The document discusses integrating palliative care in the emergency department. It begins with an outline of topics to be discussed, including how early identification of end-of-life state can reduce low-value emergency care, how to integrate discussions of goals of care and advance care planning with families of resuscitation patients, and how to optimize treatment planning to reduce inappropriate CPR attempts. It then summarizes a study which found that among patients who underwent emergency resuscitation, palliative care was associated with fewer life-sustaining treatments and less medical expenses and utilization compared to standard care. The document discusses recognizing when a patient is actively dying, common reasons palliative care patients present to the emergency department, and palliative care skills relevant
SHARE Presentation: Palliative Care for Womenbkling
Dr. Michael Pearl discusses supportive palliative care for women with cancer, how it differs from hospice care, and the New York Palliative Care Information Act. Dr. Michael Pearl is Professor and Director of the Division of Gynecologic Oncology in the Department of Obstetrics, Gynecology and Reproductive Medicine at Stony Brook University Hospital.
The document discusses palliative care, what it is, and its benefits. It provides evidence that palliative care can improve quality of life for patients with serious illnesses, help patients live longer, and reduce healthcare costs. The document proposes developing a palliative care program at HealthAlliance Hospital through a team approach and various models of consultative and inpatient palliative care services.
Palliative care white paper for RegenceErin Codazzi
This document discusses the growing need for palliative care in the United States. It notes that 90 million Americans have a serious long-term illness, and the number is expected to more than double in the next 25 years. Additionally, four in ten Americans care for loved ones with serious illnesses. The document calls for a more holistic approach to palliative care that centers on patient needs, expands access to care for patients and families, engages stakeholders, and encourages industry solutions. It provides examples of organizations working to implement more comprehensive palliative care programs.
PALLIATIVE CARE BY NIRBHAYKUMAR TRADA 531A.pptxssusercbc9e61
Palliative care aims to improve quality of life for patients with serious illnesses through early identification and treatment of pain and other distressing symptoms. It takes a holistic approach addressing physical, psychosocial and spiritual suffering of patients and their families. Palliative care can be provided alongside curative treatment and continues during bereavement. It is delivered by an interdisciplinary team for patients of any age and illness type.
I didn't know this option of Palliative care existed prior to my mother's passing earlier this year of colorectal cancer. However, I do now know about it and want to share it with all of you
Hospice care and palliative care: Is there a difference between the two, and if so, what?
Many people still think that palliative care means hospice care. But today, hospice is only a small part of palliative care.
The goal of palliative care is to prevent or treat the symptoms and side effects of a disease; and it should be part of the picture from the first day a serious illness is diagnosed.
Dr. Jim Meadows, Director of Hospice and Palliative Care at Tennessee Oncology, will discuss this important topic. How does a family and a health care team best work together to guide a patient through a terminal illness? How does everyone continue to support quality, patient-centered, end-of-life care?
The document discusses end of life care and palliative care, specifically for cancer patients. It describes what palliative care is, including managing physical, emotional, practical and spiritual needs of patients. It discusses causes of pain in cancer patients, including from tumor growth, treatments, and procedures. It also covers assessing and managing pain through both pharmacological and non-pharmacological methods. The goal of palliative care is to prevent or treat symptoms to improve quality of life, rather than cure the disease.
End of life care involves providing palliative care to improve patient quality of life during their final stages. Palliative care aims to prevent and treat physical, emotional, and spiritual suffering for both patients and their families. It focuses on managing symptoms like pain while also addressing psychosocial needs. Palliative care begins at diagnosis and continues through treatment and end of life to improve comfort.
End of life care involves providing palliative care to improve patient quality of life during their final stages. Palliative care aims to prevent and treat physical, emotional, and spiritual suffering for both patients and their families. It focuses on managing symptoms like pain while also addressing psychosocial needs. Some key aspects of palliative care include respecting patient preferences, attending to medical and non-medical needs, and acknowledging caregiver concerns. Palliative care is applicable throughout the cancer experience from diagnosis through end of life.
