CPR

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CPR
Intensive Care Unit
THE MANAGEMENT OF
ELDERLY FRAIL PATIENTS AT
THE END-OF-LIFE
Ken Hillman
AHHA Deebles Workshop: End of Live Care –
The Next Steps.
Melbourne. 22 May 2017.
The inappropriate management of he
elderly frail in acute hospitals at the
end of their lives is arguably one of
the greater challenges in health
• Often not want the elderly want
• Frustrating for all health professionals
• Major contributor to the unsustainable costs
of health care
Apoptosis –
programmed death of
cells / tissues defined
at conception
AGEING
• Is normal and inevitable
• Ageing leads to death
Good living and luck can help
you to survive to your apoptotic
potential
UP TO ONE-THIRD OF ALL
HOSPITAL INTERVENTIONS ARE
INEFFECTIVE / INAPPROPRIATE /
FUTILE IN THE LAST SIX
MONTHS OF LIFE
Int J Qual Health Care 2016;28(4):456-469
Community
Community
Ambulance
Community
Ambulance
Emergency
Department
Community
Ambulance
Emergency
Department
Hospital
Ward
Community
Ambulance
Emergency
Department
Hospital
Ward
ICU
MOST PATIENTS >85
YEARS OF AGE
ADMITTED TO ICUs
• Have died by 12 months
• Many suffer post-traumatic stress
disorder along the way
HEALTH DEPARTMENTS FIXATED
ON HOSPITAL KPIs IN THE ELDERLY
•
•
•
•
•
Reduce falls
Pressure areas
Mortality rates
Length of stay
Hospital readmission rates
MISSING THE BIGGER PICTURE
CONSIDER HOSPITAL
ADMISSIONS FOR
INFECTIONS and FALLS IN
>80 YEAR OLDS
• As a marker of ageing and nearing
end-of-life
• Not a condition to be necessarily
cured
HEALTH SYSTEM
• Built around concept of a single
diagnosis to be treated
• Matched by medical specialists
• Different population in 2017
NHS AIMS TO CUT ALL
HOSPITAL ACTIVETY BY
ONE THIRD IN THE NEXT
FOUR YEARS
Shifting the Balance of Care. Nuffield Trust
2017
Most successful initiatives
are targeting specific
populations:
Those in aged care centres
Patients at the end of life
Shifting the Balance of Care. Nuffield Trust
2017
A NEW APPROACH
Recognise elderly frail people
near the end-of-life
Construct an appropriate
response
RECOGNITION OF PEOPLE
NEAR THE END-OF-LIFE
• CriSTAL tool
• Validated in Australia and Europe
BMJ Support Palliat Care 2015;5:78-90
RESPONSE
• On admission to the emergency
department
• At the time of a rapid response call
• On admission to the ICU
• At the pre-operative clinic
RESPONSE
• Honest and empathetic
discussion with patient/carers
• Empowering patients to
establish their own Goals of
Care
RESPONSE
Initially with specifically trained
responders
Gradually embed into routine
clinical practice
RESPONSE
UNCERTAINTY – inherent
clinical practice
FLAG – not a precise number
ULTIMATE RESPONSE
Connect with community alternatives
such as:
• General practitioner
• Support in the home
• Aged care and other institutions
EVALUATION
Needs to be embedded in
implementation process:
• Were the Goals of Care achieved?
• Did the community resources match
patient/carer choices?
• Use this data to inform system
THE MEDICALISATION OF
THE DYING PROCESS IN
THE AGED
USING THE HOSPITAL ADMISSION
AS A UNIQUE OPPORTUNITY TO
PROVIDE APPROPRIATE AND
PATIENT-CENTRED CARE FOR THE
ELDERLY FRAIL

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