Ethical Challenges in End of Life Care for the Elderly. David A. Fleming, M.D., MA, FACP Professor of Medicine Chairman, Department of Medicine Director, MU Center for Health Ethics University of Missouri School of Medicine 573-882-2738 [email protected] - PowerPoint PPT Presentation
Ethical Challenges in End of Life Ethical Challenges in End of Life Care for the Elderly Care for the Elderly David A. Fleming, M.D., MA, FACP David A. Fleming, M.D., MA, FACP Professor of Medicine Professor of Medicine Chairman, Department of Medicine Chairman, Department of Medicine Director, MU Center for Health Ethics Director, MU Center for Health Ethics University of Missouri School of Medicine University of Missouri School of Medicine 573-882-2738 573-882-2738 [email protected]http//:www.ethics.missouri.edu http//:www.ethics.missouri.edu
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Ethical Challenges in End of Life Ethical Challenges in End of Life Care for the ElderlyCare for the Elderly
David A. Fleming, M.D., MA, FACPDavid A. Fleming, M.D., MA, FACPProfessor of MedicineProfessor of Medicine
Chairman, Department of MedicineChairman, Department of MedicineDirector, MU Center for Health EthicsDirector, MU Center for Health Ethics
University of Missouri School of MedicineUniversity of Missouri School of Medicine573-882-2738573-882-2738
Conflict of Interest Conflict of Interest DisclosureDisclosure
I have no significant financial I have no significant financial relationships with commercial relationships with commercial entities producing healthcare-entities producing healthcare-related products and/or services.related products and/or services.
OverviewOverview
• Observations about deathObservations about death
• EOL decisions in the elderlyEOL decisions in the elderly– Long term careLong term care
– HCD and CPR HCD and CPR
• Challenges of Challenges of FutilityFutility
• CasesCases
• Dealing with ConflictDealing with Conflict
General Observations General Observations • Difficulty accepting death at any ageDifficulty accepting death at any age• Difficulty defining futilityDifficulty defining futility
– Application is patient specificApplication is patient specific– Applies to both acute and chronic conditionsApplies to both acute and chronic conditions– May be over or under utilizedMay be over or under utilized
• Quality of life Quality of life arguments play a dubious rolearguments play a dubious role• Age and economics often come into playAge and economics often come into play• Fluid process – decisions may changeFluid process – decisions may change• Hope and fear of abandonment at the EOLHope and fear of abandonment at the EOL• Patients/families often change their mind Patients/families often change their mind • Often not much time to decideOften not much time to decide• Team/family members may disagreeTeam/family members may disagree
Hope, Expectation, CommunicationHope, Expectation, Communication• Scientific promise to “save and improve” lifeScientific promise to “save and improve” life• Faith (“the choice is not ours to make”)Faith (“the choice is not ours to make”)• Professional training (“death = enemy”)Professional training (“death = enemy”)• Medical marketing (“staff for life”)Medical marketing (“staff for life”)• Theatre (code blue = resuscitation)Theatre (code blue = resuscitation)• Family demands (guilt and fear)Family demands (guilt and fear)• Legal threatLegal threat• Therapeutic “benefit” of futile care?Therapeutic “benefit” of futile care?• Professional Professional score cards (P4P)score cards (P4P)• How Dx and Px are communicatedHow Dx and Px are communicated• Changing relationships (Doc for the day)Changing relationships (Doc for the day)
Conflict may result…Conflict may result…
… …due to lack of claritydue to lack of clarity
… …due to moral discomfortdue to moral discomfort
… …due to fear of reprisal—professional, legaldue to fear of reprisal—professional, legal
The risk:The risk:– Delay in actions may prematurely lead to deathDelay in actions may prematurely lead to death
oror– Unwanted or harmful treatment may be givenUnwanted or harmful treatment may be given
U.S. Paternalism v Autonomy:U.S. Paternalism v Autonomy:the Ethical and Legal Climatethe Ethical and Legal Climate
• Provider v Patient before 1970Provider v Patient before 1970– Generally recognized role of providers to act unilaterally Generally recognized role of providers to act unilaterally
for the patient (paternalism model)for the patient (paternalism model)– Patient and family followed “orders”Patient and family followed “orders”– Limited treatment choicesLimited treatment choices– Patients usually died at homePatients usually died at home
• Patient v Provider todayPatient v Provider today– Courts generally do not recognize the right to act Courts generally do not recognize the right to act
unilaterally unless it’s an emergencyunilaterally unless it’s an emergency– Courts generally protect the patient’s right to choose or Courts generally protect the patient’s right to choose or
refuse treatmentrefuse treatment
I’m afraid there’s very little I can do
I’m afraid there’s really very little I can do…
When is enough enough?
