Realistic Palliative Care in an Ageing Population · Realistic Palliative Care in an Ageing...
Transcript of Realistic Palliative Care in an Ageing Population · Realistic Palliative Care in an Ageing...
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Realistic Palliative Care in an Ageing Population
Multimorbidity, Frailty and Palliative Care
Martin Wilson
Consultant Physician
Raigmore Hospital
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The Long Walk Home
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To help us we are going to meet..
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Confidence and confidentiality
None of the example cases are real life stories
But
They are all True
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First the bits I want you to take away....
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Multimorbid or Frail Adults
• Often a long phase where they ‘could’ die
• Very dependant on intercurrent and unpredictable events
• Can feel like a long time to be ‘dying’ or palliative for
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Most Valuable assets in palliative care
1. Unpaid carers
2. Paid Carers
3. Nursing home beds
4. ....You’ll have to wait...
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Key Priorities
• Public (and clinician) education
– Dying can take longer and be less tidy than many
presume
– Very likely to need hands on personal care before you die.....maybe for years
– Expensive interventions sell themselves push is needed on the elements that support basic care
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A different spin on demographics
Age is NOT the main problem
(It is not even in the top 3!)
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Abba and dying
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– The majority of over-65s have 2 or more conditions
– The majority of over-75s have 3 or more conditions
Multimorbidity is common in Scotland
Epidemiology of multimorbidity. Karen Barnett, Stewart W Mercer, Michael Norbury, Graham Watt, Sally Wyke, Bruce Guthrie LANCET May 10, 2012 DOI:10.1016/S0140-6736(12)60240-2
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People living in more deprived areas in Scotland develop multimorbidity 10 years before those living in the most
affluent areas
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Deprivation and functional impairment Highland
Day to day activity limited a lot by long term health or disability
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So on average
• If you are rich
– Live longer in good health
– Have a shorter proportion of life in poor health
– More likely to have single pathology
– More likely to be the sort of person that sets up healthcare system.....
• Remember the Inverse Care Law
– Overspend tends to be in RICHEST post codes
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More ranting....
Society is really unrealistic at where they will die.....
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% change 1997-1999 to
2010-2012
NHS Hospital -16.5 %
Home/Private Address + 0.4 %
Care Home Services/Other Institution +31.5 %
Location of Death in Highland
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Place of death as a Feminist issue
• Woman a lot more likely to die in a care home than men.
– Women care for men >> who die at home
– No one to care for them
• Highland 2010- 12
– 13.1% of male deaths Care Home
– 26.1% of female deaths Care Home
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Patterns to recognise and teach
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Copyright ©2005 BMJ Publishing Group Ltd. Murray, S. A et al. BMJ 2005;330:1007-1011
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Functional history as important as Past
Medical History
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‘Bad’ UTI
Diagnosed
Diabetes
Mobility
dipped
TIA
AF COPD
MI
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Current Function
• Not driving anymore
• Lift to shops
• Cooks (a bit)
• Tires more easily
• Cognitively “fine”
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Our lady
• Probably now ‘Not in Good Health’
– Female so could be 5 to 7 years
• Long time but sounds like won’t do all that well if major illness
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Priorities here?
• Ensure the ‘simple things’ prompted – Power of Attorney
– Wills
• Future protecting – Suitable house?
– Suitable location ?
– How would you manage without the car?
• Consider ‘Time to benefit’ when considering treatments
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Priorities here?
• The Adults views
– Maybe not too much longer that they will be heard/audible
• At what point does it start to become an unwise move to avoid a peaceful death...
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Treatment outcomes
• Prospect of return to independence
• Prospect of death
• Prospect of existence in a reduced state
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Unrealistic Statements :- number 1
• ‘I never want to go into a care home’
• ‘I promised him / her I would never put them in a home’
• Never [hardly] made with any realistic expectation of what that would mean in practice.
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‘Bad’ UTI
Diagnosed
Diabetes
Mobility
dipped
TIA
AF COPD
Fall and
Lumbar
vertebral
fracture
Dementia
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Recurrent
UTIs
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Current Function
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Medication
• Metformin 1 g TDS
• Gliclazide 160mg bd
• Calcichew D3 forte 1 tab twice a day
• Alendronate 70mg once a week
• Perindopril 4mg once a day
• Indapamide 2.5mg once a day Warfarin as per INR
• Seretide 250 1 puff twice a day
• Salbutamol as required
• Clopidogrel 75mg once a day
• Atorvastatin 80mg once a day
• Mirtazapine 30mg nocte
• Zopicolone 7.5 mg at night
• Oxybutinin 5mg bd
• Thyroxine 150mcg once a day
• Atrovent inhaler 4 times a day.
• Paracetamol 1g QDS
• Omeprazole 20mg once a day
• Trimethoprim 200mg once a day prophylaxis
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– What are the patients priorities likely to be?
– What are there carers priorities likely to be?
– What are the Health Service Priorities likely to be?
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What happens next ?
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What makes the difference here?
• Home care (paid or unpaid (family) – Flexibly ~???
• Respite (of whatever type)
• Care Home move BEFORE collapse
• Lots and lot and lots of wise supportive words
• A family ‘on the same page’............
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Things that make (almost) no difference
• Most of her pills
• CT scans, blood tests
• Admissions to ‘exclude’ things
• Anyone who focuses on just one bit
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Most Valuable assets in palliative care
1. Unpaid carers
2. Paid Carers
3. Nursing home beds
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Most Valuable assets in palliative care
1. Unpaid carers
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So all agreed ?
• Talk is good
• Focus on the whole picture
• Individualise treatment
• Treat the unit as well as the individual
• ……
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This is a nightmare.
• Could die on any of the deteriorations
– But doesn’t
• “Learned immortality”
• “Docs said she would die 3 times so far
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Its a nitemare unpredictable situation
Lets call the family ‘unrealistic’
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Families
• ‘Unrealistic Relatives’ / ‘Distant Relative Syndrome
• Often just seeing a different reality...... – + emotion
– + really, really not wanting it to happen NOW
– + she bounce back the last 3 times this happened
– + sometime we (the health service) are a bit rubbish
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We really need to understand and be able to explain frailty
And all the uncertainty that goes with that
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Most Valuable assets in palliative care
1. Unpaid carers
2. Paid Carers
3. Nursing home beds
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Most Valuable assets in palliative care
1. Unpaid carers
2. Paid Carers
3. Nursing home beds
4. A human being who can explain what's going on
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What do we really want?
We want….
• Good care in our old age
What we REALLY want….
• Lots of hospitals
• Lots of [expensive] docs
• Expensive drugs
• Expensive treatments
• Short waiting lists
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Compare Hospice
• People near end of life
• Holistic Care paramount
• Free at point of access
Care Home
• People near the end of life
• Holistic Care Paramount
• Means Tested
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Palliative Care
• Has a high loveability index
• Has political influence
• Can raise a lot of cash
• Can mobilise a lot of people
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What I would like?
• Support ? Even subsidise with time / money /political influence – (Good) care homes
– (Good) care agencies
– (Good) respite
– Training in both (and pay for backfill)
• Use ‘the brand’ to increase the attractiveness of those workplaces
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A human being who understands and can explain ..
• What can palliative care do to encourage folk into...
– General Practice
– District Nursing
– ...
– .....
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Any Questions? (? Over lunch)