living your best to the end
End of life decisions and next Tuesday’s food.

End of life decisions and next Tuesday’s food.

Dr Rebecca Sudore: changing focus from planning end of life to preparing for end of life decisions An Associate Professor In-Residence in the Division of Geriatrics at University of San Francisco, the impossibly young Dr Sudore is dedicated to helping vulnerable older adults and their families make informed medical decisions, especially for advance care planning and at the end-of-life Dr Sudore, at a University of Toronto Bioethics Speakers series, used this question to illustrate the impossibility of meaningful planning for life’s end: ‘Do you know what you’re going to eat next Tuesday? The answer: ‘it depends’. And so it is in planning for what’s essentially the unknowable in the end of life journey. Dr Sudore’s research and objective instead is: prepare for decision-making. Seemingly simple questions, says she, open the floodgates. Is there anyone you’d trust to make medical decisions? Do they know? What have you talked about with them? 50%-76% will be unable to make our own end of life medical decisions The importance of conversations with the surrogate can’t be emphasized enough. Even so,having spoken to dozens of surrogates as part of her research, the findings are distressing and revealing: Many surrogates don’t want the role. Sudore thinks it of paramount importance to ask the question of patients: Are you ok with your surrogate making ‘in the minute’ decisions? Giving your surrogate permission to override or change your wishes – putting flexibility or leeway right into your Advance Directives – can make the difference between a surrogate adjusting to loss or suffering from Post Traumatic Stress Disorder. Dr Sudore gives, as an example, this discussion with her...

Cardiopulmonary resuscitation (CPR) in elderly: low survival

Study of In-Hospital Cardiopulmonary Resuscitation (CPR) in the Elderly : Cardiopulmonary resuscitation (CPR) evolved from a specific intervention applied in limited clinical situations to the default response to cardiac arrest in or out of the hospital, an evolution accompanied by a dramatic decline in survival rates after CPR.1-3 The largest study to date, which included 14,720 CPR events from the National Registry of CardioPulmonary Resuscitation, showed that 17% of patients survived to discharge.9 Associations between age and survival after CPR remain unclear, with conflicting results from previous studies.6,10,11 Black race may be associated with lower survival after in-hospital or out-of-hospital CPR and may be associated with delayed defibrillation.12-14 Subsequently, innovations allowing rapid out-of-hospital CPR resulted in improved outcomes in the out-of-hospital setting.4,5 However, it is unclear whether advances in CPR or in care after cardiac arrest have improved outcomes after in-hospital arrest. Full article New England Journal of...

Dementia: Feeding tubes may add to risk of bed sores

 PEG or Percutaneous endoscopic gastric feeding tubes, long assumed to help bed-bound dementia patients stave off or overcome pressure ulcers, may instead make the wounds more likely to develop or not improve, according to a study. “We see a substantial risk of people developing a stage II and higher pressure ulcer. We believe these risks should be discussed with family members before a decision is made to insert a feeding tube in a hospitalized nursing home resident with advanced cognitive impairment.”  Joan Teno, MD, MS, the study’s lead author and a gerontologist and professor of health services, policy and practice in the Public Health Program at Brown University in Providence, R.I., said in a news release, “This study provides new information about the risks of feeding tube insertion in people with advanced cognitive impairment.” In this study, the researchers found that among patients who did not start with an ulcer (bed sore) , 35.6% of those with a feeding tube ended up with at least a stage II ulcer, compared with 19.8% of patients without a feeding tube. The researchers found that the chance of getting an ulcer was 2.27 times higher for people with feeding tubes than for those without. The risk of developing a more serious stage IV ulcer was 3.21 times higher for those with feeding tubes. Among patients who already had an ulcer, the researchers found that 27.1% of patients with a feeding tube experienced short-term improvement, while 34.6% of those without a feeding tube experienced healing in a comparable time frame. In a previous survey, three-quarters of physicians thought the nutrition delivered by feeding...

Quality of Life Better with Less Care at the End

The study focused on patients dying of cancer, but results apply across all chronic illnesses: a multicenter study suggests patients have a better quality of life towards the end if aggressive, life-prolonging measures are avoided and if they are able to die at home. Physician engagement improves dying experience “Physicians who are able to remain engaged and ‘present‘ for their dying patients – by inviting and answering questions and by treating patients in a way that makes them feel that they matter as fellow human beings – have the capacity to improve a dying patient’s ,“ according to authors Although some earlier research has focused on general aspects of end-of-life care, such as pain management and physician responsiveness, the specific factors that matter most to patients with terminal cancer and their families have not been fully explored, the researchers said. “The concept of quality of the in cancer patients has been underexamined in cancer medicine in the quest to develop newer, more advanced, and effective modalities of interventional cytotoxic therapies,” wrote Alan B. Zonderman, PhD, and Michele K. Evans, MD, of the National Institute on Aging in Baltimore, in an invited commentary. In analyses, factors that predicted worse quality of life included major depression, panic disorder, and a high degree of worry, while “a sense of inner peacefulness” at baseline was associated with better quality of life at the end. In the analysis considering the variance in quality of life, the researchers determined that, aside from intensive care stay and in-hospital death, factors that explained quality of life variance in a negative fashion were patient worry, feeding tube placement...

Astronaut, Chris Hadfield: Does Outer Space hold the key to Aging Research?

Long Term Care and Retirement Communities Conference: Together We Care Canadian Astronaut, Commander Chris Hadfield, showed his chops as a stand-up comedian at the Together We Care: Long Term Care and Retirement Communities Conference. “There is no bad situation that you can’t make worse.” In his keynote, Commander Hadfield offered an out-of-this-world opportunity to study a disease of aging: space travel causes bones loss; coming back to earth, bone regenerates. In the spirit of Hadfield’s use of twitter to share beyond his capsule, tweeters at the conference shared with their communities: Hadfield’s message gave this perspective on his measure of success: Winston Churchill on ‘media relations’: “Be honest. Be brief. Be seated.” Hadfield is a media darling who needs no training to answer newshounds. Health, on the other hand, seems always under fire. In a panel led by author and news veteran, Steve Paikin, and featuring health reporter Andre Picard, former Ontario Hospital Association CEO Tom Closson, Psychologist, Dr Maggie Gibson, and Robert Waite, bandied about answering to the media in a healthcare crisis, with Picard advising: “There’s no shame in saying ‘I don’t know’ “. On a more serious note, Dr Sherry Dupuis, whose life focus is humanizing those with Dementia points out, “all behavior is communication”, and wants us to consider ‘intent’ before assuming a person with dementia is out-of-control: “We have to look at the intent behind the behavior. Even with severe Dementia, people can communicate with intent, which is often mis-interpreted as ‘disruptive bvehaviours’. As an example: every day, the man with Dementia would come into the lunchroom and knock the hat of the head...