Patient’s goals of care

• Symptom management – evidence based, aggressive, holistic and multidisciplinary

• Psychosocial Support Patient and Family

• Coordination and Integration of Care-across disciplines- advocating for patient and family

• Best Care in Terminal or Dying Phase

Societal Considerations

• “...the idea that cure is improbable or impossible, or that continued life support is inappropriate or unkind, is unacceptable to many families. The wider problem here is that acknowledgement of the inevitability of death, and preparation for it, have largely lost their place in our culture. For many, an almost child-like faith in medicine and science has taken its place.”

• Ashby M, Kellehear A, Stoffell B. Resolving conflict in end-of-life care. Medical Journal of Australia 2005;183(5):230-1.

Public Health Approach

• Research indicates that real benefits for individuals and communities can result from strengthening society’s awareness and understanding of death, dying, loss and palliative and end-of-life care.

• Gardner R, Rumbold B, Salau S. Strengthening palliative care in Victoria through health promotion. La Trobe University and Palliative Care Victoria; 2009.

• Kellehear A. Compassionate Cities: public health and end-of-life care. London: Routledge; 2005.

• Nutbeam D. Building health literacy in Australia. Med J Aust 2009;191(10):525-6.

Advance Care Planning

“in this world nothing can be said to be certain, except death and taxes.” (Benjamin Franklin)

“how we seek to spend our time may depend on how much time we perceive ourselves to have.” Atul Gawande, Being Mortal: Medicine and What Matters in the End

The ACP Conversation

‘Dying to Talk Campaign ‘ ‘talking about dying won’t kill you’

ACP PROCESSES- DOCUMENTATION Respecting Patient Choices Program

On line - myvalues.org.au

COMMUNICATION EOL

Goals of care

• 93yr old woman PVD admitted for work up BKA for necrotic toes

• SPCS consult for severe pain • Consult- distressed, difficult to

engage“ are you a torturer too?”“Can’t an old woman die?”

• Surgery cancelled , transferred to PCU for conservative management , peaceful death

“Allowing Natural Death”

Charlie Corke et al. How Doctors Discuss Major Interventions with High Risk Patients: An observational study. BMJ 2005;330.182-

Shared Decision making

“Goals of Care Communication”

1. Goals of Patient Care - doctor directed, clinician to clinician communication

2. Advance Care Planning - patient directed, patient to clinician communication

Vignette- Determining G of C

• 90yr old IHT for placement stent -Perforated Oesophageal SCC

• # Aspiration pneumonia, mediastinal collection, • Clinically Hypoxic, AF with stated ‘guarded

prognosis’• Goals of Patient –carer for his wife with

dementia, both indep ADL’s- does not want interventions and requests symptom relief only

• Conservative management/ palliation• Futile Transfer ??

Vignette-Determining G of C

• 68yr of woman, Met TCC, # contained large bowel perforation with fistula communicating with tumour –CR team Consult

• Symptoms, unremitting nausea, constipation, chronic abdopain- requires SPCS support

• Decision making complicated by fluctuating delirium unable to recall discussions with surgeons

• Goals of patient- QOL & time with family• Goals of surgery- improved prognosis & analgesia

unlikely achieveable for palliation • =SHARED DECISION MAKING

• Referral to Palliative Care

Traditional dichotomous model.

Adapted from Gustin Jr AN, Aslakson RA. Palliative Care for the Geriatric Anesthesiologist. Anesthesiology Clin 2015; 33: 591-605. (Further adapted from Lanken PN, Terry PB, DeLisser HM, et al. An official American Thoracic Society clinical policy statement: palliative care for patients with respiratory diseases and critical illnesses. Am J Respir Crit Care Med 2008;177:914.)

(B) Overlapping model of palliative care.

.

Adapted from Gustin Jr AN, Aslakson RA. Palliative Care for the Geriatric Anesthesiologist. Anesthesiology Clin 2015; 33: 591-605.

(Further adapted from Lanken PN, Terry PB, DeLisser HM, et al. An official American Thoracic Society clinical policy statement: palliative care for patients with respiratory diseases and critical illnesses. Am J Respir Crit Care Med 2008;177:914.)

Individualized integrated model of palliative care.

(C) InAdapted from Gustin Jr AN, Aslakson RA. Palliative Care for the Geriatric Anesthesiologist. Anesthesiology Clin 2015; 33: 591-605. (Further adapted from Lanken PN, Terry PB, DeLisser HM, et al. An official American Thoracic Society clinical policy statement: palliative care for patients with respiratory diseases and critical illnesses. Am J Respir Crit Care Med 2008;177:914.)

Integration of palliative

care

“Bowtie” model of 21st century palliative care

Hawley, P. The bow tie model of 21st century palliative care.

J Pain Symptom Manage. 2014 Jan;47(1):e2-5.

