Exam 3 Death/Caring

Trajectory 3 "Frailty":

- There is a gradual decline that takes place over a long period of time. Both cognitive and physical capacities slowly "dwindle" with each successive day. Each decline in functioning may not seem series at the time, but they add up to a trajectory that is ultimately fatal. - While it is possible for an individual to be able to make their wishes known early in the trajectory, often people wait until it is "too late" because the gradual decline does not produce a sense of urgency that would be seen with the other trajectories. - This is the trajectory most associated with forms of dementia.

Expensive technology

(both diagnostic and pharmacological) is frequently used regardless of its relatively benefit.

Cult of youth

- Anti-aging industry - Recent study: fears of aging highest in world's wealthiest countries

Medical advances

- Longer lifespan - Cures for acute illnesses - Chronic illness & old age

Distance from death

- Sanitized: out of home (1900) into hospital (2000) - Facilitates "denial of death" (E. Becker, 1974) - Psychological refusal to acknowledge mortality - Medical language (e.g., patient "expired")

True

True / False: Death is in many ways harder to define in the modern era than was the case in the past

families

____________ tend to be more aggressive than patient in terms of what forms of treatment would be desirable.

85% of respondents

"A high proportion of deaths in intensive care occur after withdrawal or withholding of life support. In a survey of critical care physicians, ____________ had withheld or withdrawn life support in the preceding year.

ADEC defines end of life decision making as

"The aspects of life-threatening illness/terminal illness that involve choices and decisions to be taken, for individuals, families, and professional caregivers."

Trajectory 1 "Terminal Illness Trajectory:

- There is a long period of vary gradual decline following by a short period of rapid decline. The terminal phase of this trajectory is generally plainly obvious. - This is the trajectory that is more commonly associated with terminal illnesses such as cancer. - There is typically plenty of time for end of life consideration, and palliative care if desired. The individual is lucid through much of this an able to make his or her desires known.

Anticipated Dying

- This category included 9 of the totally 23 deaths (almost 40%). - All of the people in this category openly recognized that they were approaching the end of their lives "some time before death." - Three had cancer, three had some form of dementia, and all nine died within the care facility. - Six reported a significant amount of pain, three of those over a prolonged period of time.

Trajectory 2 "Organ Failure":

- This is best described as the "cascade effect" death trajectory. There is a long period of marginal decline in functioning interspersed with acute episodes of serious difficulty. Sometimes there is recovery between these episodes, but generally they get worse with each successive episode. - End-of-life planning can be difficult with this trajectory as periods of recovery after acute episodes, family members may be left with the impression that full recovery is possible. - These episodes are often unexpected and may leave the patient progressively incapacitated - This is frequently the trajectory associated with heart or respiratory failure.

Uncertain Dying

- This was the death trajectory for seven of the deceased residents in the study. - This was noted as being the "most complex" of four trajectories. - Those who were on the uncertain dying trajectory were clearly not well, but at the same time not obviously nearing death. - Because there was a good deal of uncertainty in terms of a diagnosis and prognosis, these residents were admitted to the hospital

Unexpected Dying

- Three of the residents who had previously been thought to be in a stable condition until an acute illness arose unexpectedly. - None of the three residents were initially thought to have a life threatening illness. - This means that they were not admitted to the hospital, though it is not to say that admission to a hospital would have a provided an outcome that was any more favorable.

Unpredicted Dying

- Unpredictable dying characterized four of the deaths in the study. - Residents whose death fell into this category suffered a sudden acute and lethal event that made immediate hospitalization necessary. - These included stroke, heart attack, or severe hip fracture. - All of these residents were admitted quickly to the hospital via an ambulance. They died shortly after their arrival at the hospital.

Technological control

-Power to alter circumstances of life - External (environment) - Internal (our self)

2009

5% of medicare patients died, they accounted for 30% of the costs paid out by medicare; $143 billion, that is compared in $45.5 billion in education.

"place of death."

A key indicator of success is

Physician Assisted Death

A physician helps a patient hasten his or her death by providing lethal drugs, offering advice on methods of suicide, or assisting with other interventions

Living Will

Allows an individual to refuse life-sustaining treatment in the event he or she is terminally ill and life saving efforts would be futile

Advanced Directive

Any statement made by a competent person about choices for medical treatment should he or she become unable to make such decisions at some point the future

85%

Approximately ____ of those who seek out assisted suicide are already in some form of hospice care.

