End of Life Care: An Overview

Objectives

Address issues surrounding end-of-life Address issues surrounding end-of-life care and vulnerable older adultscare and vulnerable older adults

- definition of palliative care- definition of palliative care

- logistics of end-of life-care- logistics of end-of life-care

- surrogate decision making and advance - surrogate decision making and advance directivesdirectives

- symptom management- symptom management ACOVE indicators and EOL careACOVE indicators and EOL care

WHAT IS PALLIATIVE CARE? Interdisciplinary Interdisciplinary

Goal :Goal : to prevent and alleviate sufferingto prevent and alleviate suffering assist towards the best possible quality of lifeassist towards the best possible quality of life optimize functionoptimize function assist with decision making for patients with serious assist with decision making for patients with serious

illness and their families. illness and their families.

Can be the main focus of care or offered Can be the main focus of care or offered concurrently with all other life - prolonging medical concurrently with all other life - prolonging medical treatment.treatment.

END-OF-LIFE DEMOGRAPHICS

The majority of deaths occur in elderly adultsThe majority of deaths occur in elderly adults

Very ill patients may spend much of their final time Very ill patients may spend much of their final time at home, but…at home, but…

Hospitals or nursing homes are actual location of Hospitals or nursing homes are actual location of most deathsmost deaths

There is regional/ geographic variability in location There is regional/ geographic variability in location of deaths (home vs. institution)of deaths (home vs. institution)

Adapted from Geriatrics Review Syllabus, Sixth Edition

END-OF-LIFE (EOL) IN THE U.S.

For elderly, death is typically slow and For elderly, death is typically slow and associated with chronic diseaseassociated with chronic disease

Patients experience increased dependency in Patients experience increased dependency in their care needstheir care needs

EOL care can be complicated by family EOL care can be complicated by family stress, poor symptom control, and stress, poor symptom control, and discontinuity of carediscontinuity of care

In this age of technology, commonly decisions In this age of technology, commonly decisions need to be made about the use of these need to be made about the use of these agentsagents

Adapted from Geriatrics Review Syllabus, Sixth Edition

SUDDEN DEATH, UNEXPECTED CAUSE < 10%, MI, accident, etc.< 10%, MI, accident, etc.

DeathTime

Hea

lth

Sta

tus

Steady DeclineShort “Terminal Phase”

SLOW DECLINEPeriodic Crises, Sudden Death

Curative / Life ProlongingCurative / Life Prolonging

Sx Control / Sx Control / Palliative CarePalliative Care

Death

Presentation

Adapted from Institute of Medicine

Historical trajectories of care pathways

Consider an alternative trajectory…

Inclusion of palliative concepts from time of Inclusion of palliative concepts from time of diagnosisdiagnosis

This piece of the care plan may become more This piece of the care plan may become more prominent as curative therapies are less prominent as curative therapies are less availableavailable

More gradual transitions at the end of lifeMore gradual transitions at the end of life

HospiceHospicePalliative CarePalliative Care

Curative / Remissive TherapyCurative / Remissive Therapy

Presentation Death

Adapted from EPEC curriculum, 1999

WHAT IS “HOSPICE”? LocationLocation

Place for the care of dying patientsPlace for the care of dying patients

GroupGroup Organization that provides care for the dying patientOrganization that provides care for the dying patient

Approach to careApproach to care Philosophy of care for the dying patientPhilosophy of care for the dying patient

A Medicare benefitA Medicare benefit

Adapted from Geriatrics Review Syllabus, Sixth Edition

THE HOSPICE MEDICARE BENEFIT For beneficiaries with an expected prognosis of For beneficiaries with an expected prognosis of

6 months or less6 months or less

Exchange curative treatments for symptomatic/ Exchange curative treatments for symptomatic/ palliative treatmentspalliative treatments

Can be revoked at any timeCan be revoked at any time

Reimbursed per diem for one of four levels of Reimbursed per diem for one of four levels of carecare

Can be utilized in the home, nursing home, Can be utilized in the home, nursing home, inpatient hospice unitsinpatient hospice units

See referenced reading, AAHPM Bulletin

THE HOSPICE MEDICARE BENEFIT

Covered ServicesCovered Services

physician services, nursing carephysician services, nursing care

medical equipment and suppliesmedical equipment and supplies

medications related to the terminal illness designatedmedications related to the terminal illness designated

short-term inpatient care (symptom management & respite)short-term inpatient care (symptom management & respite)