0
5
10
15
20
25
30
35
Excellent Good Poor
Quality of Care
How Does the Current U.S. Health Care System Do in How Does the Current U.S. Health Care System Do in Caring for Dying PeopleCaring for Dying People??
National survey of 1,002 adults conducted byNational survey of 1,002 adults conducted byLake-Snell-Perry Associates for Last Acts, 2002Lake-Snell-Perry Associates for Last Acts, 2002
Excellent Excellent 3%3%Very GoodVery Good 8%8%GoodGood 24%24%Only FairOnly Fair 33%33%PoorPoor 26%26%Could not answerCould not answer 7%7%
ent Integration of Palliative and Disease-oriented TreatmentIntegration of Palliative and Disease-oriented Treatment
in the Trajectory of Deathin the Trajectory of Death
Abrahm, J. Update in Palliative Medicine and End of Life CareAbrahm, J. Update in Palliative Medicine and End of Life CareAnn. Rev. MedAnn. Rev. Med. 2003;54:53-72. 2003;54:53-72
““Death is not an instantaneous, Death is not an instantaneous, momentary phenomenon, but a momentary phenomenon, but a very protracted process.”very protracted process.” Frederick Engels, 1880Frederick Engels, 1880
PrognosisPrognosis
• 20% accurate within 33% survival time20% accurate within 33% survival time
• 63% overoptimistic63% overoptimistic
• 17% underestimated17% underestimated
• Accuracy decreased as the duration of Accuracy decreased as the duration of Dr-Pt relationship increasedDr-Pt relationship increased
Christakis N and Lamont E. Christakis N and Lamont E. BMJBMJ. 2000;320:469-472. 2000;320:469-472
Where Death OccursWhere Death Occurs
• 60% of deaths occur in a hospital.60% of deaths occur in a hospital.– Most with chronic conditionsMost with chronic conditions– 74% of these occur after decisions to forgo life 74% of these occur after decisions to forgo life
• 85% of patients with cancer admitted to an 85% of patients with cancer admitted to an ICU die there. ICU die there.
Dowdy, Dowdy, Crit Care MedCrit Care Med. 1998. 1998
Long Term CareLong Term Care
• 43%43% of persons of persons >>65 in 1990 entered LTC at 65 in 1990 entered LTC at some point; some point; 55%55% stayed at least 1 year; stayed at least 1 year; 21%21% stayed 5 years or longerstayed 5 years or longer
• 20%20% of U.S. deaths occur in LTC of U.S. deaths occur in LTC
• In 1990 > In 1990 > 1.5 Mil1.5 Mil (of 280 Mil) Americans lived (of 280 Mil) Americans lived in nursing homes; by 2030 this will increase in nursing homes; by 2030 this will increase to to 5 Million5 Million
Kemper P, Murtaugh CM. Lifetime use of nursing home care. Kemper P, Murtaugh CM. Lifetime use of nursing home care. NEJMNEJM. 1991; 324:595-600. 1991; 324:595-600
Zedlewski SR, Barnes RO, Burt MK, McBride TD, Meyer J. Zedlewski SR, Barnes RO, Burt MK, McBride TD, Meyer J. The Needs of the Elderly in the 21st Century. The Needs of the Elderly in the 21st Century. Washington, DC: The Urban Institute; 1989. Washington, DC: The Urban Institute; 1989.
Doty PJ. The oldest old and the use of institutional long-termDoty PJ. The oldest old and the use of institutional long-termcare from an international perspective. care from an international perspective. In: Suzman R, Willis DP, Manton KG, eds. In: Suzman R, Willis DP, Manton KG, eds. The Oldest Old. New York: Oxford University Press; The Oldest Old. New York: Oxford University Press; 1992:251-67. 1992:251-67.
Ersek M and Wilson S. The Challenges and Opportunities in Ersek M and Wilson S. The Challenges and Opportunities in Providing End-of-Life Care in Nursing HomesProviding End-of-Life Care in Nursing HomesJ Pal MedJ Pal Med. 2003, Vol. 6, No. 1: 45-57. 2003, Vol. 6, No. 1: 45-57
Changing demographicsChanging demographics• By 2030 By 2030
– 20% population > 6520% population > 65– population population >> 65 will double (30 65 will double (3060 Mil)60 Mil)– population > 85 will double (3population > 85 will double (36 Mil)6 Mil)
• Life expectancy: at 65 = 10 yearsLife expectancy: at 65 = 10 years
at 85 = 5 yearsat 85 = 5 years
• 40% of community dwelling people 40% of community dwelling people >> 85 85 have dementiahave dementia
Ouslander J, Osterweil D, Morley J. Ouslander J, Osterweil D, Morley J.
