What is a Good Death? by Ashley Shreves
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This document discusses what constitutes a good death according to patients facing end of life. It notes that patients rate non-medical factors like quality of life and personal priorities as most important, rather than medical treatments or prolonging life. However, current end of life care is often focused on resuscitation and life-prolonging measures instead of quality of life. Palliative care aims to improve quality of life and relieve suffering for patients with serious illnesses through a multidisciplinary approach. When utilized, palliative care can lead to improved medical decisions and outcomes like better symptom management, less depression, extended life, and lower costs. The key to a good death is focusing on the patient's priorities and values rather than the priorities of doctors
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What is a Good Death? by Ashley Shreves
- 1. What is a good death? SMACC June 25, 2015 Ashley Shreves, MD Assistant Professor Department of Emergency Medicine Brookdale Department of Geriatrics and Palliative Medicine Icahn School of Medicine at Mt. Sinai
- 2. Which looks like “good” dying?
- 3. What’s most important to patients facing death? Steinhauser JAMA 2000
- 4. Don’t patients want to live forever? n = 226 Advanced illnesses Fried N Engl J Med 2002
- 5. What’s most important? Non-medical >>> medical Quality of life >>> quantity of life Outcomes >>> treatments
- 6. Are we good with the non-medical? Teno JAMA 2005
- 7. Quality vs Quantity? Focused on resuscitation and life-prolongation Spectacular deaths: exciting and prioritized “Subtacular” deaths?? Care Poor Forgotten about Neglected Stuck in a corner and left there A lower class citizen in regards to EM Bailey Ann Emerg Med 2010
- 8. Outcomes? Time spent 1 min Content of conversation Descriptions of CPR Outcomes? Not mentioned
- 9. Want to do better?
- 10. Palliative Care Type of care Improve quality of life/relieve suffering Serious/advanced illness Multidisciplinary team approach Hospice System of care Improve quality of life/relieve suffering Terminal illness Multidisciplinary team approach
- 11. Mt. Sinai Palliative Care Team Doctor Nurse Practitione r Social Worker Chaplain Art therapist Massag e therapist Yoga therapis t Nurse Patient & Family
- 12. What do we do? COMMUNICATION COMMUNICATION COMMUNICATION
- 13. What happens? Medical decisions change Quality of life improves Symptom management improves Depression decreases Life often extended Costs decrease Volandes BMJ 2009 Temel N Engl J Med 2010 Teno JAMA 2004 Connor J Pain Symptom Manage 2007 Morrison Arch Int Med 2008
- 14. When is dying bad? WHEN IT’S ABOUT YOU
- 15. When is dying good? WHEN IT’S ABOUT THEM
- 16. How do patients get the good death? PALLIATIVE CARE & HOSPICE If not available LEARN COMMUNICATION SKILLS
Notas del editor
- I’m going to answer this question up front. The gave me a talk topic for which there is no precise answer. Thanks guys.
- 2 very different pts with radically different EOL experiences. One is getting the high tech experience in the ICU. The other opted for hospice at home and 16 months later, is still hanging in there. -my grandmother appears to be having a better EOL experience than that poor lady to her right. Why? Does it just look better to you? Is it better for her? Well, why don’t we start with her. Meaning the pt.
- First goal: start from the perspective of the pt -would you say medical issues like intubation, use of CPR are high up on that list. Turns out that being kept clean, maintaining a sense of dignity, maintaining a sense of humor…those things rank way way higher than many of the “medical” issues that we’re focused on addressing
- -but when it comes to making decisions about specific medical interventions, won’t most pts just choose “everything”…you know, whatever helps them live as long as possible. These pts. They just don’t get it. -so turns out, not so much. This figure is from a study of patients near the EOL, secondary to cancer, COPD or CHF. Investigators were trying to determine what factors are considered most important to pts with advanced illnesses, when making medical decisions. They were given hypothetical scenarios -turns out, not all that worried about the treatments…much more interested in the outcomes. Month in the ICU, hooked up to a vent – but at the end of the day I get to spend more time with my friends and family back home. Sign me up!
- -so let’s summarize what we’ve learned so far -issues most important to pts faving death…
- -compared to home hospice care, patients in the hospital were not always treated with respect, according to their familiies. Didn’t get the information they needed regarding what to expect about dying process, less emotional support, worries about our communication -so how do we do with the non-medical issues that pts have identitied as most important…maybe some room for improvement?
- -research personnel observed patients and ED staff during EOL situtations to better understand EOL experience of pts/families in ED and how we interface with such pts. 2 different categories of pts at the EOL. The trauma pt, the elderly pt with dementia and PNA. Interviewed pts and staff and family members and here’s what they described…it’s going to shock you so hold on