End of Life Curriculum Project-Lunchtime symposia for M1 & M2 Daniel McFarland NYCOM 2004

Introduction and overview of palliative care and hospice  1) History of the hospice movement and statistics of death and dying in America.  2) Definitions of hospice according to Medicare benefit. Define palliative and hospice care.  3) Interdisciplinary approach to patient care in hospice.  4) Never take away hope. Shift focus from curative to making person comfortable and autonomous. Change goals of care.  5) Difficulties of prognostication. Use ADL’s and Palliative Performance Scale, unintentional weight loss (cachexia) etc..as measurements.  Cancer, E/S Cardiac, E/S Pulmonary, E/S dementia, Adult Failure to Thrive-Debility  6) Physician resistance to refer to hospice, lack of understanding on part of doctor and patient: Address fear of morphine associated with respiratory suppression and addiction, 30% of patients refuse pain meds at the end of life.  7) Effective communication and communicating bad news. SPIKES. Talking about DNR, advanced directives and POA.

End of Life Physical Symptoms  1) Prevalence of weakness (#1 symptom)...multifactorial (effect of underlying disease, cachexia, anemia, depression etc..)  2) Falls can mean a shortened life span. What are the risk factors? Do physical assessment, modify environment and reduce risk. Tai chi and black holes!  3) Pressure ulcers stage 1-4. Risk factors are immobility, hypoalbuminemia, incontinence, pressure of fracture. Prevent by repositioning and dryness.  4) Edema. Causes and treatments.  5) Hospice emergencies when aggressive treatment is necessary. Spinal cord compression, DVT, subdural hematoma.  6) Delirium vs. Dementia. Depression and anxiety at the end of life.  7) Dyspnea: subjective sense that you need air. Assess cause-may be treatable. CXR findings? Provide oxygen and opioids. Anxiolytics (Ativan, Xanax) does not suppress respiration. Use of nonpharmicalogical agents  8) Gastrointestinal symptoms and management. Anorexia, xerostomia, nausea, constipation, diarrhea.

Managing acute and chronic pain  1) Etiology of pain. Visceral, somatic and neuropathic pain. Pain history.  2) WHO Step Ladder Drugs vs. Dr. Marschke’s revised addition.  3) Pain factors: psychological, socioeconomic, spiritual, physical.  4) Treating somatic, visceral and neuropathic pain. The use of pain adjuvants and CAM adjuvants.  5) How to dose using an opioid. PRN. Long acting vs. short acting opioids.  6) Opioid side effects: constipation and physical vs. psychological dependence. Pseudo-addiction.

Issues of Spirituality, ethics, law and CAM  1) Ethics vs. law  2) Skilled and caring communication, physician leadership, ethics committees.  3) What is an Advanced Directive? What happens when an AD does not exist?  4) Informed consent. When does a patient give over informed consent? Difference between capacity and competency.  5) Perspectives on withholding and withdrawing. CPR, feeding tubes, futility  6) Physician Assisted Suicide, Terminal Sedation, Voluntary Stopping Eating and Drinking.

Additional Ideas  1) Begin on-line forum, post journal articles and websites.  2) Present the movie “to live until I die”