Medical Care in the Nursing Home. McGraw-Hill.Medical Care in the Nursing Home. McGraw-Hill. 1997. 1997.
Ethical Issues Unique to Long Term CareEthical Issues Unique to Long Term Care
• Control and choice (autonomy)Control and choice (autonomy)– Loss of functional impairment and increasing dependencyLoss of functional impairment and increasing dependency– Loss of decision making capacityLoss of decision making capacity– Limited access to services and specialists Limited access to services and specialists
• Psychosocial Psychosocial – Social and spiritual isolationSocial and spiritual isolation– Limited availability of familyLimited availability of family– Depression (major 12%-25%, minor 18%-30%)Depression (major 12%-25%, minor 18%-30%)– Loss of privacyLoss of privacy
• End of lifeEnd of life– High rates of untreated pain and other symptomsHigh rates of untreated pain and other symptoms – Current quality standards and reimbursement incentivize restorative Current quality standards and reimbursement incentivize restorative
care and technologically intensive treatments rather than labor-care and technologically intensive treatments rather than labor-intensive palliative care. intensive palliative care. Only 13% of hospice pt. in LTCOnly 13% of hospice pt. in LTC
– FutilityFutility, WH/WD … re-hospitalize? , WH/WD … re-hospitalize? – Substituted judgment Substituted judgment … who decides?… who decides? Zerzan J , Stearns S, Hanson L. Access to Zerzan J , Stearns S, Hanson L. Access to
Palliative Care and Hospice in Nursing HomesPalliative Care and Hospice in Nursing Homes JAMA.JAMA. 2000;284:2489-2494 2000;284:2489-2494
Rovner BW, German PS, Brant LJ Rovner BW, German PS, Brant LJ et alet al. . Depression and mortality in nursing homes. Depression and mortality in nursing homes. JAMAJAMA 1991;265:993–996 1991;265:993–996
Health Care DirectivesHealth Care Directives“The Failure of the Living Will”“The Failure of the Living Will”
• 18% have them (18% have them (35% of dialysis patients35% of dialysis patients))• ““They don’t alter treatment” (They don’t alter treatment” (SUPPORTSUPPORT))• Failure of the PSDAFailure of the PSDA• Elderly tend not to execute one or defer to Elderly tend not to execute one or defer to
othersothers• Most overestimate effectiveness of CPRMost overestimate effectiveness of CPR• People don’t really know what they wantPeople don’t really know what they want• Will to live highly unstable when near deathWill to live highly unstable when near death• Surrogates often don’t reflect accuratelySurrogates often don’t reflect accurately
Success of CPR in the ElderlySuccess of CPR in the Elderly
• Unchanged in over 30 yearsUnchanged in over 30 years
• 15%15% of 2994 patients survived to D/C of 2994 patients survived to D/C – < 70 years = < 70 years = 16.2%16.2%– > 70 years = > 70 years = 12.4%12.4%
• Community hospitals had a higher CPR Community hospitals had a higher CPR success rate than teaching hospitals success rate than teaching hospitals
((18.5%18.5% versus versus 13.6%13.6%). ). Schneider A and Nelson D. In-hospital cardiopulmonarySchneider A and Nelson D. In-hospital cardiopulmonaryresuscitation: a 30-year reviewresuscitation: a 30-year review. J Am Board Fam PracJ Am Board Fam Prac. . 1993;6(2):91-1011993;6(2):91-101
Choice of CPR in the elderlyChoice of CPR in the elderly
How it’s presented:How it’s presented:– 12% if phrased negatively12% if phrased negatively– 18% if phrased in HCD already in use18% if phrased in HCD already in use– 30% if phrased positively30% if phrased positively– 75% changed their mind at least once 75% changed their mind at least once
when when presented differentlypresented differently
Fagerlin, 2004Fagerlin, 2004
Knowing PrognosisKnowing Prognosis• 287 patients 60 years of age or older; mean age 77 287 patients 60 years of age or older; mean age 77
years range, 60 to 99. years range, 60 to 99. • When asked about their wishes if they had cardiac When asked about their wishes if they had cardiac
arrest during an acute illness: arrest during an acute illness: – 41%41% opted for CPR before learning the probability of opted for CPR before learning the probability of
survival to dischargesurvival to discharge– After learning the probability of survival (10 to 17%) After learning the probability of survival (10 to 17%)
22%22% opted for CPR opted for CPR – 6%6% of patients 86 years of age or older opted for CPR of patients 86 years of age or older opted for CPR
