Sit down buffet breakfast featuring keynote speaker Dr. Romayne Gallagher, Head Division of Palliative Care, Department of Family & Community Medicine, Providence Health Care; Clinical Professor, Division of Palliative Care, UBC

1. LIVING AS WELL AS YOU CAN
FOR AS LONG AS YOU CAN:
WHY PALLIATIVE CARE MAKES SENSE FOR ALL FRAIL
OLDER ADULTS
ROMAYNE GALLAGHER MD, CCFP, FCFP
PROVIDENCE HEALTH CARE
CLINICAL PROFESSOR, UNIVERSITY OF BRITISH COLUMBIA

2. life
deathrebirth

3. FOR THERE TO BE LIFE THERE MUST BE DEATH
• BIOLOGICAL SYSTEMS
• FOR EVOLUTION TO OCCUR
• MAINTAINING THE GENE POOL
• NOT ALLOWING A SPECIES TO EXCEED THE CAPACITY OF THEIR HABITAT
• SOCIAL/CULTURAL SYSTEMS
• CHANGING OF ATTITUDES OVER TIME
• INNOVATION AND CHANGE
• CHANGE OF POLITICAL AND ORGANIZATION SYSTEMS OVER TIME

4. SOCIETAL CHANGE IN THE FACE OF DEATH
• BUBONIC PLAGUE FROM IN 1346-1353 – DEATH OF 50 MILLION EUROPEANS (60% OF THE
POPULATION)
• GREAT EQUALIZER – KILLED BOTH PEASANTS AND KINGS
• THE SURVIVING WORKERS WERE IN DEMAND – THE RISE OF THE INDIVIDUAL/WORKER HAD BEGUN
• ONE OF THE FACTORS LEADING TO THE RENAISSANCE
• ALSO A FACTOR IN THE REFORMATION – RELIGIOUS CHANGE
• SCAPEGOATS: LEPERS AND JEWS
• DANSE MACABRE – DEATH BECOMES PERSONALIZED IN ART

5. SOCIETAL CHANGE IN THE FACE OF DEATH

6. DEATH BRINGS PEOPLE TOGETHER – SOCIAL
SOLIDARITIES
• THE ARAB SPRING IN TUNISIA WAS STARTED
BY A VEGETABLE SELLER – MOHAMMED
BOUAZIZI WHO WAS SUPPORTING 8
PEOPLE ON $150/MONTH

7. DEATH BRINGS PEOPLE TOGETHER –
SOCIAL SOLIDARITIES
• 1911 TRIANGLE SHIRTWAIST FACTORY NEW YORK
• POORLY PAID WOMEN AND IMMIGRANTS ($15/WEEK WORKING 12 HOURS/7 DAYS A WEEK)
LOCKED IN FACTORY
• 145 DIED IN THE FIRE – 58 BY JUMPING FROM 8-10TH FLOOR
• RESULTING IN NEW FIRE LAWS AND WORKING WOMEN UNION

8. DEATH DISRUPTS SOCIETY

9. SOCIETY’S WAY OF AVOIDING DEATH’S DISRUPTION
• DEATH RITUALS – FUNERAL RITES
• MINIMIZE THE SOCIAL STATUS OF THOSE MOST LIKELY TO DIE -
CHILDREN
• DEVELOPING A SYSTEM FOR SUCCESSION OF IMPORTANT PEOPLE
• AVOIDING PREMATURE DEATH – MEDICAL ADVANCES
• A SYSTEM TO HIDE THE DYING – OUR MEDICAL SYSTEM & SOCIETY

10. DEATH RITUALS - ANCIENT
• EVIDENCE FOR DEATH RITUALS AS LONG AS 28, 000 YEARS AGO
• IN ANCIENT TIMES THERE WERE VARIOUS DEGREES OF DEATH RITUALS DEPENDING ON THE
SOCIAL STATUS OF THE PERSON

