Ashley Shreves - How to Diagnose Dying
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Transcript of Ashley Shreves - How to Diagnose Dying
How to Diagnose Dying
SMACCJune 26, 2015
Ashley Shreves, MDAssistant Professor
Department of Emergency MedicineBrookdale Department of Geriatrics and Palliative Medicine
Icahn School of Medicine at Mt. Sinai
Atul Gawande “Letting Go”
Identifying “the dying”
• It’s hard
• Somewhat subjective
• Not always possible
• Obvious in retrospect
Why does it matter?
• Patient goals/priorities change
• Treatment
– Less effective
– burdens >> benefits
• Resource utilization
Case
• 80 y/o m
• Cardiac arrest
• EMS: picked up from dialysis
• ED: ACLS 10 min – get ROSC
• Yay!
Patterns of Dying
Lunney JAMA 2003
Terminal Illness
• Cancer
• Lengthy disease, sharp decline
• Measure of function?– Time in bed
• Associated symptoms– Anorexia, weakness, pain, dyspnea
Is she dying?
• 60 y/o f– Metastatic breast CA– Worsening dyspnea
• Need more info– Function?– Dyspnea history – reversible?
Organ Failure
• COPD, CHF
• Common
• Intermittent crises
• Surprising recoveries
• Clues– Repeated admits– Higher levels of care
Is he dying?
• 70 y/o m, COPD, 2 L home O2– 5 admits/past year for COPD exacerbations– Moderate respiratory distress– On BIPAP…may need intubation
• Need more info– Function?– Still independent? QOL?
• Past experience/GOALS matter bc prognostication tough
Frailty
• Dementia
• Slow decline, profound disability
• Complications define EOL
• Clues – Infections– Eating problems
Is she dying?
• 90 y/o f– Dementia, bedbound, minimal verbal– UTI x 2 in past 3 months– Fever, PNA
• Yes – Recurrent infections + AD = months– Can extend but NOT improve life
Sudden Death
• Not chronically ill
• 10-15% US population
• EM thinks all deaths
Is he dying?
• 40 y/o m, healthy, collapsed on tennis court– Found V fib, CPR/shocked x 3– Massive STEMI
• Maybe– “Dying” when all resuscitative efforts stop
• Time to death seconds-minutes
My case
• Cachectic elderly male• NH– Dementia, ESRD, CHF– Not eating or walking lately
• Which trajectory?
• Palliative extubation/died in ED
In summary…
• Seek trajectories (context)– Ask about function– Look at old chart
• Allows qualitative prognostication
• More appropriate medical plan