knowing the prognosisknowing the prognosis• When asked about a chronic illness in which the When asked about a chronic illness in which the
life expectancy was less than a year:life expectancy was less than a year:– 11%11% opted for CPR before learning the probability of opted for CPR before learning the probability of
survival to discharge survival to discharge – After learning the probability of survival (0 to 5%) After learning the probability of survival (0 to 5%)
5%5% still said they would want CPR still said they would want CPR Murphy D et al. Murphy D et al. NEJM. 1994NEJM. 1994 ;330(8) 330:545-549 ;330(8) 330:545-549
Barriers to DNAR and other Tx limitationsBarriers to DNAR and other Tx limitations
• AttitudeAttitude– Unwillingness to accept death—hope by providers as Unwillingness to accept death—hope by providers as
well as patients/familieswell as patients/families– Paradoxical desire to avoid undue harm and sufferingParadoxical desire to avoid undue harm and suffering– Recognize and respect patient preferences Recognize and respect patient preferences
• Lack of Knowledge Lack of Knowledge [SUPPORT. [SUPPORT. JAMAJAMA 1995; 274(20):1592-8] 1995; 274(20):1592-8]
– Prognosis of both acute and chronic underlying illnessPrognosis of both acute and chronic underlying illness– Patient preferences: HCD, DPOA, verbal commentsPatient preferences: HCD, DPOA, verbal comments
• Poor CommunicationPoor Communication– Unclear and ineffective, with both patient and familyUnclear and ineffective, with both patient and family– Timeliness – discussions not early and or often enoughTimeliness – discussions not early and or often enough– Within the team and between teamsWithin the team and between teams– Unclear identification of patients with a DNAR orderUnclear identification of patients with a DNAR order
The Challenges of FutilityThe Challenges of Futility
• Frequent lack of clarityFrequent lack of clarity
• Moral discomfortMoral discomfort
• Fear of reprisalFear of reprisal
• The risk:The risk:
– Delay actions that might lead to death…Delay actions that might lead to death…
oror– Withdraw or withhold prematurely…Withdraw or withhold prematurely…
FutilityFutility
• Can it be defined?Can it be defined?
• Who defines it?Who defines it?
• Once determined is it irrefutable?Once determined is it irrefutable?
• Does this concept even pertain anymore?Does this concept even pertain anymore?
Medical FutilityMedical Futility
•Futilis-eFutilis-e ((Oxford Latin DictionaryOxford Latin Dictionary))
–of vessels: fragileof vessels: fragile
–of things: vain, pointlessof things: vain, pointless
–of persons: of persons: ineffectiveineffective(Desired or intended outcome highly unlikely)(Desired or intended outcome highly unlikely)
FutilityFutility• Oldest criterion in traditional medicineOldest criterion in traditional medicine
– Hippocrates: Hippocrates: Treatise on Medicine Treatise on Medicine ((caca 400 BC) 400 BC)
• Unrecognized in modern medicine before 1987Unrecognized in modern medicine before 1987• 134 articles in 1995134 articles in 1995• 31 articles in 199931 articles in 1999• The struggleThe struggle
– Defining it…Defining it…– Autonomy of patients v autonomy of doctorsAutonomy of patients v autonomy of doctors– Dispute resolutionDispute resolution
• No agreement about underlying principles by No agreement about underlying principles by medical communitymedical community
(Not a mathematical equation)(Not a mathematical equation)PhysicianPhysician determines “determines “EffectivenessEffectiveness”:”:
A measurable changes in natural history of disease or A measurable changes in natural history of disease or symptoms can be reasonably expected. symptoms can be reasonably expected. (…(…reasonable medical certainty of intended outcomereasonable medical certainty of intended outcome))
Patient and PhysicianPatient and Physician determine “ determine “BenefitBenefit” together” togetherPatientPatient determines “ determines “BurdenBurden”: cost of treatment”: cost of treatment
• Made by the providers (team) the patient, Made by the providers (team) the patient, the family, and othersthe family, and others
• Fluid calculus toward a defined goalFluid calculus toward a defined goal
• Accounts for new and changing variablesAccounts for new and changing variables
• Goal = “good” of the patientGoal = “good” of the patient
When does the obligation to When does the obligation to treat no longer exist?treat no longer exist?