11. DEATH RITUALS - MEDIEVAL
• IN EUROPE, ARABIA, AFRICA RELIGIOUS FAITH BECOMES THE BASIS OF THE DEATH RITUALS

12. DEATH RITUALS - RENAISSANCE
• A GREATER SENSE OF THE INDIVIDUAL
• THE BIRTH OF DUALITY – THE BODY AND MIND

13. DEATH RITUALS – VICTORIAN
• A ROMANTICIZING OF DEATH – THE RISE OF SPIRITUALISM AND BELIEF IN GHOSTS AND THE
ABILITY TO COMMUNICATE WITH THE DEAD
• FUNERALS AND MOURNING HIGHLY RITUALIZED

14. DEATH RITUALS – 20TH CENTURY
• DEATH OCCURS IN HOSPITAL AND IS HIDDEN FROM EVERYDAY SOCIAL LIFE
• DEATH BECOMES A FAILURE OF MEDICINE RATHER THAN A NATURAL COMPLETION OF LIFE
• THE DYING PROCESS IS FEARED

15. PALLIATIVE CARE
• PALLIATIVE CARE ARISES AS A PROTEST MOVEMENT AGAINST PROLONGED DIFFICULT DYING IN
HOSPITAL.
• PALLIATIVE CARE SEES DYING AS A NATURAL PROCESS OF LIFE
• PALLIATIVE CARE STARTS WITH ADULT CANCER PATIENTS, BUT GROWS TO BE HELPFUL TO ALL
AGES AND ALL DIAGNOSES

16. PHYSICIAN ASSISTED DEATH
• A PROTEST AGAINST PROLONGED DIFFICULT DYING IN HOSPITAL.
• THE ULTIMATE DENIAL OF DYING?

17. “DON’T MENTION THE WORD”
Document Death Dying
BCCPA Roadmap 6 (two references) 1
MOH Action Plan 0 0
CPA Access to Care for Seniors 1 0

18. OLD AND NEW MODELS OF CARE
• MODEL A IS UNWORKABLE AS DEATH IS
INCREASINGLY UNPREDICTABLE DUE TO:
• IMPROVED ABILITY TO RESCUE FROM
CATASTROPHIC DISEASE
• MULTIPLE MORBIDITIES
• IMPROVED ABILITY TO SUPPORT FRAILTY
• PALLIATIVE CARE IS ASSOCIATED WITH
IMPROVED SURVIVAL AND THE EARLIER IT
STARTS THE BETTER.
• MODEL B IS THE IDEAL FOR ALL PATIENTS
WITH CHRONIC ILLNESS

19. PALLIATIVE CARE ACROSS AN ORGANIZATION
• PALLIATIVE CARE CONSULTATION WITHIN THE FIRST 48
HOURS OF ADMISSION:
• REDUCED LOS BY 5.08 DAYS
• REDUCED COSTS BY 40%
• READMISSION AT 30, 60, 90 DAYS DOWN BY 61%, 47%, 42%
• REDUCED LOS IN ICU BY 1.12 DAYS
• BHARADWAJ ET AL. J PALL MED 2016

20. INCORPORATING PALLIATIVE CARE INTO ONCOLOGY
 1409 PATIENTS WITH LUNG CANCER – 1095 ON PATHWAY THAT
INCORPORATES EARLY GOALS OF CARE DISCUSSION INTO THE PATHWAY
 COSTS 35% LESS OVER 12 MONTHS
 NO DIFFERENCE IN SURVIVAL
 NEUBAUER ET AL. J CLINICAL ONCOLOGY 2010

21. NEW ENGLAND JOURNAL MEDICINE 2010
• 151 PATIENTS NEWLY DIAGNOSED WITH METASTATIC LUNG CANCER,
RANDOMIZED TO EARLY PALLIATIVE CARE V.S. USUAL CARE
• OUTCOMES: LENGTH OF LIFE, QUALITY OF LIFE, MOOD
• TWO GROUPS HAD SAME AMOUNT OF INITIAL CANCER TREATMENT
• EARLY PALLIATIVE CARE GROUP:
• QUALITY OF LIFE BETTER P=0.03
• FEWER DEPRESSIVE SYMPTOMS P=0.01
• TEMEL ET AL NEJM 2010