The document discusses complex patient journeys and tools to impact them. It begins by defining key dimensions and inflection points of patient journeys. Dimensions include the healthcare, disease/therapy, and human journeys. Inflection points are moments where outcomes are predicted. Behavioral science and cognitive-behavioral therapy can be used to intervene at these points by addressing cognitive, emotional, and behavioral barriers. A case study examines using these tools to help appropriate diabetes patients initiate insulin injections by addressing a patient's needle anxiety through cognitive reframing and desensitization exercises.
Presentation on palliative care given at the Caregiver's Conference for the Cystic Fibrosis Affiliate and Satellite Sites at Riley Children's Hospital.
Palliative care aims to improve quality of life for patients facing serious illness through comprehensive pain and symptom management and coordination of care across settings. While some view it as a form of rationing, studies show palliative care can help patients live longer while feeling better. It works to resolve conflicts among clinicians and between clinicians and patients/families around goals of care. Implementing a palliative care program at Cape Cod Hospital could help address frequent ER visits and readmissions at end of life through improved symptom control and advance care planning.
This document discusses palliative care and advance care planning. It defines palliative care as specialized care focused on relieving symptoms and stress for patients with serious illnesses. Advance care planning involves discussing goals, values and treatment preferences with medical providers and family. Early research shows palliative care can improve quality of life and symptoms for patients with serious illness. The document encourages having conversations about values and goals, completing advance directives, and revisiting discussions over time.
Palliative care aims to improve quality of life for patients with serious illnesses through pain and symptom management as well as addressing physical, psychological, social, and spiritual needs. It focuses on preventing and relieving suffering for the patient and their family from diagnosis through the end of life and into bereavement. Palliative care is provided through interdisciplinary teams in various settings including hospitals, outpatient clinics, nursing homes, and in the community.
This case study illustrates the differences between disease-centered and patient-centered clinical methods. In the disease-centered interaction, the doctor focuses solely on assessing the patient's operation and any related medical issues, without exploring the patient's perspective or concerns. In contrast, the patient-centered method seeks to understand the full psychosocial context of the patient's illness experience.
Palliative Care Across the Continuum as presented to the The Palliative Care Summit for PeopleFirst Homecare and Hospice that was held in Snowbird Utah on September 15, 2012, following the Rocky Mountain Geriatric Conference.
The document discusses recovery from mental illness, specifically schizophrenia. It provides statistics on the prevalence and outcomes of schizophrenia. Despite advances in treatment, outcomes have not significantly improved, with only 13.5% meeting recovery criteria. The recovery program described aims to facilitate personal growth and transformation beyond acute symptoms through a collaborative, strengths-based approach focused on self-directed goal setting. It emphasizes hope, well-being, social inclusion and meaning rather than just treating illness. One patient's story of improving life through the program is shared.
The roles and responsibilities of a geriatric nurse include providing specialized care to older adults that addresses their complex physical and mental health needs. Geriatric nurses work in various settings like hospitals, nursing homes, and patients' homes. Their responsibilities involve assessing patients' health status, understanding health issues, educating patients and families, and linking patients to community resources to help older adults stay independent for as long as possible. Geriatric nurses play an important advocacy role in the care of older patients.
1. This document provides an introduction to paediatric palliative care (PPC), outlining when it should be considered, common myths, and differences from adult palliative care.
2. PPC is for children with life-threatening conditions and aims to improve quality of life, providing holistic support from diagnosis until end of life. It can be provided alongside curative treatments.
3. Case studies demonstrate the role of the multidisciplinary PPC team in supporting physical, emotional, and care needs of children with life-limiting illnesses and their families.
Cancer Patients Awareness of Extent of Disease-Association with Psychological...Dr. Liza Manalo, MSc.
What is already known on this topic
►► In Southeast Asian cultures, the fear that should patients know their poor prognosis, they might become depressed, worry excessively, or lose the will to live has traditionally led families to request physicians for non-disclosure of diagnosis and prognosis.
►► The Asian Patient Perspectives Regarding Oncology Awareness, Care and Health (APPROACH) studies in other Asian countries revealed that patients who were aware or unsure of their prognosis reported higher levels of anxiety and depressive symptoms.
