1. End Of Life Decisions Soumya Niranjan, BPharm., MS, CCRP
Sociology of Death and Dying SOC 760
2. Talking about death What are End of Life Decisions (ELD)?
Dying in America Evidence supporting end of life discussions End of
life is a public health issue Summary OVERVIEW
3. Family is more aggressive than patient. Family estimate of
patients preference is not improved by living will, but improved by
talking with the physicians. Ditto PH, Danks JH, Smucker WD, et al.
Advance directives as acts of communication: a randomized
controlled trial. Arch Intern Med. 2001;161:42130. J Pain &
Sympt Manag 2005;30:498-509. Talking about death-Family
factors
4. Physicians who are uncomfortable with death (physicians with
increased death anxiety) tend : Treat more aggressively. Less
tolerant of clinical uncertainty. Like elderly patients less.
Merrill J, Lorimor R, Thornby J, et al. Caring for terminally ill
persons: comparative analysis of attitudes (thanataphobia) of
practising doctors, medical students and student nurses. Psychol
Rep 1998;83:1238. Talking about death-Clinicians perspective
5. The act of the physician (administering drugs, forgoing
treatments) The intention of the physician concerning the
life-shortening effect (explicitly/partly intended, only taken into
account) The involvement of the patient (actively involved in the
decision making process or not) V Provoost, L Deliens et al. Acta
Paediatr 2004, 93:301-5 Definition of ELD
6. How we die What we want Nearly half of all Americans die in
a hospital What happens That number increases to 70% when nursing
homes / long- term-care facilities are included Centers for Disease
Control (2005)
7. How we die (contd.) What we want 7 out of 10 Americans say
they would prefer to die at home. Time/CNN Poll (2000) What happens
Only 25 percent of Americans actually die at home. Centers for
Disease Control (2005)
8. How we die (contd.) What we want More than 80 percent of
patients with chronic diseases say they want to avoid
hospitalization and intensive care when they are dying. What
happens Hospitalizations during the last six months of life are
rising: from 1,302 hospital admissions per 1,000 Medicare
recipients in 1996 to 1,442 in 2005 Dartmouth Atlas of Health Care
(2005)
9. Particularly relevant to the seriously ill and the elderly.
When do ELDs matter the most?
10. Discussions about EOL were NOT associated with feeling
Depressed, sad, terrified, worried or meeting DSM criteria for
mental disorder Patients who had discussions about EOL with
physicians were More likely to: Accept diagnosis as terminal Prefer
medical treatment focused on relieving pain / discomfort over life
extending procedures Complete a DNR order Wright, Alexi A., et al.
"Associations between end-of-life discussions, patient mental
health, medical care near death, and caregiver bereavement
adjustment." Jama 300.14 (2008): 1665-1673. Does end of life
discussions harm patients?
11. In final week of life, QOL decreased with increasing number
of aggressive interventions In final weeks of life, QOL increased
with hospice care Wright, Alexi A., et al. "Associations between
end-of-life discussions, patient mental health, medical care near
death, and caregiver bereavement adjustment." Jama 300.14 (2008):
1665-1673. What about Quality of Life (QOL)?
12. No! If physicians discussed EOL options/the future with
patients, bereaved families reported: Higher satisfaction with
communication from physician Better understanding of what to expect
as family member died Teno JM, Lynn J, Connors AF Jr et al. The
illusion of end-of-life resource savings with advance directives.
SUPPORT Investigators. Study to Understand Prognoses and
Preferences for Outcomes and Risks of Treatment. J AmGeriatr Soc
1997;45:513518. Does it harm families?
13. High impact Major burden Potential for preventing suffering
associated with illness Rao, Jaya K., Lynda A. Anderson, and
Suzanne M. Smith. "End of life is a public health issue." American
journal of preventive medicine 23.3 (2002): 215-220. End of Life is
a public health issue
14. There is no unanimity regarding the statistical threshold
for a treatment to be considered futile. Medical futility has been
conceptualized as a power struggle for decisional authority between
physicians and patients/surrogates. This situation is not optimal
for neither the patient nor the family---its best to not rely on
this method Medical futility in end of life care
15. End of life decision making should not be the result of
semi- informed guesswork. We need to be able to create
well-functioning health care delivery systems that make end of life
care genuinely available. We deserve no less Summary
16. Letting Go: What should medicine do when it cant save your
life? - Atul Gawande The New Yorker, August 2, 2010
http://www.newyorker.com/reporting -An interesting read
17. -An alternative point of view Its Not Just About Quality of
Life-- Sandeep Jauhar
http://www.nytimes.com/2015/05/03/opinion/sunday/sandeep-
jauhar-its-not-just-about-quality-of-life.html