End-of-Life Care Perspectives

1
End-of-Life Care Perspectives

• Eric J. Warm M.D.
• Department of Internal Medicine
• 4/3/02
• ICP-II

2
Historical Perspective

• Curative model of medicine disarms us with
  regards to the dying patient
• Death of a patient now means failure
• Of Medicine
• Of the physician
• Hill TP. Treating the Dying Patient. Arch Intern
  Med, 1995155pp.1263-69

3
Historical Perspective

• Changes in Medical Education
• Subtle and slow
• Curriculum had to accommodate all the new
  knowledge
• Billings JA, Block S. Palliative Care in
  Undergraduate Education. JAMA. 1997278733-738

4
Historical Perspective

• Softer subjects such as communication skills,
  ethics, psychological aspects of medicine have
  been diminished
• mostly lecture format
• usually pre-clinical
• Billings JA, Block S. Palliative Care in
  Undergraduate Education. JAMA. 1997278733-738

5
Historical Perspective

• EOL care in medical textbooks
• Texts shape knowledge and attitudes
• Caron (1999) reviewed 12 leading causes of death
• Harrisons Textbook of Medicine
• Merck Manual
• Scientific American CD-ROM
• Washington Manual
• Carron AT, et al. End-of-Life Care in Medical
  Textbooks. Ann Intern Med. 1999130pp.82-86

6
Historical Perspective

• Textbooks rarely characterize the way in which
  persons with disease die
• Frankness about death absent -- often inferred
• Supportive Care mentioned but not spelled out
• Carron AT, et al. End-of-Life Care in Medical
  Textbooks. Ann Intern Med. 1999130pp.82-86

7
Current Perspective

• Exaggerated sense of Medical Power
• unwarranted confidence in medical expertise and
  ability to forestall death
• unprepared for uncertainty and loss
• Barnard D. Preparing the Ground Contributions of
  the Pre-clinical Years To Medical Education Near
  the End of Life. Acad. Med 199974499-505

8
Current Perspective

• Skewed vision of what doctors do
• underestimate value of palliation has for
  patients
• relief of suffering comes from relief of disease
• Barnard D. Preparing the Ground Contributions of
  the Pre-clinical Years To Medical Education Near
  the End of Life. Acad. Med 199974499-505

9
Objectives

• After this presentation the learner should be
  able to
• Describe the double effect vs. unintended
  consequences
• Develop proper technique to breaking bad news
• Formulate different concepts of hope
• Determine the goals of care

10
Panel

• Stanley Troup M.D.
• Paul Nidich J.D.
• Mary Gallagher M.D.

11
Case One

• An 81 year old female with end stage lung cancer
  is dying on the hospital ward. She has
  disseminated metastases and is in constant pain.
  She had been taking large amounts of per oral
  morphine at home, but this is no longer
  effective.

12
Case One

• After admission she was placed on an IV infusion
  of morphine. Despite ever increasing doses her
  pain is not well controlled. She is asking for
  more pain medication and an end to her misery.

13
Case One

• She has liver dysfunction and is already
  receiving more morphine than has ever been given
  to anyone on this hospital floor. The nurses are
  concerned about overdose and respiratory
  depression.
• WHAT SHOULD YOU DO???

14
Case One

• A. Increase the patients morphine dose until
  pain relief
• B. Intubate the patient and increase the morphine
  until pain relief
• C. Increase the pain medication only after
  Psychiatry states that the patient is not
  suicidal
• D. Not increase the pain medication because of
  the risk of respiratory failure
• E. Not increase the pain medicine until you have
  discussed the case with the hospital lawyer

15
Case One

• Key Points
• Double effect Vs. Unintended Consequences
• Pain management at End-of-Life

16
Case Two

• A 57 year old man presents with mild abdominal
  pain and jaundice. After several tests (including
  biopsy) you diagnose pancreatic cancer. Despite
  being relatively asymptomatic the patient has
  late stage disease. His prognosis is on the order
  of a few months.

17
Case Two

• You are called to his bedside to give him the
  news regarding his cancer. He is anxious. You
  know this news will be shocking and unexpected.

18
Case Two

• How do you tell him the news?

19
Case Two

• How do you handle the following questions?
• Doc, how long to I have to live?

20
Case Two

• How do you handle the following questions?
• Doc, how long to I have to live?
• Doc, is there any hope for cure?

21
Case Two

• How do you handle the following questions?
• Doc, how long to I have to live?
• Doc, is there any hope for cure?
• Doc, is there any hope at all?

22
Case Two

• Key Points
• Breaking Bad News
• Concept of Hope

23
Case Three

• A 66 year old woman presents to your primary care
  office. She was diagnosed with lymphoma 22 months
  prior. She underwent extensive chemotherapy and
  radiation and participated in multiple organized
  trials.

24
Case Two

• Her specialists told her at the last visit that
  there was no more chemotherapy or radiation that
  would help her. She is losing weight, and had to
  be brought to your office in a wheelchair.

25
Case Three

• She tells you that the other doctors said There
  is nothing more we can do for you
• How do you respond?

26
Case Three

• Key Points
• Defining the goals of care
• Knowing how to give supportive care