What this study adds
►► One of the most important findings in this study was the absence of an association between advanced cancer patients’ awareness of the extent of the disease and psychological morbidity.
►►Contrary to what might be expected, awareness of advanced cancer was associated with higher social well-being.
How this study might affect research, practice, or policy
►► The results of this research could impact how doctors in this cultural context communicate with cancer patients and allay concerns among families that sharing a cancer diagnosis and prognosis with the patient could lead to distress or worry. Future studies could focus on examining the effect of cultural beliefs and values, such as faith and spirituality, and social support networks on the well-being of cancer patients.
Palliative sedation aims to relieve refractory suffering through proportional use of sedatives like midazolam for patients with life-limiting illness. It is used for uncontrolled symptoms like pain, dyspnea, delirium or in end-of-life weaning from life support. A multidisciplinary team discusses indications case-by-case, involving patients and families in decisions whenever possible. Sedation is adjusted based on comfort until death, with support for families throughout the process.
This document discusses several myths and facts related to palliative care and opioids. It begins by addressing a common myth that having palliative care means a patient will die soon, and explains that palliative care is a holistic approach that can be provided alongside curative treatment. It then goes on to address additional myths around who can benefit from palliative care, how pain is managed, and where services are provided. The document aims to dispel misconceptions and ensure all patients have access to equitable and comprehensive end-of-life care.
The document discusses finding purpose and meaning in life through understanding one's purpose as set by God. It argues that without God, life has no significance or hope. It emphasizes that God created each person with a specific role to play and gifts to offer the world. Living according to God's plan and discovering one's vocation can lead to a purposeful and fulfilling life. The document encourages reflecting on how to share in God's dreams and fulfill the mission He intends for each individual.
Discusses human life & human dignity, beginning of life issues like abortion and In Vitro Fertilization, as well as end of life issues like euthanasia, physician assisted suicide and
allowing natural death
Care of persons in the critical and terminal phases of life. With quotes from Samaritanus bonus, letter of the Congregation of the Doctrine of the Faith
Climate change protection of the environment-biosphere-biodiversity-laudato siDr. Liza Manalo, MSc.
The document summarizes key principles for environmental protection and sustainable development. It discusses the scientific consensus on climate change, the interconnectedness of environmental and social issues, and outlines 16 principles addressing ecological integrity, social and economic justice, and democracy and peace. The principles call for actions like protecting biodiversity, adopting sustainable consumption, ensuring environmental and social justice for all, strengthening education around sustainability, and promoting a culture of nonviolence.
The anthropological, philosophical and Christian teaching on human sexuality, marriage and the family. The Injustices of the Surrogacy Industry based on Catholic teaching on surrogacy is receiving reinforcement from current research.
This document discusses self-care in end-of-life care. It defines self-care as maintaining one's usual practices to deal with problems independently. Exploring self-care empowers patients to learn about their condition and identify support needs. Benefits of self-care for cancer patients include improved health, reduced symptoms, and feeling in control. However, psychological distress and caregiver strain can prevent self-care. Key self-care strategies discussed are maintaining normality, preparing for death, managing physical symptoms, accepting the illness, and relying on social support from family and other patients. The document emphasizes empowering patients through self-care.
End of life issues in advanced heart failure manalo palliative careDr. Liza Manalo, MSc.
Why aren’t countries accountable to commitment on end of life (#EOL) care for vulnerable people?
For lack of know-how. This presentation aims to teach cardiologists how to provide good palliative care to their patietnts.
Pope John Paul II and Pope Francis discuss the importance of mercy and compassion. Mercy means treating the wounds of suffering with care, listening attentively to people in need, and accompanying them on their journey. True mercy takes a compassionate approach by understanding others, sharing in their feelings, and being committed to relieving suffering without judgment. The Church seeks to put mercy into practice through pastoral care that suffers with people.
The passage discusses the importance of protecting personal data and privacy as technology advances. It notes that while technology provides benefits, it also creates new risks to how data is collected and used that were not issues in the past. Overall it argues that laws and regulations need to modernize to ensure privacy protections keep up with changing technology to prevent misuse of people's information.