Obligation to treatObligation to treat
EffectiveEffectiveIneffectiveIneffective
BurdenBurden BenefitBenefit
There are legitimate moral limits There are legitimate moral limits to what physicians “must do”… to what physicians “must do”… physician autonomy.physician autonomy.
““Futility” in the ElderlyFutility” in the Elderly• The ChallengeThe Challenge: Is : Is aggressiveaggressive diseasedisease treatment treatment
morally justified in old people near the end of life?morally justified in old people near the end of life?• Palliative vs. therapeuticPalliative vs. therapeutic
– Some treatments may be compatible with Some treatments may be compatible with “allowing for a more comfortable death”“allowing for a more comfortable death”
• FutilityFutility may pertain to an underlying disease but may pertain to an underlying disease but not the acute conditionnot the acute condition
• Treatment GoalsTreatment Goals: Consider treatment that is : Consider treatment that is reasonably “effective”, “beneficial”, and not reasonably “effective”, “beneficial”, and not unduly “burdensome” short of CPR or other life unduly “burdensome” short of CPR or other life sustaining interventions…as with anyone elsesustaining interventions…as with anyone else
Economics as a CriterionEconomics as a Criterion
• Morally Morally validvalid if by the patient if by the patient– The competent patientThe competent patient– The incompetent patientThe incompetent patient
• Morally Morally invalidinvalid if by anyone else not if by anyone else not primarily representing the patientprimarily representing the patient
• Incompetent patients without valid surrogateIncompetent patients without valid surrogate
• Social criterion:Social criterion:– Morally variable (fairness of rationing)Morally variable (fairness of rationing)– Policy decisionPolicy decision
Age as CriterionAge as Criterion• Chronology vs. PhysiologyChronology vs. Physiology
• Chronology vs. Effectiveness of TreatmentChronology vs. Effectiveness of Treatment
• Relevant as it pertains to impacting the Relevant as it pertains to impacting the prognosis of underlying and acute prognosis of underlying and acute conditions.conditions.
• Danger of Ageism (discrimination)Danger of Ageism (discrimination)– young/old value conflictsyoung/old value conflicts– economic and fiscal pressureseconomic and fiscal pressures
• What is a “normal” lifespan?What is a “normal” lifespan?
The Principle of Double EffectThe Principle of Double Effect
• Action itself must be “good”Action itself must be “good”
• The agent must intend a good effectThe agent must intend a good effect
• The “bad” effect is foreseen, not intendedThe “bad” effect is foreseen, not intended
• The good and bad effects must follow The good and bad effects must follow immediately from the same actionimmediately from the same action
• Proportionality between the two should Proportionality between the two should favor the “good” effectfavor the “good” effect
……in other wordsin other words
• One act, two effectsOne act, two effects
• One effect is One effect is goodgood, the other , the other badbad
• One intends to do goodOne intends to do good
• The unintended The unintended badbad effect is not the effect is not the cause of the intended cause of the intended goodgood
• All things considered, the All things considered, the goodgood that that results far outweighs the results far outweighs the bad bad that is that is likely to occurlikely to occur
CasesCases
82yo man in NH with dementia, mild CHF and 82yo man in NH with dementia, mild CHF and Cr=2.2 now with pneumonia; DPOA suggests he Cr=2.2 now with pneumonia; DPOA suggests he would not want “aggressive treatment” should he would not want “aggressive treatment” should he deteriorate.deteriorate.
• Best options?Best options?
• Offer DNAROffer DNAR
• Offer LOT—consider withholding elective Offer LOT—consider withholding elective intubation, dialysis, artificial hydration intubation, dialysis, artificial hydration and nutrition, and perhaps antibiotics.and nutrition, and perhaps antibiotics.
• Reasons: patient preferences per HCD Reasons: patient preferences per HCD and DPOA; futilityand DPOA; futility
75yo man in NH following a CVA has pneumonia 75yo man in NH following a CVA has pneumonia and is willing to accept a feeding tube and perhaps and is willing to accept a feeding tube and perhaps short term vent support if there is hope of recovery short term vent support if there is hope of recovery but does not want CPR. This is consistent with his but does not want CPR. This is consistent with his HCD; speech deficit but has capacity and is HCD; speech deficit but has capacity and is capable of communicating.capable of communicating.
• Best options?Best options?
