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Updates in Palliative & End of Life Care

This is a prezi I used to present some of the collaborative work between palliative care and critical care. It is a start... I look forwards to see what other people do with it, add to it, what other research is referenced.

Suzana Makowski

on 6 May 2010

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Transcript of Updates in Palliative & End of Life Care

• Surrogate decisionmakers
• Rethinking the living will
• MOLST Difficult
Decisions Use of video to facilitate decision-making*:
Symptoms at
end-of-life Breathlessness
Agitation Chlorpromazine and other neuroleptics:
- call for more research
O’Neill P, Morton P, Stark R. Chlorpromazine: a specific effect on breathlessness? Br J Clin Pharmacol 1985;19:793-7.
• If used well, do not shorten life,, unless through overdose.
• Bruera et al was the first to look at use for morphine for dyspnea in cancer patients: no change in respiratory rate or O2sat.
• Mazzocato et al demonstrated that a dose as low as 5mg SQ morphine can control dyspnea in opioid-naive patients.
• Light et al studied morphine in opioid-naive patients w/ COPD with average FEV1 0.99L - 0.8mg/kg oral morphine given before exercise (56mg): PCO2 increased slightly, PO2 decreased slightly, respirations minimally suppressed, BUT exercise tolerance and dyspnea improved. Which opioids?
Morphine - standard of care
Fentanyl - preferable with renal failure, oliguria. What about olanzapine? http://www.icudelirium.org/index.html *J Clin Oncol. 2010 Jan 10;28(2):305-10. Epub 2009 Nov 30.
http://www.informedmedicaldecisions.org/vid3.htm Narrative discussion - decisions Video with same verbal narrative:
1- life-prolonging care
2- basic care (hospitalization, no CPR)
3- comfort care (symptom relief) 25.9% of participants preferred life-prolonging care,
51.9% basic care, and
22.2% comfort care no participants preferred life-prolonging care,
4.4% preferred basic care,
91.3% preferred comfort care, and
4.4% were uncertain http://www.informedmedicaldecisions.org/ Respondents described a complicated relationship involving negotiation with patients who require high-risk surgical procedures. According to physicians, this interaction creates an informal contract between the surgeon and patient in which the patient not only consents to the operative procedure, but commits to the postoperative surgical care anticipated by the surgeon. We have named this implicitly understood contract “surgical buy-in.” Schwarze, M., Bradley, C., & Brasel, K. (2010).
Surgical “buy-in”: The contractual relationship between surgeons and patients that influences decisions regarding life-supporting therapy*
Advance Directives and Outcomes of Surrogate Decision Making before Death
Maria J. Silveira, M.D., M.P.H., Scott Y.H. Kim, M.D., Ph.D., and Kenneth M. Langa, M.D., Ph.D
NEJM April 1, 2010.
3764 patients
42.5% required decision-making
70.3% lacked capacity

Patients who had written living will or healthcare directive, were more likely to:
• not die in hospital
• receive less agressive care, but if they requested aggressive care - to receive it to its fullest
than patients without explicit directives.
CMO = Continuous morphine only Why?
Morphine and hydromorphone metabolize to:
morpine/hydromorphone 3-glucoronide
neurotoxicity myoclonus
delirium (agitated)
hyeralgesia &alodynia Non-sedating antipsychotic: haloperidol
Sedating antipsychotics: atypicals - new & old due to opioid-induced neurotoxicity:
Antipsychotics may worsen!
Benzodiazepines and phenobarbitol are options Terminal delirium ICU delirium Integrating Cultures:
Critical Care & Palliative Care co- PIs: A Billings, A Keeley
Robert Wood Johnson Foundation,
"PROMOTING PALLIATIVE CARE EXCELLENCE IN INTENSIVE CARE." Study Aims: This is a quality improvement demonstration project whose aims are to:
1) improve and standardize physical and psychosocial/spiritual care approaches to the alleviation of suffering for all patients in the Medical Intensive Care Unit (MICU) and their families;
2) strengthen staff education and support programs to assure that every trainee and practitioner in the MICU is exposed to state-of-the-art palliative care; and
3) generate, publish, and otherwise disseminate useful evaluation data about transferable improvements, thus allowing us to serve as a model for other ICUs. The study design is a pre-post intervention Quality Demonstration Project.

Our hypothesis is that a set of clinical and educational interventions will promote the integration of patient-and-family-centered palliative care practice into the medical intensive care unit (MICU). Structured Family Meeting
Family Meetings Bibliography
Guide to Family Meetings (3 x 5 format)
Palliative Care Nurse Champions
Medical ICU Family Brochure
Multidisciplinary Rounds
House Officer daily Worksheet
Vent Withdrawal Protocol
"Get to Know Me" Poster©,
"Preparing to be a Health Care Agent"
"Planning in Advance for Your Health Care" brochure© What are we doing? Family meeting guide
Palliative Care Nurse Champion
Lois Green Learning Community
Vent withdrawal protocol
Communication plans
Comfort care order set
Interventional palliative care:
through collaboration with pulmonary, surgery, anesthesia Laura Lambert - surgery
Paolo Oliveira - pulmonary
Christian Gonzalez, Issam Khayata - anesthesia
Rick Pieters - rad-onc Palliative subspecialty:
emergency medicine
family medicine
surgery Updates in End-of-Life Care
Suzana Makowski, MD MMM FACP
UMassMemorial/UMassMedicalSchool Conclusions:
Between 2000 and 2006, many elderly Americans needed decision making near the end of life at a time when most lacked the capacity to make decisions
Patients who had prepared advance directives received care that was strongly associated with their preferences
These findings support the continued use of advance directives
MGH studies
- 50 patients with malignant glioma were randomized: Innotations in shared-decision making Opioids - for dyspnea and pain Neuroleptics for dyspnea Critical Care Medicine, 38 (3), 843-848 DOI: 10.1097/CCM.0b013e3181cc466b Critical Care Symposium
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