Palliative care aims to provide comfort and improve quality of life for those facing serious illnesses, rather than cure the illness itself. Contrary to common myths, choosing palliative care does not mean giving up but rather focusing on relief from symptoms, pain, and stress of illness. Palliative care services can be provided at home, in the hospital, or elsewhere, allowing patients to stay involved in medical decisions with their own doctors. The goal is enhancing life daily until its natural end.
The document discusses end-of-life decisions around withholding or withdrawing life-sustaining treatments. It notes that competent patients have the right to make decisions about their own medical treatment, including the right to refuse treatments. When medical intervention becomes futile and will only prolong the dying process, physicians should shift the goal of care to comfort. Withholding or withdrawing life-sustaining therapies in these situations can be ethically and medically appropriate. Open communication is important to understand patients' values and goals of care and make decisions that respect patient autonomy.
This document discusses the virtues that are important for professionalism, particularly in the doctor-patient relationship. It defines profession as a public commitment to excellence and service. Key virtues discussed include prudence, justice, courage, temperance, fidelity to trust, benevolence, intellectual honesty, compassion, and truthfulness. The opposite vices of these virtues, such as untrustworthiness and indifference, are destructive to professionalism. The document traces the concept of medical professionalism back to the first century AD.
The document discusses the Christian meaning of work according to St. Josemaria Escriva and others. It emphasizes that work should be done with industriousness, professional competence by fulfilling one's duties. God wills work as a way to glorify Him, provide for needs, help others, and build bridges for the gospel. Work can become a means of sanctification when done in reliance on God's power according to His excellence.
Considerations when deciding about withholding or withdrawing life-sustaining...Dr. Liza Manalo, MSc.
Towards the end of life, physicians face dilemmas of discontinuing life-sustaining treatments or interventions. In some circumstances, these treatments are no longer of benefit, while in others the patient or family no longer want them. The physician plays an essential role in clarifying the goals of medical treatment, defining the care plan, initiating discussions about life-sustaining therapy, educating patients and families, helping them deliberate, making recommendations, and implementing the treatment plan. Communication is key. It should be clarified that when inevitable death is imminent, it is legitimate to refuse or limit forms of treatment that would only secure a precarious and burdensome prolongation of life, for as long as basic humane, compassionate care is not interrupted. Agreement to DNR status does not preclude supportive measures that keep patients free from pain and suffering as possible. Acceptable clinical practice on withdrawing or withholding treatment is based on an understanding of the medical, ethical, cultural, and religious issues. There is a need to individualize care option discussions to illness status, and patient and family preferences, beliefs, values, and cultures. The process of shared decision making between the patient, the family, and the clinicians should continue as goals evolve and change over time.
The document discusses the dignity and purpose of human sexuality, marriage, and family from a Catholic perspective. It covers how:
1) God created humans in His image to share in His blessed life, calling them to communion.
2) The Trinity reveals God as a divine family of love, and earthly families should reflect this.
3) Marriage allows companionship between spouses, procreation of children, and fulfillment of the sexual bond in a sacred manner.
4) The marital act should fully express the spouses' self-giving love for one another as a reflection of God's love for His people. Contraception contradicts this by withholding full self-gift.
The document provides an overview of Christian eschatology, or the doctrine of "last things," including initiated eschatology. It discusses earthly life, death, and purification beyond this world from a Christian theological perspective. The key points covered include how baptism initiates one's incorporation into Christ, how earthly life involves ongoing configuration with Christ, the mystery surrounding death but also how it completes one's baptism, and the belief that those not fully purified may undergo further purification after death before entering heaven.
The document provides an overview of Christian eschatology, or the "last things", according to notes from a book on the topic. It discusses key concepts like the Parousia (the second coming of Christ), the resurrection, judgment, and eternal life. The first section focuses on the Parousia, explaining that in the New Testament it refers to Christ's glorious return at the end of history. It also examines how the idea of God drawing near to humanity reaches its culmination in the Parousia, as well as biblical references to its imminence and signs that will precede it.