22. 22
Length of life 2.7 months longer
p=0.02
IMPROVED SURVIVAL

23. WHAT DID PALLIATIVE CARE TEAMS DO DIFFERENTLY?
• QUALITATIVE STUDY OF ONCOLOGIST VISIT VS PALLIATIVE
CARE VISIT
• ONCOLOGIST: SYMPTOMS AND ILLNESS STATUS, CANCER
TREATMENT AND COMPLICATIONS
• PALLIATIVE CARE: ADDRESSING SYMPTOMS, COPING,
UNDERSTANDING OF ILLNESS AND PROGNOSIS AWARENESS

24. HOW CAN WE APPLY THIS KNOWLEDGE
TO FRAIL OLDER ADULTS

25. ACCURACY OF PROGNOSTICATION
• ACCURACY IS LESS THAN 35%
• MORE THAN 90% OVERESTIMATED LIFESPAN
• LESS THAN 50% OF THE TIME, THE PREDICTED LIFE EXPECTANCY IS LESS THAN 1/2 THE ACTUAL LIFE
SPAN
• HOW DO WE DISCUSS THIS WITH PATIENTS/FAMILY?
• “YOU ARE SICK ENOUGH TO DIE BUT WE ARE NOT SURE WHEN THAT WILL BE”

26. Frail Older
Adults
APPLICATION TO FRAIL OLDER ADULTS
Presentation Death
Therapies to modify disease and/or
improve function
Bereavement
Care
Therapies to relieve suffering and/or
improve quality of life
Palliative Approach

27. Gill et al. NEJM 2010

28. Gill et al. NEJM 2010
Conclusion:
The course of disability in
the last year of life did
not follow a predictable
pattern based on the
condition leading to
death.

29. PALLIATIVE APPROACH
• “TO HELP YOU LIVE AS WELL AS YOU CAN FOR AS LONG AS YOU CAN”
• SYMPTOM-BASED APPROACH TO CARE
• OUTCOMES BASED ON RESOLUTION/CONTROL OF SYMPTOMS RATHER
THAN DISEASE INDICES
• “TIME TO BENEFIT” FOR NON-SYMPTOM CONTROL MEDICATIONS
• AWARENESS OF PROGNOSIS
• UNDERSTANDING PATIENT AND FAMILY “LIFE GOALS”
• CARE FOR BODY/MIND/SPIRIT

30. A PALLIATIVE APPROACH TO CARE
• 3.36 HOURS OF CARE PER DAY – WHAT KIND OF CARE?
• CARE TO IMPROVE SYMPTOMS AND QUALITY OF LIFE – NOT CHECKING DISEASE INDICES
• A PALLIATIVE APPROACH IS APPLIED TO EVERYONE – NOT JUST THOSE IN A “SPECIALIZED
STREAM” OR IN AN EOL BED.

31. GUIDELINES FOR CHRONIC DISEASE
• SAME GUIDELINE FOR:
• 54 YEAR OLD WITH DIABETES MELLITUS TYPE II
• 88 YEAR OLD WITH DIABETES MELLITUS TYPE II,
ATRIAL FIBRILLATION, CHF, CRF, OSTEOPOROSIS,
OSTEOARTHRITIS, DEAFNESS, DEMENTIA

32. DIABETES MELLITUS
• LESS STRINGENT CONTROL REASONABLE IN THOSE WITH A LONG
HISTORY OF DIABETES, LIMITED LIFE EXPECTANCY, OR COMORBID
CONDITIONS
Sjoblom P. Diabetes Res Clin Prac 2008; 82:197-202.
 Drug withdrawal study in
17 nursing homes in
patients with HbA1c <6:
safe to discontinue all oral
meds, and stop or reduce
insulin

33. PALLIATIVE CARE SERVICES
IN BRITISH COLUMBIA 2012
• 2012 DATA: 31,000 DEATHS
• APPROX. 11% SUDDEN DEATH: ACCIDENT/CATASTROPHIC ILLNESS
• 20% ACCESSED TERTIARY/SPECIALIST PALLIATIVE CARE PROGRAMS
• 31% WERE IDENTIFIED AS PALLIATIVE CARE PATIENTS AND RECEIVED CARE FROM PRIMARY
PROVIDERS
• 38% COULD HAVE BENEFITED BUT DID NOT RECEIVE PALLIATIVE CARE
• 2% OF POPULATION DIES EACH YEAR = 38% OF HEALTH CARE SPENDING