PT or OT based on the goalsPT or OT based on the goals

bereavement servicesbereavement services

home-health aide serviceshome-health aide services

OBSTACLES Limited access, i.e. rural areasLimited access, i.e. rural areas

Logistical supportLogistical support

Late referral – median duration time spent Late referral – median duration time spent with hospice is only 21 days with hospice is only 21 days (Hospice Association of (Hospice Association of America 2006)America 2006)

Difficulties in determining prognosis Difficulties in determining prognosis

PROGNOSIS

More straightforward for cancer diagnosisMore straightforward for cancer diagnosis Often unpredictable for chronic diseaseOften unpredictable for chronic disease

COPDCOPD

Alzheimer’s DiseaseAlzheimer’s Disease

Heart diseaseHeart disease

Failure to Thrive/ DebilityFailure to Thrive/ Debility

PROGNOSIS

In general:In general:

Patient’s condition is life limiting, and pt/ family Patient’s condition is life limiting, and pt/ family are awareare aware

Pt/ family have elected relief of sx treatment goals Pt/ family have elected relief of sx treatment goals rather than curative goalsrather than curative goals

Pt has either documented clinical progression of Pt has either documented clinical progression of disease or documented recent impaired nutritional disease or documented recent impaired nutritional status related to the terminal processstatus related to the terminal process

Karnofsky Scale

DELIVERING BAD NEWS PreparePrepare

Plan an agendaPlan an agenda Ensure availability of all medical facts Ensure availability of all medical facts Pick an appropriate settingPick an appropriate setting Minimize interruptionsMinimize interruptions

What does the patient understand? What does the What does the patient understand? What does the patient want to know?patient want to know?

Deliver the newsDeliver the news Be straightforward, avoiding medical jargonBe straightforward, avoiding medical jargon

Provide a “warning shot”Provide a “warning shot”

Allow time for discussionAllow time for discussion

Create a plan and organize for follow-upCreate a plan and organize for follow-up

DECISION MAKING

Autonomous choices are voluntary, Autonomous choices are voluntary, adequately informed and based on adequately informed and based on reasoningreasoning Does the patient have the ability to Does the patient have the ability to

choose?choose? Does the patient understand pertinent Does the patient understand pertinent

information?information? Does the patient appreciate the clinical Does the patient appreciate the clinical

situation/ choices/ consequences?situation/ choices/ consequences? Can the patient reason through choices?Can the patient reason through choices?

The patient identifies the goal(s). The plan follows the goal.

SURROGATE DECISION MAKING

May be required with both younger and older May be required with both younger and older adultsadults

Specific surrogate may be identified via a Specific surrogate may be identified via a DPOA (durable power of attorney) for health DPOA (durable power of attorney) for health carecare

Goal of surrogate is to advocate for patient Goal of surrogate is to advocate for patient based on what they know of patient’s wishesbased on what they know of patient’s wishes- based on prior discussions, advance directives/ - based on prior discussions, advance directives/ living willsliving wills

SOME DEFINITIONS

Durable Power of Attorney for Health CareDurable Power of Attorney for Health Care Appointing someone to make medical decisions for you if you Appointing someone to make medical decisions for you if you

cannot make them yourselfcannot make them yourself Does not require presence of AD or living willDoes not require presence of AD or living will

Living WillLiving Will Description of wishes about life sustaining medical treatments if one is Description of wishes about life sustaining medical treatments if one is

terminally illterminally ill

Advance directivesAdvance directives Instructions / guidance for for health care should one become Instructions / guidance for for health care should one become

incapacitatedincapacitated Can name an “agent” to make decisions for themCan name an “agent” to make decisions for them Wishes stated must be honored by surrogate unless court orders Wishes stated must be honored by surrogate unless court orders

otherwiseotherwise Can be revoked at any timeCan be revoked at any time

Adapted from University of New Mexico SoM

DECISION MAKING

If a patient cannot make their medical If a patient cannot make their medical decision and has not identified a surrogate decision and has not identified a surrogate decision maker, does not have an advance decision maker, does not have an advance directive, or has not made their wishes directive, or has not made their wishes known, a surrogate may have to be identified.known, a surrogate may have to be identified. Some states have an automatic order of priority Some states have an automatic order of priority

for identifying surrogates for identifying surrogates Kansas and Missouri have no such statues Kansas and Missouri have no such statues

availableavailable

OTHER PALLIATIVE CARE ISSUES

Symptom management Symptom management Cross-cultural issuesCross-cultural issues Spiritual concernsSpiritual concerns Psychosocial issuesPsychosocial issues