कायाकल्प क्लिनिक: पटना के अग्रणी सेक्सोलॉजिस्ट और स्किन केयर विशेषज्ञ
पटना का एक शानदार स्वास्थ्य सेवा प्रदाता, कायाकल्प क्लिनिक, आपके स्वास्थ्य और त्वचा की देखभाल में विशेषज्ञता प्रदान करता है। हमारे नवीनतम तकनीकी समाधानों और अनुभवी विशेषज्ञों के साथ, हम पुरुष और महिलाओं के स्वास्थ्य सम्बंधित मुद्दों को हल करते हैं। यहां पर हम प्रदान करते हैं:
Expert Treatment for Sex Issues at Kaya Kalp Clinic in Patna -best sexologist in patna
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Discover the Best Sexologist in Patna: Expert Care at Kayakalp Clinic
Kayakalp Clinic - Best Sexologist in Patna
Kayakalp Clinic - Best Sexologist in Patna
When it comes to sexual health, finding the right expert is essential for effective diagnosis and treatment. At Kayakalp Clinic in Patna, we pride ourselves on providing exceptional care for a wide range of sexual health issues. If you’re searching for the best sexologist in Patna, look no further. Our team of highly skilled professionals is here to help you navigate and resolve your concerns with confidentiality and compassion.
Why Choose Kayakalp Clinic?
1. Experienced Professionals
Our sexologists are highly trained and experienced in dealing with various sexual health issues. They stay updated with the latest advancements in the field to provide the best care possible.
2. Comprehensive Services
At Kayakalp Clinic, we offer a wide range of services, including:
- Treatment for erectile dysfunction
- Solutions for premature ejaculation
- Counseling for low libido
- Infertility treatment
- Management of sexual pain disorders
- STI screening and treatment
- Relationship and intimacy counseling
3. Personalized Treatment Plans
We understand that every individual is unique, and so are their health concerns. Our sexologists take the time to understand your specific needs and create personalized treatment plans to ensure the best outcomes.
Osvaldo Bernardo Muchanga- MALE CIRCUMCISION, ITS Vs SOCIOCULTURAL BELIEFS (C...Osvaldo Bernardo Muchanga
MALE CIRCUMCISION consists of the surgical act of removing the foreskin (skin that covers the glans of the penis), leaving the glans more prominent and better cleanable.
MALE CIRCUMCISION itself has medical as well as sociocultural implications, as it has been proven to be an act that can minimize SEXUALLY TRANSMITTED INFECTIONS (STIs), especially HIV, but it also represents the SOCIOCULTURAL IDENTITY of some people, respectively.
Now, in a SERO-EPIDEMIOLOGICAL PROFILE like that of Mozambique where the prevalence of HIV is around 12.5% which corresponds to approximately 2 million people living with HIV, where the province of GAZA is the most seroprevalent with a positivity rate of 21% (INSIDA, 2021), it is extremely necessary to THOROUGHLY scrutinize all possibilities for preventing or minimizing the spread of HIV and other STIs.
This document contains an overview of different types of ocular neoplastic disorders or ocular tumors among pediatric patients. you can have a quick basic concept about ocular tumors among children and a basic management strategy. You will have perfect idea about almost 8 ocular tumors among pediatric patients .
Subcutaneous nodules in rheumatic diseases Ahmed Yehia Assistant Professor of internal Medicine, Immunology, rheumatology and allergy
How to use subcutaneous nodules as a clue for diagnosis by completing the puzzle
Report Back from ASCO 2024: Latest Updates on Metastatic Breast Cancer (MBC)....bkling
Join Dr. Kevin Kalinsky, breast oncologist and researcher from Emory Winship Cancer Institute, to learn about the latest updates from The American Society of Clinical Oncology (ASCO) annual meeting 2024.
Safety should always come first when it comes to medical operations involving the use of a Huber needle. Disposable safety Huber needles are useful in this situation. A secure and effective method of accessing and delivering medication to a patient's port is provided by these single-use devices. But it might be difficult to choose the best option when there are so many on the market. We've put up the best advice to selecting the ideal disposable safety Huber needle so you can make an educated choice.
