End of Life Care: An OverviewSlide 2
Objectives Address issues encompassing end-of-life consideration and powerless more seasoned grown-ups - meaning of palliative consideration -logistics of end-of life-consideration -surrogate basic leadership and development mandates -side effect administration ACOVE markers and EOL careSlide 3
WHAT IS PALLIATIVE CARE? Interdisciplinary Goal : to avert and reduce enduring help towards the most ideal personal satisfaction improve capacity help with basic leadership for patients with genuine ailment and their families. Can be the primary center of consideration or offered simultaneously with all other life - dragging out restorative treatment.Slide 4
END-OF-LIFE DEMOGRAPHICS The dominant part of passings happen in elderly grown-ups Very sick patients may invest quite a bit of their last energy at home, yet… Hospitals or nursing homes are real area of most passings There is provincial/geographic variability in area of passings (home versus organization) Adapted from Geriatrics Review Syllabus, Sixth EditionSlide 5
END-OF-LIFE (EOL) IN THE U.S. For elderly, demise is ordinarily moderate and connected with unending malady Patients experience expanded reliance in their consideration needs EOL consideration can be confounded by family stretch, poor side effect control, and intermittence of consideration In this time of innovation, regularly choices should be made about the utilization of these operators Adapted from Geriatrics Review Syllabus, Sixth EditionSlide 6
SUDDEN DEATH, UNEXPECTED CAUSE < 10%, MI, mishap, and so on. Wellbeing Status Death TimeSlide 7
Steady Decline Short "Terminal Phase"Slide 8
SLOW DECLINE Periodic Crises, Sudden DeathSlide 9
Curative/Life Prolonging Presentation Death Sx Control/Palliative Care Adapted from Institute of Medicine Historical directions of consideration pathwaysSlide 10
Consider an option direction… Inclusion of palliative ideas from time of conclusion This bit of the consideration arrangement may turn out to be more conspicuous as remedial treatments are less accessible More progressive moves toward the end of lifeSlide 11
Curative/Remissive Therapy Death Presentation Hospice Palliative Care Adapted from EPEC educational modules, 1999Slide 12
WHAT IS "HOSPICE"? Area Place for the consideration of passing on patients Group Organization that gives consideration to the withering patient Approach to care Philosophy of tend to the diminishing patient A Medicare advantage Adapted from Geriatrics Review Syllabus, Sixth EditionSlide 13
THE HOSPICE MEDICARE BENEFIT For recipients with a normal visualization of 6 months or less Exchange remedial medicines for symptomatic/palliative medications Can be repudiated whenever Reimbursed routine set of expenses for one of four levels of consideration Can be used in the home, nursing home, inpatient hospice units See referenced perusing, AAHPM BulletinSlide 14
THE HOSPICE MEDICARE BENEFIT Covered Services doctor administrations, nursing care therapeutic gear and supplies pharmaceuticals identified with the terminal ailment assigned fleeting inpatient care (side effect administration & reprieve) PT or OT taking into account the objectives deprivation administrations home-wellbeing assistant administrationsSlide 15
OBSTACLES Limited access, i.e. provincial territories Logistical bolster Late referral – middle length time went through with hospice is just 21 days (Hospice Association of America 2006) Difficulties in deciding forecastSlide 16
PROGNOSIS More clear for tumor analysis Often flighty for interminable illness COPD Alzheimer\'s Disease Heart infection Failure to Thrive/DebilitySlide 17
PROGNOSIS by and large: Patient\'s condition is life constraining, and pt/family know Pt/family have chosen help of sx treatment objectives instead of corrective objectives Pt has either reported clinical movement of ailment or archived late impeded wholesome status identified with the terminal procedureSlide 18
Karnofsky ScaleSlide 19
DELIVERING BAD NEWS Prepare Plan a motivation Ensure accessibility of every single medicinal truth Pick a fitting setting Minimize interferences What does the patient get it? What does the patient need to know? Convey the news Be clear, dodging therapeutic language Provide a "notice shot" Allow time for examination Create an arrangement and sort out for developmentSlide 20
DECISION MAKING Autonomous decisions are intentional, sufficiently educated and in view of thinking Does the patient can pick? Does the patient comprehend apropos data? Does the patient welcome the clinical circumstance/decisions/outcomes? Will the patient reason through decisions?Slide 21
The patient distinguishes the goal(s). The arrangement takes after the objective.Slide 22
SURROGATE DECISION MAKING May be required with both more youthful and more established grown-ups Specific surrogate might be recognized by means of a DPOA (tough force of lawyer) for social insurance Goal of surrogate is to advocate for patient in light of what they know of patient\'s desires -in light of earlier exchanges, advance mandates/living willsSlide 23
