End of Life Conversation | Good Practice Example

Summary

This sensitive conversation between Dr. James Cassano and a family member discusses end-of-life care for a woman with advanced dementia. After several hospital admissions, her condition has worsened, and the medical team suggests focusing on palliative care in her familiar care home rather than hospitalizations that distress her. The family is given time to discuss the options, with a plan for comfort and dignity in the final stages of her life. Advanced care planning documents, including the RESPECT form, are explained to ensure the patient's wishes are honored. The family is reassured that no decisions will be rushed.

Takeaways

• 😀 Dorian Davies is a frail elderly patient with advanced dementia who was recently hospitalized for pneumonia and has multiple previous admissions.
• 😀 The medical team is concerned about Dorian’s frailty and the likelihood of future medical issues, such as infections, due to her advanced dementia.
• 😀 The hospital team is proposing a shift in care focus to palliative care, prioritizing comfort and dignity over aggressive treatment, especially in light of her advanced condition.
• 😀 Dorian’s care team suggests she remain in her care home, where she is familiar with the staff and environment, rather than returning to the hospital.
• 😀 The family is advised to consider advanced care planning, including a 'Respect' form, to outline Dorian's treatment preferences if she becomes unwell again.
• 😀 The 'Respect' form provides guidance for medical decisions but does not preclude hospitalization if a medical emergency, like a fall or severe symptom, occurs.
• 😀 The daughter is the primary decision-maker, but she is encouraged to consult with other family members to ensure everyone agrees on the care plan.
• 😀 The conversation emphasizes that decisions should be made with full agreement among the family, ensuring that Dorian’s best interests are respected.
• 😀 Dr. Cassano emphasizes the importance of taking time to think through the care options and consult with family before making any final decisions.
• 😀 The aim is to make the transition back to the care home as smooth as possible by having a clear care plan in place, minimizing the need for further hospitalizations.

Q & A

What is the main medical concern for the patient discussed in the transcript?

The patient, a woman with advanced dementia, is frail and has recently recovered from pneumonia. The primary concern is her ongoing frailty, frequent hospital admissions, and the progression of her dementia, suggesting she is likely in her final months of life.

Why has the patient been admitted to the hospital multiple times?

The patient has had several hospital admissions due to respiratory infections, including pneumonia. Each time, she has been treated and recovered, but her frailty continues to worsen with each admission.

What are the main options discussed for the patient's future care?

The two main options are: 1) continuing with hospital treatment for any future medical issues, such as infections, and 2) focusing on palliative care in the care home, prioritizing comfort and dignity rather than aggressive treatments.

Why is the doctor concerned about the patient’s frequent hospitalizations?

The doctor is concerned that repeated hospitalizations are making the patient more frail and distressed, as she does not want to be in the hospital and the treatments may be diminishing her quality of life. The doctor suggests that the cycle could continue, and it may not be in the patient's best interest.

What is the doctor’s recommendation regarding the patient's future care?

The doctor recommends a palliative approach, focusing on managing symptoms and providing comfort in the care home, where the patient is familiar with the staff and environment, instead of bringing her back into the hospital.

How does the family feel about the options for care?

The family, especially the daughter, agrees with the doctor’s recommendation to prioritize comfort and dignity in the care home, as the patient is more at ease there. The family does not want to continue bringing her to the hospital if it causes her distress.

What is an advanced care plan, and how is it relevant in this situation?

An advanced care plan, specifically the 'Respect form' in this case, is a document that outlines the patient's wishes for medical treatment in the event of further illness or deterioration. It helps guide decisions, such as whether the patient should be hospitalized or remain in the care home, focusing on comfort rather than aggressive treatment.

What happens if the patient’s condition worsens and she requires hospital care?

If the patient’s condition worsens to the point that she cannot be managed in the care home, such as in cases of severe pain or complications like fractures, the hospital can still be an option. The 'Respect form' does not prevent hospital care in these emergencies, but it helps avoid unnecessary hospitalizations for conditions that can be managed in the care home.

What role does the family play in the decision-making process?

The family, particularly the daughter as the next of kin, plays a crucial role in the decision-making process. Since the patient is unable to express her wishes, the family’s input is vital to ensure that the care plan reflects what would be in the patient’s best interest.

What is the next step after the family has had time to consider their options?

The family is encouraged to think about the options, consult with other relatives, and then inform the medical team of their decision. The doctors will ensure that the patient’s care plan is updated accordingly and that everyone involved in her care is on the same page.