GERIATRICS: End of Life Care in Older Australians
Epidemiology of deaths
Ø High risk behaviour® MVA
Ø Increased rates of dementia in older age group (increased
diagnosis and rising population)
Ø Where do deaths occur? – although most like to die at home:
o 54% of deaths in hospitals
o 32% in residential aged care
Ø After CPR ® reduced poor level of function and QoL
Ethics of dying patient: why should we resuscitate an older patient?
FOR AGAINST
1) Social justice and equity 1. Violent act CPR is a traumatic, undignified and usually unsuccessful in
patients of all ages
2) May be the one who succeeds 2. Futile treatment and Act of maleficence - why would we do harm?
May be that (0.6%) that survives in residential aged care QoL
and possibly the even smaller % who maintains same QoL
(how would you know if you don’t try)
3) Previously functioning well with limited morbidity 3. Prolonging the Is it terminable cancer and that pneumonia or ACS a blessing
inevitable rather than curse?
4) Because we can 4. Resource cost Funding and staff required
May need ICU- post-CPR – taking bed space away from the
younger population who need it
5) Right to life 5. Patient refuses (DNR) Right to be free from inhuman or degrading treatment e.g. “a
good natural death”
6) Because patient wants us to
Frailty Frailty measurement What are our (doctor’s) rights?
Health practitioners are NOT obligated to provide treatments that
• Syndrome of increased vulnerability to stressors due Rockwood frailty scale (good predictor are futile (i.e. Rx is unreasonable and offers minimal benefit to
to multisystem impairments of DEATH) patient’s medical condition)
1. Fit
• Increases in prevalence with advanced ageing
2. Well (no disease)
Ø Inappropriate requests may include:
§ Tests that will NOT assist w/ patient’s goal or Mx
• NOT part of normal ageing 3. Well (stable co-morbidity) § Patient will deteriorate even with optimal therapeutic
4. Vulnerable (symptomatic) interventions
5. Mildly frail (minimal dependence) § Rx will not be successful in producing clinical effect
6. Mod. Frail (need help with ADL) è § Where Rx may produce clinically successful effect but still
high risk of immobility, falls, death, FAIL to serve important pt goals (e.g. independence from
post-op complications life-support devices, survival to leave hospital or improve
7. Severely frail (complete dependence) from permanent unconsciousness)
Fried scale (1 or 2 features = frailty)
• UWL (>10 pounds/year) Consultation is imperative with the family – adequate discussions
necessary as to why Rx is not necessary
• Sense of constant exhaustion Ø Always offer alternative doctor for second opinions
• Poor grip strength
• Slow walking speed
• Poor PA
, Delivering Palliative Care:
“Palliative care = an approach that improves the QoL of patients and their families facing the problems associated with life-threatening illness by identifying
early and treating assoc. pain/distress and physical and psychosocial problems”
• Requires MDT inc. bereavement counselling
• Affirms life and regards death as a normal process
• Intends neither to hasten or postpone death
• Is applicable early in the course of illness in conjunction with other active therapies that are intended to prolong life
Indication for PC referral Patients People involved Where delivered
• Death within 12 mths 1. METS • PC physician = symptom control & GP/oncologist liaison 1. Acute hospitals
• Recurrent hospitalisation 2. end-stage organ failure • PC nurse = coordinates with MDT + prescribe meds 2. Palliative Care
(CCF, CKD, COPD) • PC social worker = counselling, coping strategies and referral to Units/hospitals
• Progressive illness despite
3. Neurodegenerative meal and respite care
therapy 3. Home
(PD, dementia, MND) • PC physiotherapist = keep pt moving, manage SOB, energy
• Recent decline in physical 4. Residential aged care
• PC OT = manage physical aspects of daily living (e.g. mobility
function 4. Terminal diseases facilities
aids, maintain independence)
• Care exceeds health *CAD (leading cause of death • PC pastoral care = spiritual support & organise prayers/ rituals
professional and carer scope in males) • Other Allied Health may include:
o Dietitian, Speech pathology, Pharmacy, Clinical
psychologists, ATSI Workers, Volunteer Services
Advanced care planning Advanced care directive
• Clarify goals of care for patients ® ensures EOL wishes more likely achieved • Written advance care plan signed by the patient ® should