American Individualism

Autonomy, self-reliance

brain death

Defined as the stoppage of higher-level cognitive function. The person is unresponsive permanently, but the sympathetic nervous system still functions through the lower-brain stem.

Non-maleficence

Essentially come down to medical professional have an obligation to "do no harm."

Doctors and families make the vast majority of end of life decisions

How are end-of-life decisions made?

one in five

In the UK, about _______________ deaths occurs is a care facilities (20.7%) - about half related to dementia

final year of life

In the vast majority of people, the ______________ is the most expensive in terms of health care costs, most of which is picked up by the federal government through Medicare.

Beneficence

Is the principal of always doing good or conferring benefit that enhance personal or social well-being for the patient. This in few words is the pursuit of enhancing lives of patients. - is the source of much of the debate around the ethics of end-of-life care decision making.

Qualitative

MDs Readily Provide _____________ Terminal News; Withhold Quantitative Data

Withholding treatment

Medical professionals abandoning preventative treatment, typically at the request of the patient or the patient's next of kin.

5%

Of dying patients in intensive care, less than _____ of patients are able to communicate.

23

Of the 121 participants, ____ died during the study. (Low N hurts validity)

Five out of the fifty states have some form of legalized assisted suicide

Oregon was the first (1994; Ballot measure: 51%). Washington (2008; Ballot measure: 58% ), Montana (2009; State Supreme Court 5-4), and Vermont (2013; state legislation) have since followed with similar laws. California

Futile Care

Preventative care that will not significantly extend the life of the patient for whom it is given.

Clinical death

Principally defined as the stoppage of the heart. Clinical death in few (very few) cases is reversible. The heart can be restarted in certain conditions.

limited

Since the US only has universal healthcare for those age 65 and older (Medicare), its government has __________ bargaining power compared to other countries

Do Not Resuscitate Order

Specifies contexts of natural death outside of the clinical environment (like in the case of EMTs)

- Understand the disease - Maximized health and lifestyle - Optimize coping strengths

Tasks associated with acute phase include:

- Managing symptoms and side effects - Carry out health regimens - Manage stress and examine coping behaviors. - Normalize life to extent possible.

Tasks associated with chronic phase include:

- Managing discomfort, pain, incapacitation, and other symptoms - Cope with health procedures and institutional stress - Manage stress and examine coping behaviors - Sustain self-concept and appropriate relationships with others.

Tasks associated with terminal phase include:

final month

The ______________ of one's life is especially expensive, frequently account for almost half of the overall expense of a person's final year

$25,000

The approximate average cost of a hospitalization ending in death: _________. 70% of the time this is picked up by the federal government

increasing death at the place of residence or home

The big emphasis is _________________________________. People who are dying generally prefer to die at home, and dying in the home environment is typically much cheaper (for the federal government) than dying in a clinical care environment.

Euthanasia

The direct act of one person ending an other person's life at the patients request or to avoid suffering

"life and death"

The ethics of end-of-life decision making has become a large part of the discussion in clinical medicine since the death trajectory has grown so much longer and the bright line between ________________ has become more ambiguous

retrospectively

The main unique value of this study it's design. While there have been a handle of studies that examine the death trajectory, the vast majority of these studies look at the death trajectory ________________ rather than prospectively.

Biological death

The point when the cells of the basic human organs begin to permanently die, generally because of a lack of oxygen. Biological death is not reversible.

Cellular death

The point when the cells of the basic human organs begin to permanently die, generally because of a lack of oxygen. Biological death is not reversible.

buying power

The____________ of a universal healthcare system generally gives governments the ability to negotiate on prices.

The patient must have adequate understanding

There are very few formal laws or standards dictating what defines a level of understanding as "adequate."

Unexpected dying

There were deaths that occurred "following an acute illness or sudden event."

Unpredictable dying

These were death that "occurred in hospital after an unexpected acute event in the care home that had precipitated hospital admission."

Uncertain Dying

These were deaths that occurred "after a period of diagnostic uncertainty or difficult symptom management that had led to hospital admission."

