1. 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

2. 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

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

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

5. 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

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

7. 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

8. 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

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

10. 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, ; Vandersteen JAMDA 2007; 8(6): ; Fabiszewski, JAMA 1990;263: 316

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

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

13. Goals of Care Advance Care Planning Cycle

14. Conversation Examples:

15. Conversation examples:

16. Goals of Care
Questions?