aligning w/ patient’s values share w/ GP
• Paperwork (ACD, power of attorney (legally appointed guardian), decision • Contains instructions that consent to, or refuse medical Rx in
competency) future
• Appointed Guardian > spouse/partner > UNPAID care > relative/friend (any • Becomes effective when person incompetent to make
supportive individual w/ no conflict interest) decisions
Identify Dying Signs: Other considerations (SPIKES)
• DYING QUESTION = Am I surprised if this patient will die in the next • Single room
12 months? • Pressure area and eye care
• Assess SPICT tool • Family/carer support
o identify people with deteriorating health due to advanced
• Cultural considerations (e.g. language, ATSI, religious faith)
conditions or a serious illness, and prompts holistic
assessment and future care planning. • Verifying death:
o Ensure that patient is not depressed or have o Be respectful to family
• Identify trends and signs o No palpable carotid
o Increased frowning, agitation, o No heart or breath sounds (>2 mins)
o ↑RR and have meds ready to go o Fixed mydriasis (non-reactive)
o Bedridden o No motor response/ grimace to central pain
stimuli
Unaffected by drugs/EtOH, hypothermia. BP>100
Mx in final days – Sx management o
o Date and time of death
Deliver care w/ kindness and compassionate:
“I don’t have a crystal ball for a day or time, but what I can tell you is that if there are changes and we will do
everything we can to make them comfortable” Care after death:
• STOP: Non-essential meds (e.g. Abs, Anti-Coags, statins), devices (ICD) & cannulas, stop BP checks • Death certification – notify ALL relevant people
• CONVERT: oral to SC route, hospital to home or RACF (location of death) o registrars, relatives,
• Educate family about symptoms of EOL and meds: o in-charge RN, social worker,
o Nutrition/hydration ® may cause discomfort and does NOT prolong survival o GP discharge summary
o Mouth care = maintain comfort more than IV/SC hydration o ward clerk ® upload to medical records
o Spiritual needs or Love of sport, pets, family • IT IS ILLEGAL TO PUT PERSON IN MORTUARY FRIDGY
WITHOUT VERIFICATION OF DEATH (WRITTEN IN NOTES
SYMPTOMS ANTICIPATORY MEDICATIONS
exactly as below)
1. Pain & SOB • oral doses of morphine (gold standard) OR
• Renal issue ® HYDROmorphine (Jurnista) PO/SC– 16mg daily o
r fentanyl (TD), buprenorphine (TD), methadone, oxycodone
2. Nausea • Metoclopramide (SC), Haloperidol (SC)
• *avoid in SBO, Parkinson’s, lewy body dementia è cyclizine, ondansetron • MEDICAL/CREMATION CERTIFICATE OF CAUSE OF DEATH
3. Agitation • Benzodiazepines - lorazepam (SL), Midozalam (SC), SIGNED BEFORE dead patient leaves hospital. Can be done
/restless Clonazepam (drops, tblt, SC) after mortuary
4. Secretions • Reassurance + reposition to encourage postural drainage Glycopyrrolate or • Social implications ® this data is used to inform appropriate
hyoscine (suction if tolerated) fund/resource allocation for surveillance studies, research
• IDC, bladder scans investment to address rising burden of particular diseases
• 5. Retention
• Bereavement support – social worker
Epidemiology of deaths
Ø High risk behaviour® MVA
Ø Increased rates of dementia in older age group (increased
diagnosis and rising population)
Ø Where do deaths occur? – although most like to die at home:
o 54% of deaths in hospitals
o 32% in residential aged care
Ø After CPR ® reduced poor level of function and QoL
Ethics of dying patient: why should we resuscitate an older patient?
FOR AGAINST
1) Social justice and equity 1. Violent act CPR is a traumatic, undignified and usually unsuccessful in
patients of all ages
2) May be the one who succeeds 2. Futile treatment and Act of maleficence - why would we do harm?
May be that (0.6%) that survives in residential aged care QoL
and possibly the even smaller % who maintains same QoL
(how would you know if you don’t try)
3) Previously functioning well with limited morbidity 3. Prolonging the Is it terminable cancer and that pneumonia or ACS a blessing
inevitable rather than curse?
4) Because we can 4. Resource cost Funding and staff required
May need ICU- post-CPR – taking bed space away from the
younger population who need it
5) Right to life 5. Patient refuses (DNR) Right to be free from inhuman or degrading treatment e.g. “a
good natural death”
6) Because patient wants us to
Frailty Frailty measurement What are our (doctor’s) rights?
