END OF LIFE CARE

DR PRADEEP KULKARNI
CONSULTANT PALLIATIVE MEDICINE,
DEENANATH MANGESHKAR HOSPITAL, PUNE
1 06/18/2022
 MEDICAL END OF LIFE

2 06/18/2022
 WHAT HAS CHANGED ?

 Young and children  Elderly – age function

 Communicable  Non communicable
 Natural / social event  Failure of medicine
 Death word acceptable  Euphemisms
 Acceptance by society  Fight at any cost
 Home, battlefield  Nursing homes/ICU
 Die quickly  Prolong the death
 No end of life  Decisions , counselling
decisions

3 06/18/2022
 ROLE OF DOCTOR

 A team leader- unique experience, normalize,

destigmatize, good care

 A learner

 An implementer

 An educator

4 06/18/2022
 WHAT WE SEE
Advances in medical sciences

Ethical issues

Goals of care

Medicalization of death

Money spent , suffering

5 06/18/2022
 TRAJECTORIES

6 06/18/2022
 WHAT IT IS ?

“Death is not extinguishing the light; it is

putting out the lamp because the dawn has
come.” - Rabindranath tagore

End-of-life care is multidisciplinary team approach

toward “whole person care” for people with
advanced, progressive, incurable or life
limiting illness so that they can live as well,
before they die.

The process of care is not just limited to the person

who is dying but extends to his/her families and
caregivers.
7 06/18/2022
8 06/18/2022
 STEPS INVOLVED IN EOLC

9 06/18/2022
 SIX STEP APPROACH

10 06/18/2022
 MIGHT
LIVING DYING
DIE

Ceilings of Comfort
All active treatment active treatment Measures only
11 06/18/2022
 HOW TO DIAGNOSE EOLC

 A ‘no’ answer to the question ‘would I be

surprised if the patient were to die in the next
12 months?’
 Two or more unplanned admissions in the last 6
months
 Poor or deteriorating performance status
 Persistent symptoms despite optimal therapy
 Secondary organ failure arising from an
underlying condition

12 06/18/2022
 THE FIVE GSF GOLD STANDARDS

 Right people – identification of patients nearing the end

of life

 Right care – assessing their needs: clinical & personal

 Right place – planning coordinated cross boundary care

 Right time – planning care in the final days

 Every time – embedding consistent good practice and

identifying areas to improve further

13 06/18/2022
 GSF ESSENTIAL Cs

 Communicate- Register-blue, green, yellow, red

 Coordinate
 Control of symptoms
 Continuity of care- out of hours
 Continued learning
 Carer support
 Care at dying phase

14 06/18/2022
 CORE PRINCIPLES FOR END-OF-
LIFE CARE

 Respect the dignity of patients, families, and

caregivers
 Display sensitivity and respect for patient and
family wishes
 Use appropriate interventions to accomplish
patient goals
 Alleviate pain and symptoms
 Assess, manage, and refer psychological, social,
and spiritual problems

15 06/18/2022
 CORE PRINCIPLES FOR END-OF-
LIFE CARE

 Offer continuity and collaboration with others

 Provide access to palliative care and hospice services
 Respect the rights of patients and families to refuse
treatments
 Promote and support evidence-based clinical practice
research

16 06/18/2022
 COST OF EOLC
 74TH IN AFFORDABILITY
– QUALITY OF DEATH
INDEX
 39 MILLION BECOME
POORER EVERY YEAR
 OUT OF POCKET 89%
 BELIEF OF DOCTORS-
INAPPROPRIATE CARE
 LACK OF AWARENESS
PC
 DENIAL OF EOLC,
TORTURE
 COST OF SUFFERINGS-
17
UNMEASURED 06/18/2022
THE LEGAL POSITION IN INDIA

Decision on Aruna Shanbaug case in 2011 had some lacunae

Five judge bench-on 9 march 2018 Common Cause VS State

 Living will is a valid document
 Legal procedure is tedious
 Hospital committee and the collector are deciding
 Time consuming
 At least a step forward
 ELICIT group- End of Life Care in India Task force
 Right
18 to live with dignity, includes right to die with dignity 06/18/2022
 INDIAN WAY

 What it means
 Who can do it- sound mind, voluntary
 What are essentials- clarity, revoking,
consequences known
 How to record- witnesses countersigned by JMFC,
copies to court registry, corporation, physician,
info to family
 When to be implemented- Hospital, Collector

19 06/18/2022
ETHICAL PRINCIPLES OF EOL DECISIONS

The four fundamental ethical principles are :

 Autonomy : Autonomy means respecting patient’s choices and
preferences. This translates in practice as the right of informed consent
or refusal. Goals of care to be discussed.
 Beneficence: Beneficence flows from the fiduciary obligation to act
always in patient’s best interests. While the disease can still be cured
or controlled, this obligation translates as the need to carefully weigh
the risks and benefits of any intervention.
 Non maleficence : Non maleficence comes from the doctrine of “first
of all do no harm.”
 Social justice : Social justice means allocating resources appropriate
to the medical condition of the patient in order to maximize their
benefits and minimize wastage. Futile application of therapies would
clearly violate this social obligation.