See recommended readings for further information

SYMPTOM MANAGEMENT

Multiple symptoms of concern near the end of lifeMultiple symptoms of concern near the end of life- - PainPain- - DyspneaDyspnea- Constipation- Constipation- - NauseaNausea- Anxiety- Anxiety- - DeliriumDelirium- Fatigue- Fatigue- Anorexia- Anorexia

PAIN

Treatment based on assessmentTreatment based on assessment- - severityseverity- - nociceptive vs. neuropathicnociceptive vs. neuropathic- step-wise - step-wise approachapproach

Potential modalitiesPotential modalities- Non-opioid- Non-opioid

acetominophenacetominophen NSAIDs/ COX-2 –INSAIDs/ COX-2 –I

- - OpioidOpioid- Adjunctive - Adjunctive

Anti-convulsantsAnti-convulsantsSteroidsSteroidsTCAsTCAs

And now a little about opioids…

Bind to one or more of the opiate receptors (mu, Bind to one or more of the opiate receptors (mu, kappa, delta)kappa, delta)

Mu receptor is 7 transmembrance G protein Mu receptor is 7 transmembrance G protein coupled receptorcoupled receptor- - binding stabilizes the membrane so neuron doesn’t firebinding stabilizes the membrane so neuron doesn’t fire

Where are the mu receptors?Where are the mu receptors?- periphery, dorsal root ganglia of spinal cord, periaqueductal grey of - periphery, dorsal root ganglia of spinal cord, periaqueductal grey of brainstem, midbrain, gutbrainstem, midbrain, gut

Opioids

““weak” opioidsweak” opioids- codeine- codeine- hydrocodone- hydrocodone- oxycodone- oxycodone

““strong” opioidsstrong” opioids- hydromorphone- hydromorphone- fentanyl- fentanyl- morphine- morphine

Opioids

DistributionDistribution- HydrophilicHydrophilic

* morphine, oxycodone, hydromorphone* morphine, oxycodone, hydromorphone- LipophilicLipophilic

* fentanyl, methadone* fentanyl, methadone

Opioids

IV- IV- morphine, hydromorphone, fentanylmorphine, hydromorphone, fentanyl PO- PO- morphine (LA & SA), oxycodone (LA & SA), morphine (LA & SA), oxycodone (LA & SA),

hydromorphone, methadone, fentanyl, hydrocodonehydromorphone, methadone, fentanyl, hydrocodone Transdermal- Transdermal- fentanylfentanyl Initial decisions based on Initial decisions based on

- route of administration- route of administration- need for continuous vs. intermittent dosing- need for continuous vs. intermittent dosing- severity of pain- severity of pain

LA= long actingLA= long actingSA= short actingSA= short acting

Opioids-Pharmacology

All water soluble opioids behave similarly:All water soluble opioids behave similarly: Cmax is 60-90 minutes after PO doseCmax is 60-90 minutes after PO dose

30 minutes after SQ or IM30 minutes after SQ or IM

6-10 minutes after IV dose6-10 minutes after IV dose All are conjugated in liver and 90% excreted via All are conjugated in liver and 90% excreted via

the kidneythe kidney With normal renal fx, all have ½ life of 3-4 hours, With normal renal fx, all have ½ life of 3-4 hours,

reach steady state in 4-5 ½ livesreach steady state in 4-5 ½ lives

Special Notes

MorphineMorphine

- low protein binding- low protein binding

- dialyzes off- dialyzes off

- active metabolite is morphine 6- glucuronide - active metabolite is morphine 6- glucuronide (10%)(10%)

* accumulates in renal failure and causes * accumulates in renal failure and causes neuroexcitationneuroexcitation

