THE MANAGEMENT OF ELDERLY FRAIL PATIENTS AT THE END-OF-LIFE Intensive Care Unit AHHA Deebles Workshop: End of Live Care – The Next Steps. Melbourne. 22 May 2017. Ken Hillman

The inappropriate management of he elderly frail in acute hospitals at the end of their lives is arguably one of the greater challenges in health Often not want the elderly want Frustrating for all health professionals Major contributor to the unsustainable costs of health care

Apoptosis – programmed death of cells / tissues defined at conception

AGEING Is normal and inevitable Ageing leads to death

Good living and luck can help you to survive to your apoptotic potential

Int J Qual Health Care 2016;28(4):456-469 UP TO ONE-THIRD OF ALL HOSPITAL INTERVENTIONS ARE INEFFECTIVE / INAPPROPRIATE / FUTILE IN THE LAST SIX MONTHS OF LIFE Int J Qual Health Care 2016;28(4):456-469

Community

Community Ambulance

Emergency Department Community Ambulance

Hospital Ward Emergency Department Community Ambulance

Hospital Ward Emergency Department Community Ambulance ICU

MOST PATIENTS >85 YEARS OF AGE ADMITTED TO ICUs Have died by 12 months Many suffer post-traumatic stress disorder along the way

HEALTH DEPARTMENTS FIXATED ON HOSPITAL KPIs IN THE ELDERLY Reduce falls Pressure areas Mortality rates Length of stay Hospital readmission rates MISSING THE BIGGER PICTURE

CONSIDER HOSPITAL ADMISSIONS FOR INFECTIONS and FALLS IN >80 YEAR OLDS As a marker of ageing and nearing end-of-life Not a condition to be necessarily cured

HEALTH SYSTEM Built around concept of a single diagnosis to be treated Matched by medical specialists Different population in 2017

Shifting the Balance of Care. Nuffield Trust 2017 NHS AIMS TO CUT ALL HOSPITAL ACTIVETY BY ONE THIRD IN THE NEXT FOUR YEARS Shifting the Balance of Care. Nuffield Trust 2017

Shifting the Balance of Care. Nuffield Trust 2017 Most successful initiatives are targeting specific populations: Those in aged care centres Patients at the end of life Shifting the Balance of Care. Nuffield Trust 2017

A NEW APPROACH Recognise elderly frail people near the end-of-life Construct an appropriate response

RECOGNITION OF PEOPLE NEAR THE END-OF-LIFE CriSTAL tool Validated in Australia and Europe BMJ Support Palliat Care 2015;5:78-90

RESPONSE On admission to the emergency department At the time of a rapid response call On admission to the ICU At the pre-operative clinic

RESPONSE Honest and empathetic discussion with patient/carers Empowering patients to establish their own Goals of Care

RESPONSE Initially with specifically trained responders Gradually embed into routine clinical practice

RESPONSE UNCERTAINTY – inherent clinical practice FLAG – not a precise number

ULTIMATE RESPONSE Connect with community alternatives such as: General practitioner Support in the home Aged care and other institutions

EVALUATION Needs to be embedded in implementation process: Were the Goals of Care achieved? Did the community resources match patient/carer choices? Use this data to inform system

THE MEDICALISATION OF THE DYING PROCESS IN THE AGED

USING THE HOSPITAL ADMISSION AS A UNIQUE OPPORTUNITY TO PROVIDE APPROPRIATE AND PATIENT-CENTRED CARE FOR THE ELDERLY FRAIL