• Offer DNAROffer DNAR
• No LOT order—if feeding tubes or vent No LOT order—if feeding tubes or vent support are required they can be withdrawnsupport are required they can be withdrawn
65yo female with PVS, recurrent aspiration 65yo female with PVS, recurrent aspiration pneumonia, renal failure, sepsis, and SBE is pneumonia, renal failure, sepsis, and SBE is deteriorating. The family insists that CPR be deteriorating. The family insists that CPR be attempted and refuses to allow LOT or DNAR.attempted and refuses to allow LOT or DNAR.
• Best options?Best options?• Continue communication efforts with the Continue communication efforts with the
family to garner trust .family to garner trust .• Take DNAR and LOT off the table to relieve Take DNAR and LOT off the table to relieve
the situation and assure nonabandonment.the situation and assure nonabandonment.• Do what is Do what is medically indicatedmedically indicated, including , including
CPR, but assure the family that CPR, but assure the family that resuscitation efforts will not go on ad resuscitation efforts will not go on ad infinitum in the face of medical futilityinfinitum in the face of medical futility
Reaching CompromiseReaching Compromise• Legal (tort) risk: the medical legal environment has Legal (tort) risk: the medical legal environment has
historically favored the patient, with one exception: historically favored the patient, with one exception: – Gilgunn vs. Mass General Hospital, 1995Gilgunn vs. Mass General Hospital, 1995
• Prognosis (futility) is the most important variable (0-15%)Prognosis (futility) is the most important variable (0-15%)• Compassionate communication is the most important Compassionate communication is the most important
interventionintervention• Recognize the importance of hope and trust, and the fear Recognize the importance of hope and trust, and the fear
of abandonment— ? therapeutic “benefit” to futile care…of abandonment— ? therapeutic “benefit” to futile care…• Limiting treatment never precludes good CARELimiting treatment never precludes good CARE• It is reasonable to attempt resuscitation, even in the face of It is reasonable to attempt resuscitation, even in the face of
a poor prognosis if so desired, but it is not obligatory to a poor prognosis if so desired, but it is not obligatory to continue beyond reason.continue beyond reason.
• Don’t let the DNAR debate become a barrier to effective Don’t let the DNAR debate become a barrier to effective and compassionate care of the patient and their familyand compassionate care of the patient and their family
A Practical ApproachA Practical ApproachPatient/Surrogate/Family Patient/Surrogate/Family Together with PhysicianTogether with Physician
• Define “futility” TogetherDefine “futility” Together– Exchange values and beliefsExchange values and beliefs– Set medical and non-medical goalsSet medical and non-medical goals
• Set Time Limits (re-evaluate)Set Time Limits (re-evaluate)• Prepare and Discuss Meaning of Advance Prepare and Discuss Meaning of Advance
Directives 9written and verbal)Directives 9written and verbal)• Early use of Ethics ConsultantsEarly use of Ethics Consultants• If no compromise the provider can withdraw or If no compromise the provider can withdraw or
the family can discharge provider or transfer carethe family can discharge provider or transfer care
Opportunities for ChangeOpportunities for Change• Training and education—team concept, enhanced Training and education—team concept, enhanced
communication, greater awarenesscommunication, greater awareness• Encourage dialogue about cases—utilize ethics Encourage dialogue about cases—utilize ethics
and palliative care consultation servicesand palliative care consultation services• Encourage hospital policy that promotes and Encourage hospital policy that promotes and
automates automates earlyearly palliative care and hospice palliative care and hospice referralreferral
• Advocate for health policy reformAdvocate for health policy reform– OH DNR—success!OH DNR—success!– Clarify and enhance eligibility criteria for hospiceClarify and enhance eligibility criteria for hospice– Improve reimbursementImprove reimbursement
• Promote cultural awareness and health literacyPromote cultural awareness and health literacy• Promote social awarenessPromote social awareness
SummarySummary• End of life care is challenging and often End of life care is challenging and often
conflicted at any age conflicted at any age • Hope and fear of abandonment may Hope and fear of abandonment may
influence decisions about futile treatment influence decisions about futile treatment • Futility is a useful but fluid and difficult Futility is a useful but fluid and difficult
concept to understand and applyconcept to understand and apply• Palliative and interventional treatment can Palliative and interventional treatment can
coexist – don’t waitcoexist – don’t wait• Good communication and the narrative of Good communication and the narrative of
relationships are crucial to good outcomesrelationships are crucial to good outcomes• Consult ethics team earlyConsult ethics team early