* prolonged CNS effects* prolonged CNS effects

Special Notes

FentanylFentanyl

- little or no active metabolites- little or no active metabolites

- Not dialyzable- Not dialyzable

- Elderly more sensitive to effects- Elderly more sensitive to effects

- Unclear how TD route is affected by low subcutaneous fat- Unclear how TD route is affected by low subcutaneous fat

HydromorphoneHydromorphone

- Generally considered to have inactive metabolites- Generally considered to have inactive metabolites

- Drug of choice with renal failure- Drug of choice with renal failure

Special Notes

MethadoneMethadone- binds mu and blocks NMDA receptorsbinds mu and blocks NMDA receptors- highly protein boundhighly protein bound- highly variable and prolonged half lifehighly variable and prolonged half life- Phase I metabolism and may prolong the QT Phase I metabolism and may prolong the QT

intervalinterval- caution when changing from another opioid caution when changing from another opioid

to methadoneto methadone

Potential opioid side effects

NauseaNausea CNS depression/ sedationCNS depression/ sedation PruritisPruritis ConstipationConstipation DeliriumDelirium Endocrine dysfunction with long term useEndocrine dysfunction with long term use

DYSPNEA

Subjective symptomSubjective symptom Pathophysiology can reflect disorder in Pathophysiology can reflect disorder in

regulation or act of breathing regulation or act of breathing Treatment directed at underlying causeTreatment directed at underlying cause

-- Most common reversible causes Most common reversible causesbronchospasm, hypoxia, anemiabronchospasm, hypoxia, anemia

- Both non-pharmacologic and non-pharmacologic - Both non-pharmacologic and non-pharmacologic treatments can be helpfultreatments can be helpful- Opioids used for sx relief when more directed - Opioids used for sx relief when more directed therapy doesn’t reverse the dypsneatherapy doesn’t reverse the dypsnea

NAUSEA

Potentially debilitating symptoms near the Potentially debilitating symptoms near the end of lifeend of life

Treatment based on sourceTreatment based on source

- Brain - Brain chemoreceptor trigger zone, cerebral cortex, chemoreceptor trigger zone, cerebral cortex, vestibular apparatusvestibular apparatus

- - GI tract GI tract obstruction, motility, mucosal irritationobstruction, motility, mucosal irritation

www,aafp.org, Sept.1, 2001, Vol.64, No.5

DELIRIUM

Common near the end of lifeCommon near the end of life

- - geriatric patients with multiple risk factors for geriatric patients with multiple risk factors for developmentdevelopment

Large number of cases can be reversibleLarge number of cases can be reversible Control of delirium may be important for both Control of delirium may be important for both

patient and familypatient and family

- - pharmacologic and non-pharmacologic meanspharmacologic and non-pharmacologic means

ACOVE Indicators

Assessing Care of Vulnerable EldersAssessing Care of Vulnerable Elders Comprehensive set of quality Comprehensive set of quality

assessment tools for ill older adultsassessment tools for ill older adults

- - Covering domains of prevention, diagnosis, Covering domains of prevention, diagnosis, treatment, and follow uptreatment, and follow up

Designed to evaluate health care at Designed to evaluate health care at system level rather than individual levelsystem level rather than individual level

DECISION MAKING (ACOVE)

If a vulnerable older adult is admitted directly If a vulnerable older adult is admitted directly to the intensive care unit (from the outpatient to the intensive care unit (from the outpatient setting or emergency department) and setting or emergency department) and survives 48 hours, THEN within 48 hours of survives 48 hours, THEN within 48 hours of admission, the medical record should admission, the medical record should document consideration of the patient’s document consideration of the patient’s preferences for care or that these could not preferences for care or that these could not be elicited or are unknownbe elicited or are unknown

DECISION MAKING (ACOVE)

ACOVE indicator for quality care of the ACOVE indicator for quality care of the older adult:older adult:

1)1) If a vulnerable older adult with dementia, coma, or If a vulnerable older adult with dementia, coma, or altered mental status is admitted to the hospital, altered mental status is admitted to the hospital, THEN within 48 hours of admission, the medical THEN within 48 hours of admission, the medical record should contain an advance directive record should contain an advance directive indicating the patient’s surrogate decision makerindicating the patient’s surrogate decision maker

2)2) Document a discussion about who would be Document a discussion about who would be surrogate decision maker or a search for a surrogate decision maker or a search for a surrogate, orsurrogate, or

