Session: Last-Minute Heroics and Palliative Care – Do They Meet in the Middle?
HM15 Presenter: Tammie Quest, MD
Summation: Heroics– a set of medical actions that attempt to prolong life with a low likelihood of success.
Palliative care– an approach of care provided to patients and families suffering from serious and/or life limiting illness; focus on physical, spiritual, psychological and social aspects of distress.
Hospice care– intense palliative care provided when the patient has terminal illness with a prognosis of 6 months or less if the disease runs its usual course.
We underutilize Palliative and Hospice care in the US. Here in the US fewer than 50% of all persons receive hospice care at EOL, of those who receive hospice care more than half receive care for less than 20 days, and 1 in 5 patients die in an ICU. Palliative Care can/should co-exist with life prolonging care following the diagnosis of serious illness.
Common therapies/interventions to be contemplated and discussed with patient at end of life: cpr, mechanical ventilation, central venous/arterial access, renal replacement therapy, surgical procedures, valve therapies, ventricular assist devices, continuous infusions, IV fluids, supplemental oxygen, artificial nutrition, antimicrobials, blood products, cancer directed therapy, antithrombotics, anticoagulation.
Practical Elements of Palliative Care: pain and symptom management, advance care planning, communication/goals of care, truth-telling, social support, spiritual support, psychological support, risk/burden assessment of treatments.
Key Points/HM Takeaways:
1-Palliative Care Bedside Talking Points-
- Cardiac arrest is the moment of death, very few people survive an attempt at reversing death
- If you are one of the few who survive to discharge, you may do well but few will survive to discharge
- Antibiotics DO improve survival, antibiotics DO NOT improve comfort
- No evidence to show that dying from pneumonia, or other infection, is painful
- Allowing natural death includes permitting the body to shut itself down through natural mechanisms, including infection
- Dialysis may extend life, but there will be progressive functional decline
2-Goals of Care define what therapies are indicated. Balance prolongation of life with illness experience.
Julianna Lindsey is a hospitalist and physician leader based in the Dallas-Fort Worth Metroplex. Her focus is patient safety/quality and physician leadership. She is a member of TeamHospitalist.