SOME DEFINITIONS Durable Power of Attorney for Health Care Appointing somebody to settle on restorative choices for you on the off chance that you can\'t make them yourself Does not require nearness of AD or living will Living Will Description of wishes about existence maintaining medicinal medications on the off chance that one is at death\'s door Advance orders Instructions/direction for human services if one get to be weakened Can name a "specialist" to settle on choices for them Wishes expressed must be regarded by surrogate unless court arranges generally Can be repudiated whenever Adapted from University of New Mexico SoMSlide 24
DECISION MAKING If a patient can\'t settle on their therapeutic choice and has not distinguished a surrogate leader, does not have a development order, or has not made their desires known, a surrogate may must be recognized. A few states have a programmed request of need for recognizing surrogates Kansas and Missouri have no such statues accessibleSlide 25
OTHER PALLIATIVE CARE ISSUES Symptom administration Cross-social issues Spiritual concerns Psychosocial issues See suggested readings for additional dataSlide 26
SYMPTOM MANAGEMENT Multiple side effects of worry close to the end of life -Pain -Dyspnea -Constipation -Nausea -Anxiety -Delirium -Fatigue -AnorexiaSlide 27
PAIN Treatment taking into account evaluation -seriousness -nociceptive versus neuropathic -step-wise methodology Potential modalities -Non-opioid acetominophen NSAIDs/COX-2 –I -Opioid -Adjunctive Anti-convulsants Steroids TCAsSlide 29
And now somewhat about opioids… Bind to one or a greater amount of the sedative receptors (mu, kappa, delta) Mu receptor is 7 transmembrance G protein coupled receptor -restricting settles the layer so neuron doesn\'t fire Where are the mu receptors? - outskirts, dorsal root ganglia of spinal line, periaqueductal dim of brainstem, midbrain, gutSlide 30
Opioids "feeble" opioids -codeine -hydrocodone -oxycodone "solid" opioids -hydromorphone -fentanyl -morphineSlide 31
Opioids Distribution Hydrophilic * morphine, oxycodone, hydromorphone Lipophilic * fentanyl, methadoneSlide 32
Opioids IV-morphine, hydromorphone, fentanyl PO-morphine (LA & SA), oxycodone (LA & SA), hydromorphone, methadone, fentanyl, hydrocodone Transdermal-fentanyl Initial choices in light of - course of organization -requirement for nonstop versus irregular dosing -seriousness of torment LA= long acting SA= short actingSlide 33
Opioids-Pharmacology All water dissolvable opioids act comparably: Cmax is 60-a hour and a half after PO dosage 30 minutes after SQ or IM 6-10 minutes after IV measurements All are conjugated in liver and 90% discharged through the kidney With typical renal fx, all have ½ life of 3-4 hours, achieve consistent state in 4-5 ½ livesSlide 34
Special Notes Morphine - low protein restricting -dialyzes off -dynamic metabolite is morphine 6-glucuronide (10%) * amasses in renal disappointment and causes neuroexcitation * delayed CNS impactsSlide 35
Special Notes Fentanyl - next to zero dynamic metabolites -Not dialyzable -Elderly more touchy to impacts -Unclear how TD course is influenced by low subcutaneous fat Hydromorphone - Generally considered to have inert metabolites -Drug of decision with renal disappointmentSlide 36
Special Notes Methadone ties mu and squares NMDA receptors very protein bound exceedingly variable and delayed half life Phase I digestion system and may draw out the QT interim alert when transforming from another opioid to methadoneSlide 37
Potential opioid reactions Nausea CNS gloom/sedation Pruritis Constipation Delirium Endocrine brokenness with long haul useSlide 38
DYSPNEA Subjective side effect Pathophysiology can reflect jumble in direction or demonstration of breathing Treatment coordinated at basic cause -Most normal reversible causes bronchospasm, hypoxia, iron deficiency - Both non-pharmacologic and non-pharmacologic medications can be useful -Opioids utilized for sx alleviation when more coordinated treatment doesn\'t switch the dypsneaSlide 39
NAUSEA Potentially weakening side effects close to the end of life Treatment taking into account source -Brain chemoreceptor trigger zone, cerebral cortex, vestibular mechanical assembly - GI tract block, motility, mucosal botheringSlide 40
www,aafp.org, Sept.1, 2001, Vol.64, No.5Slide 41
DELIRIUM Common close to the end of life -geriatric patients with numerous danger elements for improvement Large number of cases can be reversible Control of ridiculousness might be critical for both patient and family -pharmacologic and non-pharmacologic meansSlide 42
ACOVE Indicators Assessing Care of Vulnerable Elders Comprehensive arrangement of value appraisal instruments for sick more established grown-ups -Covering areas of anticipation, conclusion, treatment, and follow up Designed to assess
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