3)3) Indicate that there is no identified surrogateIndicate that there is no identified surrogate

DECISION MAKING (ACOVE)

If a vulnerable older adult carries a diagnosis of If a vulnerable older adult carries a diagnosis of severe dementia, is admitted to the hospital, and severe dementia, is admitted to the hospital, and survives 48 hours, THEN within 48 hours of survives 48 hours, THEN within 48 hours of admission, the medical record should document admission, the medical record should document consideration of the patient’s previous preferences consideration of the patient’s previous preferences for care or that these could not be elicited or are for care or that these could not be elicited or are unknownunknown

DECISION MAKING (ACOVE)

All vulnerable older adults should have in All vulnerable older adults should have in their outpatient chartstheir outpatient charts1) An advance directive indicating the 1) An advance directive indicating the patient’s surrogate decision maker, orpatient’s surrogate decision maker, or2) Documentation of a discussion about who 2) Documentation of a discussion about who would be a surrogate decision maker or a would be a surrogate decision maker or a search for a surrogate, orsearch for a surrogate, or3) Indication that there is no identified 3) Indication that there is no identified surrogatesurrogate

CASE 1 (1 of 3) A 79-year-old man with a history of prostate cancer has A 79-year-old man with a history of prostate cancer has

had worsening back pain for 3 weeks. He recalls no had worsening back pain for 3 weeks. He recalls no recent accident or injury.recent accident or injury.

The pain limits the patient’s ability to dress and bathe The pain limits the patient’s ability to dress and bathe himself. He cannot get comfortable in bed and has been himself. He cannot get comfortable in bed and has been sleeping in a reclining chair for the past few nights. He sleeping in a reclining chair for the past few nights. He took acetaminophen with codeine last night with no took acetaminophen with codeine last night with no relief.relief.

Physical examination is normal except for tenderness on Physical examination is normal except for tenderness on palpation over the lower spine.palpation over the lower spine.

Bone scan demonstrates metastatic disease in the Bone scan demonstrates metastatic disease in the lumbar spine and pelvis.lumbar spine and pelvis.

CASE 1 (2 of 3)Which of the following is the most Which of the following is the most appropriate initial management strategy appropriate initial management strategy for this patient’s pain?for this patient’s pain?

(A) Immediate-release oxycodone(A) Immediate-release oxycodone (B) Sustained-release oxycodone (B) Sustained-release oxycodone (C) Propoxyphene(C) Propoxyphene (D) Transdermal fentanyl(D) Transdermal fentanyl (E) Acetaminophen with codeine(E) Acetaminophen with codeine

CASE 1 (3 of 3)Which of the following is the most Which of the following is the most appropriate initial management strategy appropriate initial management strategy for this patient’s pain?for this patient’s pain?

(A) Immediate-release oxycodone(A) Immediate-release oxycodone (B) Sustained-release oxycodone (B) Sustained-release oxycodone (C) Propoxyphene(C) Propoxyphene (D) Transdermal fentanyl(D) Transdermal fentanyl (E) Acetaminophen with codeine(E) Acetaminophen with codeine

CASE 2 (1 of 3) For the third time in 6 months, an 84-year-old man with For the third time in 6 months, an 84-year-old man with

advanced dementia is admitted to the hospital for aspiration advanced dementia is admitted to the hospital for aspiration pneumonia.pneumonia.

He has lost 9.5 kg (20 lb) over the past 10 months and has a He has lost 9.5 kg (20 lb) over the past 10 months and has a sacral pressure ulcer. He is nonverbal, unable to ambulate, and sacral pressure ulcer. He is nonverbal, unable to ambulate, and dependent for all ADLs.dependent for all ADLs. His wife cares for him at home. He His wife cares for him at home. He does not want to go to a nursing home.does not want to go to a nursing home.

A swallow study indicates that all food consistencies are A swallow study indicates that all food consistencies are unsafe. The hospitalist suggests tube feeding. The advanced unsafe. The hospitalist suggests tube feeding. The advanced care plan states that the patient’s wife is his agent and that he care plan states that the patient’s wife is his agent and that he does not want extraordinary measures used to extend his life, does not want extraordinary measures used to extend his life, including artificial nutrition.including artificial nutrition.

