End of Life

Discussions

Dr. Shivan Mahabir

Psychiatrist
SFGH Internal Medicine Grand
Rounds
April 17th, 2019
Overview
 The importance of EoL Discussions
 Predicting life expectancy
 Preparing for the discussion
 A Framework for the discussion
 Notes on the discussion itself
 Advance Directives
 Self Care
 Online Resources
 Feedback
Why Is It Important?
 Aging population
 Increased time from onset of illness to Death
 We are taught to prioritise Life and
 Easier to chase cure than have the hard talk
but
 Death is inevitable and does not mean we
have failed
 Doctor’s role includes helping people prepare
for death and helping them have as peaceful
a death as possible.
Why Is It Important?
 Patients often expect medical professionals to
initiate end of life discussions. These need to
go beyond DNR decisions.
 Patients appreciate honesty re: prognosis /
terminal diagnosis.
 Do not think of it as stealing hope – think of it
as not giving false hope.
 Change focus from cure to living long enough
to do tasks and having a death free from pain
and suffering.
Predicting Life Expectancy
 Overestimate 63% of the time
 Epidemiological limitations
 Equivocation
 Fear of giving bad news
 Tools and guidelines are available to help
clinicians more accurately estimate life
expectancy eg.
Predicting Life Expectancy
 Key clinical indicators that indicate a life
expectancy <6 months:
 Unintentional weight loss >= 10% of TBW,
recurrent infections eg asp. Pneumonia,
infected decubitus , pyelonephritis, serum
albumin <2.5, functional decline.
 Ask yourself, “ Would I be surprised if this
patient died in 6 months?”. If answer is no
refer for hospice and palliation.
Predicting Life Expectancy
 Trynot to give exact predictions but still
stay generally specific eg. Weeks rather
than months, months rather than years.
Preparing to Have The
Discussion
 Clear sufficient time on your schedule.
 Find an appropriate space with privacy.
 Turn off your cell phone/ pager.
 Prepare for the discussion ie. Think about
what you will say, what patient/family will
ask, is there anything unique about this
patient’s circumstances?
 Don’t hide behind jargon (to cover
vulnerability)
Preparing to have the
discussion
 Listencarefully to patient and family
responses.
 Make accommodations for patient’s
challenges eg. Decreased hearing, low
education level, cognitive decline,
language barrier (translators)
A Framework for having the
Discussion
 Initiate the discussion
 Clarify the prognosis
 Identify the patient’s goals
 Develop the plan.
Notes on the Discussion Itself
 Early discussions are largely hypothetical.
 There are limitations of communication
 Aggravated by the professional-layman
divide: 67% of patients who had just discussed
mechanical ventilation did not understand
that patients cannot talk on mechanical
ventilation.
 People overestimate the effectiveness of CPR
based on what they see on TV – they don’t
know about the rib #’s and poor outcomes.
Notes on the Discussion Itself
 Repeat the conversation to enhance
understanding.
 Have the conversation again as the situation
worsens – have their desires changed?
 Have the conversation again when Death in
imminent.
 Advanced directives should NEVER
supercede the patient’s current stated
interests.
Types of Advance Directives
A Thought on Self Care
 These are difficult discussions which can bring
up a wide range of emotions in us as medical
professionals.
 If not addressed these can fester and
become unhealthy leading to burnout or
moral injury.
 We recognise that doctors need safe spaces
to vent, to discuss their emotions and difficult
patients and situations and there are options
available…
References and Online
Resources
 Theconversationproject.org
 Balaban RB. A Physician’s Guide to talking about End-
of-Life Care. J Gen Intern Med. 2000 Mar; 15(3): 195–200.
 Old JL. Discussing End-of-Life care with your patients.
Fam Pract Manag. 2008 Mar; 15(3): 18-22.
 The Palliative Performance Scale (PPS) is available
at http://www.victoriahospice.org/ed_publications.html
 General guidelines for predicting life expectancy can
be found at the National Hospice and Palliative Care
Organization Web site (http://www.nhpco.org) or the
American Academy of Hospice and Palliative Medicine
Web site (http://www.aahpm.org).
Questions? and Comments…
Thank You For Your Attention