This document discusses end-of-life care and the differences between palliative care and intensive care. It notes that while most clinicians feel end-of-life care should be part of their core duties, it is often outsourced to other teams. The document contrasts the roles of palliative care professionals and intensivists, and argues that patients would benefit more from palliative care rather than intensive care when they are dying from irreversible conditions. It advocates for improving palliative care exposure and involvement in intensive care to help change practices around end-of-life care.
2. “
First I will define what I conceive medicine
to be. In general terms, it is to do away with
the sufferings of the sick, to lessen the
violence of their diseases, and to refuse
to treat those who are overmastered by
their disease, realising that in such
cases medicine is powerless.
Hippocrates
400 BC
3.
4. “Most clinicians felt strongly
that end-of-life care should be
part of their core business,
but it appears that this is not
always usual practice.
Outsourcing end-of-life care
to the medical emergency team,
the palliative care team or the
intensive care team appears to
be common practice.”
5. 50% of Australians will die in hospital despite
most wanting to die at home
Risk factors associated with in-hospital death include advanced age,
history of severe organ failure, immunosuppression, abnormal vital
signs & severe electrolyte derangement
8. 6
I think it’s clinicians’ fear.
As my oncologist said,
‘We’re here to keep you
alive.’ When I asked him
some years ago, ‘Look
realistically, what’s my
time frame?’, he didn’t
like that question.
Death is everyone’s
business, it’s our
common lot. It’s not a
medical problem.
Dying isn’t a failure
of medicine: it just is.
PATIENT
DIRECTOR OF
PALLIATIVE CARE
9. sick person with a
reversible process who
would benefit most
from intensive care
dying person with an
irreversible process
who would benefit most
from palliative care
12. Old Medical Model Current Medical Practice
Single acute pathology Multiple chronic pathologies
Short term conditions
predominate
Long term conditions
predominate
Diagnose, treat, cure
Ameliorate, listen, explain,
advise, console
Survival dependent upon
skills of paramedical,
medical & nursing staff
Survival dependent upon
patient’s lifestyle choices
Smith, BMJ 2015
15. 6
SUPPORT
THEM, THEIR
FAMILY &
YOUR
COLLEAGUES
WHILE THEY
DIE
YES
Are you
sure?
NO
DO
MEDICAL
STUFF
YES
NO
YES
TELL THEM
then ask them
what they
would like
Go you!
High fives
all round &
go to Pub
NO
YES
NO
‘Everything’
‘Comfort’
Review patient Are they
dying?
MET or ICU
REFERRAL
Are you sure
they’re not just
actually dying?
Did you make
them better?
19. 4
the bad death
•Occurs on bedroom floor or
in an acute hospital bed
•Nurses or doctors present,
not family or friends
•Occurs during or
immediately after a
treatment or procedure that
doesn’t change outcome
•Patient may have been
unaware they were dying
•Monitors & alarms
•Lack of dignity
•Ignorance of cultural/
spiritual needs
•THE DEFAULT
20. “
To answer your question very directly, you asked
‘Do people die well in this hospital?’
They absolutely do not. People are allowed to
linger for far too long, in far too much pain, and
causing far too much distress to themselves and
their family and the people who care for them…
The current situation, to speak frankly, is
completely unacceptable.
Intensive Care Consultant,
Australian Public Hospital
21. 3
how can we change things?
•encourage palliative care exposure for ICU trainees
•talk to patients about not doing stuff & why
•ask your patients what they want
•ask your hospital to employ more palliative care clinicians
then invite them into your ICU
•always consider ‘is this patient actually dying?’
22. “Sometimes patients know they are
dying and just hope that
someone actually mentions it at
some point.
Chaplain,
Australian Public Hospital