CASE 2 (2 of 3)What is the most appropriate recommendation for this What is the most appropriate recommendation for this patient?patient?

(A) Long-term placement of a feeding tube and (A) Long-term placement of a feeding tube and discharge to a skilled nursing facility (SNF)discharge to a skilled nursing facility (SNF)

(B) Short-term placement of a feeding tube and (B) Short-term placement of a feeding tube and discharge to a SNF until the pressure ulcer healsdischarge to a SNF until the pressure ulcer heals

(C) Discharge to a SNF for wound care until the(C) Discharge to a SNF for wound care until the pressure ulcer has healedpressure ulcer has healed

(D) Discharge home with home-health services(D) Discharge home with home-health services

(E) Discharge home with home hospice(E) Discharge home with home hospice

CASE 2 (3 of 3)What is the most appropriate recommendation for this What is the most appropriate recommendation for this patient?patient?

(A) Long-term placement of a feeding tube and (A) Long-term placement of a feeding tube and discharge to a skilled nursing facility (SNF)discharge to a skilled nursing facility (SNF)

(B) Short-term placement of a feeding tube and (B) Short-term placement of a feeding tube and discharge to a SNF until the pressure ulcer healsdischarge to a SNF until the pressure ulcer heals

(C) Discharge to a SNF for wound care until the(C) Discharge to a SNF for wound care until the pressure ulcer has healedpressure ulcer has healed

(D) Discharge home with home-health services(D) Discharge home with home-health services

(E) Discharge home with home hospice(E) Discharge home with home hospice

CASE 3 (1 of 3) A 67-year-old woman with terminal metastatic ovarian cancer A 67-year-old woman with terminal metastatic ovarian cancer

presents with a 2-day history of nausea and vomiting. She has presents with a 2-day history of nausea and vomiting. She has been unable to tolerate any oral intake and has not had a bowel been unable to tolerate any oral intake and has not had a bowel movement in 4 days.movement in 4 days.

The patient is reluctant to undergo further invasive procedures The patient is reluctant to undergo further invasive procedures or hospitalization.or hospitalization.

Medications are acetaminophen with codeine as needed and Medications are acetaminophen with codeine as needed and docusate sodium stool softener every morning.docusate sodium stool softener every morning.

The patient appears uncomfortable. No fever, BP 98/60, pulse The patient appears uncomfortable. No fever, BP 98/60, pulse 105, tachycardia. Abdomen is markedly distended with 105, tachycardia. Abdomen is markedly distended with decreased bowel sounds, tympany on percussion, diffuse decreased bowel sounds, tympany on percussion, diffuse tenderness on palpation. Rectal exam is normal.tenderness on palpation. Rectal exam is normal.

CASE 3 (2 of 3)In addition to providing the patient with In addition to providing the patient with morphine, which of the following is the most morphine, which of the following is the most appropriate management strategy?appropriate management strategy?

(A) Diverting colostomy(A) Diverting colostomy

(B) Nasogastric suctioning(B) Nasogastric suctioning

(C) Octreotide(C) Octreotide

(D) Atropine(D) Atropine

(E) Ondansetron(E) Ondansetron

CASE 3 (3 of 3)In addition to providing the patient with In addition to providing the patient with morphine, which of the following is the most morphine, which of the following is the most appropriate management strategy?appropriate management strategy?

(A) Diverting colostomy(A) Diverting colostomy

(B) Nasogastric suctioning(B) Nasogastric suctioning

(C) Octreotide(C) Octreotide

(D) Atropine(D) Atropine

(E) Ondansetron(E) Ondansetron

SUMMARY

The goal of palliative care is to relieve suffering The goal of palliative care is to relieve suffering and assist patients with serious illness and their and assist patients with serious illness and their families with medical decision making families with medical decision making

Advance directives are an important way to Advance directives are an important way to facilitate this and are viewed as an important facilitate this and are viewed as an important quality indicatorquality indicator

Learning to communicate these issues in keyLearning to communicate these issues in key Palliative care also encompasses a wide realm of Palliative care also encompasses a wide realm of

symptom management, as well as support symptom management, as well as support surrounding psychosocial and spiritual issuessurrounding psychosocial and spiritual issues