20 06/18/2022
 ALGORITHM OF EOLC

21 06/18/2022
 IS DEATH APPROACHING-
TERMINAL PHASE

 Sleeping for long

 Loss of appetite
 Loss of interest in surrounding
 Disorientation, confusion
 Cool skin, hand and feet
 Changing respiration

22 06/18/2022
 ETHICAL DILEMMAS

 IV FLUIDS
 CPR
 INOTROPES
 VENTILATOR
 FIGHT TILL END
 TERMINAL SEDATION
 ROUTES OF ADMINISTRATION
 PREFERRED PLACE OF CARE

23 06/18/2022
MEDICALLY FUTILE/ INAPPROPRIATE
The idea of futility is not new. The famous Hippocratic corpus
included a promise not to treat patients who were “overmastered by
their disease.”
Various definition and subtypes of futility

Physiological futility - Treatment that cannot achieve its
physiological aim

Quantitative futility - Treatment that has < 1% chance of being
successful

Qualitative futility - Treatment that cannot achieve an acceptable
quality-of-life, treatment that merely preserves unconsciousness or
fails to relieve total dependence on intensive care

Lethal condition futility - The patient has an underlying condition
that will not be affected by the intervention and which will lead to
death within weeks to months

Imminent demise futility - An intervention that will not change the
fact
24that the patient will die in future. 06/18/2022
WHAT IS A GOOD DEATH – PRINCIPLES
AND COMPONENTS

 Components of a Good Death

 Pain and symptom management, clear decision-making,

preparation for death, completion, contributing to others, and
affirmation of the whole person
 Principles of a Good Death

25 06/18/2022
 SYMPTOMS AT END OF LIFE

 Pain
 Breathlessness
 Nausea, vomiting, reduced appetite, fatigue
 Urinary retention, incontinence
 Constipation
 Delirium, agitation
 Convulsions

26 06/18/2022
 COMMUNICATION

 Difficult situations- collusion, denial

 Communicating with patient/family
 Communicating in the medical team, with
colleague and doctors
 Record keeping
 Family meeting- same platform

27 06/18/2022
 BARRIERS TO COMMUNICATION

 Patient and family- misunderstanding, strong

emotions

 Doctors- uncertainty, relation with patient, blame

 Circumstances- lack of privacy/ previous

relationship

28 06/18/2022
 QUALITY OF DEATH INDEX
 Basic end-of-life
health care
environment (20 %
weightage)

 Availability of end-of-
life health care (25 %
weightage)

 Cost of end-of-life
care (15 %
weightage)

 Quality of end-of-life
care (40 %
29
weightage) 06/18/2022
 HELP THE PATIENT TO PLAN
DEATH
 CONTROL OVER THE
LIFE EVENT

 REDUCE SUFFERING

 DIGNITY MAINTAINED

 PREFERRED PLACE OF
CARE

 CAREGIVERS NOT
STRESSED

30  GRIEF CAN BE REDUCED 06/18/2022

 CAN READ

31 06/18/2022
IT MATTERS

32 06/18/2022
 BHAGWAD GEETA ABOUT DEATH

जातस्य हि ध्रुवो मृत्युर्ध्रुवं जन्म मृतस्य च |

तस्मादपरिहार्येऽर्थे न त्वं शोचितुमर्हसि

33 06/18/2022
 THANK YOU

34 06/18/2022
35 06/18/2022
36 06/18/2022
 DEATH IN MODERN MEDICINE
Advances in medical sciences

Ethical issues

Goals of care

Preferred place of care

Medicalization of death

Money spent

37 06/18/2022
38 06/18/2022
06/18/2022 39
06/18/2022 40
06/18/2022 41
06/18/2022 42
06/18/2022 43
 MEDICAL END OF LIFE

06/18/2022 44
06/18/2022 45
06/18/2022 46
06/18/2022 47
06/18/2022 48
06/18/2022 49
06/18/2022 50