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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
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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
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Apoptosis – programmed death of cells / tissues defined at conception
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AGEING Is normal and inevitable Ageing leads to death
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Good living and luck can help you to survive to your apoptotic potential
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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):
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Community
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Community Ambulance
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Emergency Department Community Ambulance
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Hospital Ward Emergency Department Community Ambulance
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Hospital Ward Emergency Department Community Ambulance ICU
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MOST PATIENTS >85 YEARS OF AGE ADMITTED TO ICUs
Have died by 12 months Many suffer post-traumatic stress disorder along the way
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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
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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
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HEALTH SYSTEM Built around concept of a single diagnosis to be treated
Matched by medical specialists Different population in 2017
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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
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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
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A NEW APPROACH Recognise elderly frail people near the end-of-life
Construct an appropriate response
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RECOGNITION OF PEOPLE NEAR THE END-OF-LIFE
CriSTAL tool Validated in Australia and Europe BMJ Support Palliat Care 2015;5:78-90
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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
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RESPONSE Honest and empathetic discussion with patient/carers
Empowering patients to establish their own Goals of Care
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RESPONSE Initially with specifically trained responders
Gradually embed into routine clinical practice
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RESPONSE UNCERTAINTY – inherent clinical practice
FLAG – not a precise number
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ULTIMATE RESPONSE Connect with community alternatives such as:
General practitioner Support in the home Aged care and other institutions
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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
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THE MEDICALISATION OF THE DYING PROCESS IN THE AGED
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USING THE HOSPITAL ADMISSION AS A UNIQUE OPPORTUNITY TO PROVIDE APPROPRIATE AND PATIENT-CENTRED CARE FOR THE ELDERLY FRAIL
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