Goals of Care Dr. P. Methvin, Langley Division of Family Practice Dementia is a progressive, terminal illness for which there is no cure. Starts with knowing the person has an illness they will die from Dementia is often not viewed as a terminal illness Goals of Care Dr. P. Methvin, Langley Division of Family Practice

Goals of Care: Palliative approach Anticipates change decline and death Conversations about: Values Needs Wishes Disease Management: Comfort & Quality Information: to support decision making Support: physical, psychosocial, spiritual needs Provisions for death and care after death

Integrated approach through advancing illness Goals of Care Integrated approach through advancing illness Palliative Approach Advanced Illness Actively Dying

“Most chronically ill older people have ambiguous medical prognosis … Goals of Care “Most chronically ill older people have ambiguous medical prognosis …

Key Roles – Physician / NP Goals of Care Guide Goals of Care Conversations Clarify Understanding Anticipate transitions Provide medical plan & orders Care planning based on goals of care

Goals of care diagnosis prognosis treatment options Clarify understanding & provide: diagnosis prognosis treatment options Explore feelings / needs Advise Educate Explain Goals of care

Family information Needs Communication of information is the utmost expressed need of family care givers When family understand natural course & expected complications of dementia, there is reduced burdensome interventions Treatments regarding eating problems and infections are the most common

Advanced Dementia Unable to: walk, sit unsupported, smile, hold up head, control bowel or bladder Decreased ability to: swallow fight infections speak Physical rigidity MMSE- 0

Tube feeding in advanced dementia There is NO evidence for: Preventing weight loss Preventing pneumonia Prolonging life

Antibiotics Failing immune system response: After pneumonia 5x increased risk of re-occurrence 6 month mortality post pneumonia 36-48% Antibiotics do not change outcomes in severe dementia Route makes no difference in survival Mitchell et. al, Annals of Internal Medicine, 2012 156 45-51; Vandersteen JAMDA 2007; 8(6):396-403; Fabiszewski, JAMA 1990;263: 316

Anticipate transitions Goals of care Anticipate transitions what changes do you anticipate? expected complications Dementia trajectory - Clinical indicators of functional decline

Provide medical plan & orders Goals of care Provide medical plan & orders Effective symptom management Pain management Comfort & quality

Goals of Care Advance Care Planning Cycle

Conversation Examples:

Conversation examples:

Goals of Care Questions?