Anticipated dying

These were deaths that occurred after a "period of planned end-of-life care."

Justice

This entails doctors being impartial and treating all patients fairly in terms of giving the same standard of care for.

The patient must be competent

This is frequently difficult to establish in end-of-life decision making cognitive decline is frequently associated with physical decline in the final years, months, and days of life.

artificially maintain cardio-pulmonary functions

This is largely the result of our ability to _______________________________ (maintaining the circulation of oxygenated blood).

life expectations

This is when people adjust ______________ and deal with narrative disruption. Individuals must "integrate present reality into sense of past and future."

Consent must be given freely

This means that the patient can not be coerced into a decision. Generally doctors will really emphasize that any possible choice is a valid one. The doctor in the "Cost of Dying" 60 Minutes video did this pretty clearly.

Autonomy of the patient

This refers to a patients ability to be self governing, to exercise their own personal decisions, freedom, and moral independence.

prospective study

This study is a ______________________ that recruited 121 residents at residential care homes in England.

d. More than 70% - more than 90%

What percentage of US intensive care deaths are preceded by withholding or withdrawing life-sustaining treatment?

90%

When surveyed about the prospect of end-of-life care _____ of people would prefer family members to act as decision makers in that circumstance.

both cultural standards and new technology.

Where morality generally is based on long-held cultural norms and taboos, ethics is something that is constantly evolving with _________________________________.

guiding values

While ethics is an many way defined by its ambiguity, there are several principals that serve as universal _________________ that are common in the Western clinical setting.

nursing homes

have nursing staff available.

chronic phase

also the period of time in which people try to find meaning in the suffering and uncertainty they are experiencing. They may develop a "everything happens for a reason" mantra.

conflict

common during end-of-life decision making, especially if they patient is complete incapacitated and has not openly made their wished known either through an advanced directive or verbally.

Advancements in technology

do extend lives, but frequently extend the "death trajectory" or terminal phase, which is by far the most expensive part of one's life.

Physician assisted suicide

has become an increasingly socially acceptable, and legal option for those dealing with terminal illness

technological imperative

has been a major contributor to the cost of health care, suggests that if there is technology available that can even marginally extend life, it should be used. This has two major implications

End of life decision making

has only recently been treated as a distinct concept in both clinical medicine and the social sciences.

Care Homes

have become increasingly popular in most modern countries. They are seen as offering: - A home-like environment - Continuity of care - Relationship-centered care until death

"Living in Uncertain Times"

is based out of the United Kingdom, through most of this is fairly generalizable to the US and other Western Nations.

informed consent

is considered to be a fundamental right to patients and consists of their ability to be fully informed about the proposed plenty of treatment so that they can decided whether to go forward with it.

The Association for Death Education and Counseling

is one of the few non-profit specifically oriented around "Death education" and making death a more socially acceptable thing to discuss for patients and their families.

lingering trajectory

is the more common trajectory for those with chronic illness. The ______________ can take three different forms.

expected quick trajectory

is the result of sudden, acute, and massive failure of one of the body's core life sustaining functions.

the terminal phase

it becomes necessary to find meaning in life and death. In knowing that one's life is nearing the end, one can look back on their life history and know that's the entirety of the story. Many strive to extract meaning from there life story at this point.

Prospective

means their source of data was the outcomes of the participants after their initial entry into the study.

residential care homes

offer living assistance by typically not on-site nursing care

dying trajectory

patterns of functional decline over the months prior to death.

Morality

refers to more abiding by "objective" standards of what is has long been established as right or wrong.

Ethics

refers to the more nuanced process of figuring out what is right and wrong in novel situations in which moral standards are ambiguous.

"acute"

the period immediately after diagnosis with life threatening illness. This is not interested to mean the illness its self is acute, but rather the trauma and shock are acute.

chronic phase

the period in which dealing with the illness has become routine. Individuals develop coping strategies that they utilize on a day-to-day basis. They are familiar with the disease at this point and are carrying out their plan of action.

The Terminal Phase

the period of time in which it becomes apparent that the individual's life will end as a result of the disease. Questions of futility come into play. "Fighting" becomes less of a priority in favor or retaining a degree of comfort and dignity in the face of death.