INTEGRATED MODELS

• upstream orientation to care• adaptation of palliative care knowledge and expertise• Application of a palliative approach through integration

and contextualization within healthcare systemsConceptual foundations of a palliative approach: a knowledge synthesis.Richard Sawatzky et al

• RENAL SUPPORTIVE CARE • HEPATOLOGY SUPPORTIVE CARE• HEART FAILURE SUPPORTIVE CARE• CANCER SUPPORTIVE CARE

BARRIERS TO REFERRAL PC in CHRONIC DISEASE

• PROGNOSTIC PARALYSIS- unpredictable trajectory

• COMMUNICATION BARRIER(Dalgard et al 2014)

• PHYSICIAN PREDICTION 6/12 MORTALITY

In 16% patients (Hauptman et al 2008)

• CHF PATIENTS 2/7 PRIOR TO DEATH GIVEN ~6/12 PROGNOSIS BY CLINICIAN AND COMPUTER (SUPPORT STUDY)

Individualised Integrated

(D) Individualized integrated model of palliative care.

Adapted from Gustin Jr AN, Aslakson RA. Palliative Care for the Geriatric Anesthesiologist. Anesthesiology Clin 2015; 33: 591-605.

(Further adapted from Lanken PN, Terry PB, DeLisser HM, et al. An official American Thoracic Society clinical policy statement: palliative care for patients with respiratory diseases and critical illnesses. Am J Respir Crit Care Med 2008;177:914.)

The American College of Surgeons (ACS) and American Geriatrics Society (AGS) have issued joint best practice recommendations

for geriatric perioperative care

1. The recommendations address immediate preoperative, intraoperative, and postoperative management, as well as managing transition to care after surgery. The guideline also includes various checklists and appendices, such as advance directive position statements and perioperative risk factors for delirium.

2. The postoperative management section addresses postoperative delirium, functional decline, and preventing pulmonary complications, falls, urinary tract infections, and pressure ulcers.

3. The healthcare team prefeshould discuss the patient's personal goals and treatment rencesbefore surgery, including advance directive and a designated healthcare proxy.

4. Provide an early postoperative palliative care consultation for patients with a poor prognosis.

5. Before surgery, develop an appropriate, multimodal analgesic plan, including opioid-sparing techniques and avoiding potentially inappropriate analgesics and anxiolytics.

6. Assess patients for delirium risk factors (age older than 65 years, chronic cognitive decline, dementia, poor vision/hearing, critical illness, and infection).

7. Patients with postoperative delirium should receive multicomponent nonpharmacologicinterventions, and pharmacologic interventions only if they pose substantial harm to themselves or others.

Time for a Paradigm Shift

Vignette

• 68 yr old man with advanced IPF , increasing dyspnoea, reluctance physician to prescribe any opioids/benzodiazepines

• Attempts to hang himself at home

• Admitted for escalation of acute management

• I/P -Severely dyspnoeic, distressed

• Patient and Family ‘beg’ for Palliative Care

Moral Distress

• “We do a lot of terrible things to critically ill patients and at the end of life. It’s routine care, and I feel pretty numb to having done those things…it seems like there is no benefit and only risk. Yet I am accepting the patient to have these procedures done to them. I’m in that situation all the time. I’m pretty powerless to do anything about it”

Dzeng et al. Moral Distress Amongst American Physician Trainees Regarding Futile Treatments at the End of Life: A Qualitative Study Journal of General Internal Medicine

January 2016, Volume 31, Issue 1, pp 93–99

•

Resolving the Tension?

We can no longer afford, in either fiscal or human terms, to think about palliative care as relevant only to the final weeks or days of life. Meaningful support for living well before you die does not naturally follow when a Chronic Disease Model philosophy dominates the care strategy until some event signals that death is impending

Unravelling the Tensions Between Chronic Disease Management and End-of-Life PlanningThorne, Sally; Roberts Della; Sawatzky, Richard. Research and Theory for Nursing Practice,Volume 30, Number 2, 2016, pp. 91-103(13)

Achieving Integrated care 1-Education /Knowledge

• Improved Education• Undergraduate Curriculum- PCC4U www.pcc4u.org/learning-modules

• Postgraduate• RACP Diploma Pall Med-(most preferred med attachement Qld - ICU

training)• Dual training Medical subspecialties;• Emergency Medicine, Oncology• Journal ClubsEducation Resources-• (Flinders Univ. EOL Essentials Package)

– Managing EOL issues in Hospitals– Recognising Dying– Communication and Decision-makingwww.caresearch.com.au/EndofLifeEssentials

Achieving Integrated Care 2-Improved Communication

• Process Change

– System driven- - eg Goals of Care Documents

– Mandatory Communication skills training

– Measuring quality of death- ANZSPM EOL INDICATORS

• Engaging in Interdisciplinary/Multidisciplinary Care- vs. ‘Craft group’ Care

“A few conclusions become clear when we understand this: that our most cruel failure in how we treat the sick and the aged is the failure to recognize that they have priorities beyond merely being safe and living longer; that the chance to shape one’s story is essential to sustaining meaning in life; that we have the opportunity to refashion our institutions, our culture, and our conversations in ways that transform the possibilities for the last chapters of everyone’s lives.”

Atul Gawande, Being Mortal: Medicine and What Matters in the End