REFERENCES

AGS Panel on Persistent Pain in Older Persons, “ The Management of AGS Panel on Persistent Pain in Older Persons, “ The Management of Persistent Pain in Older Persons,” Persistent Pain in Older Persons,” Journal of the American Geriatrics SocietyJournal of the American Geriatrics Society, , June 2002, Vol. 50, No.6 supplementJune 2002, Vol. 50, No.6 supplement

Finucane, Christmas, and Travis, “Tube Feeding in Patients with Advanced Finucane, Christmas, and Travis, “Tube Feeding in Patients with Advanced Dementia: A Review of the Evidence,” Dementia: A Review of the Evidence,” JAMAJAMA, Oct. 13, 1999, Vol. 282, No. 14, Oct. 13, 1999, Vol. 282, No. 14

Ganzini et al, “Ten Myths about Decision-Making Capacity,” Ganzini et al, “Ten Myths about Decision-Making Capacity,” Journal of the Journal of the American Medical Directors AssociationAmerican Medical Directors Association, May/ June 2005, May/ June 2005

Tulsky, “Beyond Advance Directives: Importance of Communications Skills at Tulsky, “Beyond Advance Directives: Importance of Communications Skills at the End of Life,” the End of Life,” JAMAJAMA, July 20,2005, Vol. 294, No. 3, July 20,2005, Vol. 294, No. 3

Ross and Alexander, “Management of Common Symptoms of Terminally Ill Ross and Alexander, “Management of Common Symptoms of Terminally Ill Patients: Part I,” Patients: Part I,” American Family PhysicianAmerican Family Physician, Sept. 1, 2001, Vol. 64, No. 5, Sept. 1, 2001, Vol. 64, No. 5

Ross and Alexander, “Management of Common Symptoms of Terminally Ill Ross and Alexander, “Management of Common Symptoms of Terminally Ill Patients: Part II,” Patients: Part II,” American Family PhysicianAmerican Family Physician, Sept. 15, 2001, Vol. 64, No. 6, Sept. 15, 2001, Vol. 64, No. 6

http://aspe.hhs.gov/daltcp/reports/impquesa.htm (Click to Appendix C for prognosis guidelines)(Click to Appendix C for prognosis guidelines)

ADDITIONAL REFERENCES

““Health Care Decision Making Web Module for Health Care Decision Making Web Module for Medical Students.” Developed by Dr. Christine Medical Students.” Developed by Dr. Christine Hayward, Carla Herman. University of New Hayward, Carla Herman. University of New Mexico School of Medicine. Funded by Donald Mexico School of Medicine. Funded by Donald W. Reynolds Foundation, John A Hartford W. Reynolds Foundation, John A Hartford Foundation. Web-based, self directed learning Foundation. Web-based, self directed learning modulemodule

EPEC Participant’s Handbook 1999EPEC Participant’s Handbook 1999 Geriatric Review Syllabus 6 teaching slidesGeriatric Review Syllabus 6 teaching slides Kinzbrunner, “The Medicare Hospice Benefit,” Kinzbrunner, “The Medicare Hospice Benefit,”

AAHPM Bulletin Spring 2001,Vol. 1, No. 3AAHPM Bulletin Spring 2001,Vol. 1, No. 3

Acknowledgements

Dr. Karin Porter-Williamson, Medical Director of the Dr. Karin Porter-Williamson, Medical Director of the Palliative Care team at the University of Kansas Palliative Care team at the University of Kansas Medical CenterMedical Center

For GRS sixth edition teaching slides:For GRS sixth edition teaching slides:Co-Editors: Co-Editors: Karen Blackstone, MD & Elizabeth L. Cobbs, Karen Blackstone, MD & Elizabeth L. Cobbs, MDMD

GRS6 Chapter Authors:GRS6 Chapter Authors: Stacie T. Pinderhughes, MD & R. Sean Stacie T. Pinderhughes, MD & R. Sean Morrison, MDMorrison, MD

GRS6 Question Writers: GRS6 Question Writers: Susan Charette, MDSusan Charette, MD

Medical Writer: Medical Writer: Barbara B. Reitt, PhD, ELS (D)Barbara B. Reitt, PhD, ELS (D)

Managing Editor: Managing Editor: Andrea N. Sherman, MSAndrea N. Sherman, MS© American Geriatrics Society© American Geriatrics Society