34. IMPROVING CARE
FOR FRAIL OLDER ADULTS
• A PALLIATIVE APPROACH
• PROGNOSIS AWARENESS – “SICK ENOUGH TO DIE”
• LINKING EVERYDAY EVENTS TO DISEASE PROGRESSION – BUILDING HEALTH LITERACY
• CARE CONFERENCES LOOK AHEAD TO DECISIONS THAT MAY NEED TO BE MADE AND NOT AT
THE PRESENT
• RECOGNIZING AND RESPECTING THE IMPORTANCE OF CULTURE AND DIFFERING VALUES
• GOALS OF CARE DISCUSSIONS

35. THE NATURAL HISTORY OF THE DISEASE
• CLINICIANS NEED TO COMMUNICATE THE CONNECTION BETWEEN DAILY
EVENTS (LACK OF APPETITE, POOR SWALLOWING, UTI, DYSPNEA ETC…) WITH
THE NATURAL COURSE OF THE DISEASE (INCREASED INFECTION RISK WITH
ADVANCED DEMENTIA, LACK OF APPETITE IS NATURAL IN ALL ADVANCED
ILLNESS)
• CLINICIANS MUST COMMUNICATE THE NATURAL PROCESS OF DYING TO
FAMILIES

36. 27
THE BRAIN

37. HEALTH LITERACY
PREDICTS EOL CARE PREFERENCES, NOT RACE
• 80 AFRICAN AMERICANS AND 64 WHITES VISITING THEIR
FAMILY PHYSICIAN
• HEALTH LITERACY MEASURED
• VERBAL DESCRIPTION OF ADVANCED DEMENTIA FOLLOWED BY
QUESTIONS ON PREFERENCE FOR CARE
• TWO MINUTE VIDEO OF ADVANCED DEMENTIA FOLLOWED BY
QUESTIONS ON PREFERENCE FOR CARE
Volandes et al. J Palliative Medicine 2008

38. HEALTH LITERACY PREDICTS EOL CARE
PREFERENCES, NOT RACE
• AFTER VERBAL DESCRIPTION, LOW HEALTH LITERACY PREDICTED
THOSE WHO CHOOSE MORE AGGRESSIVE INTERVENTIONS
O.R. 5.1-7.1
• AFTER WATCHING VIDEO THERE WERE NO SIGNIFICANT DIFFERENCES
IN PREFERENCE FOR CARE BY RACE OR HEALTH LITERACY
Volandes et al. J Palliative Medicine 2008

39. EXPLORING CULTURAL BELIEFS:
KLEINMAN’S QUESTIONS + 2 MORE
1. WHAT DO YOU CALL YOUR PROBLEM?
2. WHAT HAS CAUSED IT?
3. WHY DO YOU THINK IT STARTED WHEN IT DID?
4. WHAT DOES IT DO TO YOU?
5. HOW SEVERE IS IT?
6. WHAT DO YOU FEAR MOST ABOUT IT?
7. WHAT ARE THE CHIEF PROBLEMS IT HAS CAUSED YOU?
8. WHAT KIND OF TREATMENT DO YOU THINK YOU SHOULD
RECEIVE?
9. WHAT DO YOU HOPE FOR IN THE FUTURE?
10. WHAT WOULD BE A GOOD OUTCOME FOR YOU?

40. GOALS OF CARE DISCUSSIONS
• KEY FACTORS
• PROGNOSIS AWARENESS
• ONGOING CONVERSATION
• PROMOTE DIGNITY: “WHAT DO I NEED TO KNOW ABOUT YOU TO HELP ME
TAKE THE BEST CARE POSSIBLE OF YOU?”
• ARE WE RESPECTING YOUR PREFERENCES?

41. IMPROVING OUR CARE FOR FRAIL OLDER ADULTS
• WHAT DO PEOPLE REMEMBER ABOUT THEIR EXPERIENCE?
• THE PEAK OF THE EXPERIENCE (GOOD OR BAD) AND THE END
• SMALL THINGS: MAKING A CONNECTION PERSON TO PERSON
• SMALL THINGS: ACTS OF KINDNESS