End of Life Care Presentation
End of Life Care Presentation
End of Life Care Presentation
DR PRADEEP KULKARNI
CONSULTANT PALLIATIVE MEDICINE,
DEENANATH MANGESHKAR HOSPITAL, PUNE
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MEDICAL END OF LIFE
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WHAT HAS CHANGED ?
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ROLE OF DOCTOR
A learner
An implementer
An educator
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WHAT WE SEE
Advances in medical sciences
Ethical issues
Goals of care
Medicalization of death
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TRAJECTORIES
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WHAT IT IS ?
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SIX STEP APPROACH
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MIGHT
LIVING DYING
DIE
Ceilings of Comfort
All active treatment active treatment Measures only
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HOW TO DIAGNOSE EOLC
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THE FIVE GSF GOLD STANDARDS
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GSF ESSENTIAL Cs
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CORE PRINCIPLES FOR END-OF-
LIFE CARE
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CORE PRINCIPLES FOR END-OF-
LIFE CARE
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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-
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UNMEASURED 06/18/2022
THE LEGAL POSITION IN INDIA
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
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ETHICAL PRINCIPLES OF EOL DECISIONS
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ALGORITHM OF EOLC
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IS DEATH APPROACHING-
TERMINAL PHASE
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ETHICAL DILEMMAS
IV FLUIDS
CPR
INOTROPES
VENTILATOR
FIGHT TILL END
TERMINAL SEDATION
ROUTES OF ADMINISTRATION
PREFERRED PLACE OF CARE
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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
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SYMPTOMS AT END OF LIFE
Pain
Breathlessness
Nausea, vomiting, reduced appetite, fatigue
Urinary retention, incontinence
Constipation
Delirium, agitation
Convulsions
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COMMUNICATION
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BARRIERS TO COMMUNICATION
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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
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IT MATTERS
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BHAGWAD GEETA ABOUT DEATH
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THANK YOU
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DEATH IN MODERN MEDICINE
Advances in medical sciences
Ethical issues
Goals of care
Medicalization of death
Money spent
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MEDICAL END OF LIFE
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