Health practitioners are NOT obligated to provide treatments that
• Syndrome of increased vulnerability to stressors due Rockwood frailty scale (good predictor are futile (i.e. Rx is unreasonable and offers minimal benefit to
to multisystem impairments of DEATH) patient’s medical condition)
1. Fit
• Increases in prevalence with advanced ageing
2. Well (no disease)
Ø Inappropriate requests may include:
§ Tests that will NOT assist w/ patient’s goal or Mx
• NOT part of normal ageing 3. Well (stable co-morbidity) § Patient will deteriorate even with optimal therapeutic
4. Vulnerable (symptomatic) interventions
5. Mildly frail (minimal dependence) § Rx will not be successful in producing clinical effect
6. Mod. Frail (need help with ADL) è § Where Rx may produce clinically successful effect but still
high risk of immobility, falls, death, FAIL to serve important pt goals (e.g. independence from
post-op complications life-support devices, survival to leave hospital or improve
7. Severely frail (complete dependence) from permanent unconsciousness)
Fried scale (1 or 2 features = frailty)
• UWL (>10 pounds/year) Consultation is imperative with the family – adequate discussions
necessary as to why Rx is not necessary
• Sense of constant exhaustion Ø Always offer alternative doctor for second opinions
• Poor grip strength
• Slow walking speed
• Poor PA
, Delivering Palliative Care:
“Palliative care = an approach that improves the QoL of patients and their families facing the problems associated with life-threatening illness by identifying
early and treating assoc. pain/distress and physical and psychosocial problems”
• Requires MDT inc. bereavement counselling
• Affirms life and regards death as a normal process
• Intends neither to hasten or postpone death
• Is applicable early in the course of illness in conjunction with other active therapies that are intended to prolong life
Indication for PC referral Patients People involved Where delivered
• Death within 12 mths 1. METS • PC physician = symptom control & GP/oncologist liaison 1. Acute hospitals
• Recurrent hospitalisation 2. end-stage organ failure • PC nurse = coordinates with MDT + prescribe meds 2. Palliative Care
(CCF, CKD, COPD) • PC social worker = counselling, coping strategies and referral to Units/hospitals
• Progressive illness despite
3. Neurodegenerative meal and respite care
therapy 3. Home
(PD, dementia, MND) • PC physiotherapist = keep pt moving, manage SOB, energy
• Recent decline in physical 4. Residential aged care
• PC OT = manage physical aspects of daily living (e.g. mobility
function 4. Terminal diseases facilities
aids, maintain independence)
• Care exceeds health *CAD (leading cause of death • PC pastoral care = spiritual support & organise prayers/ rituals
professional and carer scope in males) • Other Allied Health may include:
o Dietitian, Speech pathology, Pharmacy, Clinical
psychologists, ATSI Workers, Volunteer Services
Advanced care planning Advanced care directive
• Clarify goals of care for patients ® ensures EOL wishes more likely achieved • Written advance care plan signed by the patient ® should
aligning w/ patient’s values share w/ GP
• Paperwork (ACD, power of attorney (legally appointed guardian), decision • Contains instructions that consent to, or refuse medical Rx in
competency) future
• Appointed Guardian > spouse/partner > UNPAID care > relative/friend (any • Becomes effective when person incompetent to make
supportive individual w/ no conflict interest) decisions
Identify Dying Signs: Other considerations (SPIKES)
• DYING QUESTION = Am I surprised if this patient will die in the next • Single room
12 months? • Pressure area and eye care
• Assess SPICT tool • Family/carer support
o identify people with deteriorating health due to advanced
• Cultural considerations (e.g. language, ATSI, religious faith)
conditions or a serious illness, and prompts holistic
assessment and future care planning. • Verifying death:
o Ensure that patient is not depressed or have o Be respectful to family
• Identify trends and signs o No palpable carotid
o Increased frowning, agitation, o No heart or breath sounds (>2 mins)
o ↑RR and have meds ready to go o Fixed mydriasis (non-reactive)
o Bedridden o No motor response/ grimace to central pain
stimuli
Unaffected by drugs/EtOH, hypothermia. BP>100
Mx in final days – Sx management o
o Date and time of death
Deliver care w/ kindness and compassionate:
“I don’t have a crystal ball for a day or time, but what I can tell you is that if there are changes and we will do
everything we can to make them comfortable” Care after death:
• STOP: Non-essential meds (e.g. Abs, Anti-Coags, statins), devices (ICD) & cannulas, stop BP checks • Death certification – notify ALL relevant people
• CONVERT: oral to SC route, hospital to home or RACF (location of death) o registrars, relatives,
• Educate family about symptoms of EOL and meds: o in-charge RN, social worker,
o Nutrition/hydration ® may cause discomfort and does NOT prolong survival o GP discharge summary
o Mouth care = maintain comfort more than IV/SC hydration o ward clerk ® upload to medical records
o Spiritual needs or Love of sport, pets, family • IT IS ILLEGAL TO PUT PERSON IN MORTUARY FRIDGY
WITHOUT VERIFICATION OF DEATH (WRITTEN IN NOTES
SYMPTOMS ANTICIPATORY MEDICATIONS
exactly as below)
1. Pain & SOB • oral doses of morphine (gold standard) OR
• Renal issue ® HYDROmorphine (Jurnista) PO/SC– 16mg daily o
r fentanyl (TD), buprenorphine (TD), methadone, oxycodone
2. Nausea • Metoclopramide (SC), Haloperidol (SC)
• *avoid in SBO, Parkinson’s, lewy body dementia è cyclizine, ondansetron • MEDICAL/CREMATION CERTIFICATE OF CAUSE OF DEATH
3. Agitation • Benzodiazepines - lorazepam (SL), Midozalam (SC), SIGNED BEFORE dead patient leaves hospital. Can be done
/restless Clonazepam (drops, tblt, SC) after mortuary
4. Secretions • Reassurance + reposition to encourage postural drainage Glycopyrrolate or • Social implications ® this data is used to inform appropriate
hyoscine (suction if tolerated) fund/resource allocation for surveillance studies, research
• IDC, bladder scans investment to address rising burden of particular diseases
• 5. Retention
• Bereavement support – social worker