- Video recording of this lecture in English language: https://youtu.be/AWaobASkZM4
- Video recording of this lecture in Arabic language: https://youtu.be/1cQRmJ3SKWc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Human blood has a hydrogen ion concentration [H+ ] of 35 to 45 nmol/L and it is essential that its concentration is maintained within this narrow range.
Hydrogen ions are nothing but protons which can bind to proteins and alter their characteristics.
All the enzymes present in the body are proteins and an alteration in these enzyme systems can change the homeostatic mechanisms of the body.
Hence, a disturbance in acid-base balance can result in malfunction of the various organ systems.
The normal pH of blood is 7.35-7.45.
Acidosis is defined as a pH Less than 7.35.
Conversely, when the pH is more than 7.45, alkalosis is said to exist.
Acidosis and alkalosis are of two types each: respiratory and metabolic.
An increase in carbon dioxide (CO2 ) levels increases the plasma [H+ ] and decreases the pH (respiratory acidosis).
Similarly, a decrease in plasma carbon dioxide levels reduces the [H+ ] and increases the pH (respiratory alkalosis).
A decrease in [HC03 -] reduces the pH and is called metabolic acidosis.
Similarly, an increase in [HC03 -] increases the pH and produces metabolic alkalosis.
The pH is regulated in the human body mainly by two organs: the respiratory system and the renal system.
The arterial carbon dioxide levels are regulated by the respiratory system.
Any increase in carbon dioxide levels stimulates the respiratory centre in the medulla thus augmenting respiration, alveolar ventilation and elimination of extra CO2 levels.
A decrease in CO2 levels may reduce the stimulus to breathe and cause hypoventilation.
This response is limited by hypoxia as the hypoxic drive stimulates the patient to maintain respiration.
Respiratory response to changes in CO2 level occurs very fast.
The plasma bicarbonate levels are regulated by the kidneys.
Any decrease in [HC03 -] stimulates the kidney to retain and synthesise bicarbonate.
High [HC03 -] results in elimination of more bicarbonate in urine.
In general, the pulmonary response to a change in acid-base status is faster and occurs immediately.
However, renal regulation takes time, a few hours to days.
Kidneys filter and reabsorb all the bicarbonate in the urine.
When necessary, kidneys can also produce extra bicarbonate through the glutamine pathway.
When an acid-base disorder occurs, the initial disturbance that occurs is termed the primary disorder.
The body attempts to normaliZe the pH by certain compensatory mechanisms resulting in a secondary disorder, e.g. primary metabolic acidosis results in an increase in hydrogen ions and a consequent decrease in bicarbonate ions.
To compensate for this, the patient hyperventilates and reduces the arterial carbon dioxide levels, thus moving the pH back to normal ( compensatory respiratory alkalosis )
A medical treatment that uses high doses of radiation to kill cancer cells or shrink tumors by damaging their DNA. When the DNA is damaged, cancer cells can no longer divide and grow, and they eventually die.
The Revolutionary Nature of Needleless Double Transfer Spikes in HealthcareNanchang Kindly Meditech
It's likely that you have witnessed medical personnel using needles to transmit fluids or medicines if you have ever visited a hospital or other healthcare facility. But as technology advances, needleless double transfer spikes are becoming more and more common and revolutionizing the delivery of healthcare.
This Presentation provides information on hyperlipidemic drugs. It begins with an introduction to hyperlipidemia and its causes. It then discusses various drug classes for treating hyperlipidemia, including their mechanisms of action, effects on lipid levels, pharmacokinetics, therapeutic uses, adverse effects and interactions. The major drug classes discussed are HMG-CoA reductase inhibitors (statins), bile acid sequestrants, fibrates, and niacin. For each class, specific drugs are highlighted and their properties compared.
Co-Chairs, Hussein Tawbi, MD, PhD, and Prof. Christian Blank, MD, PhD, discuss melanoma in this CME activity titled “Deploying the Immune GAMBIT Against Melanoma: Guidance on Advances and Medical Breakthroughs With ImmunoTherapy.” For the full presentation, downloadable Practice Aids, and complete CME information, and to apply for credit, please visit us at https://bit.ly/4edfNpE. CME credit will be available until July 5, 2025.
All the information you need to know about Hypothyroidism - Introduction,
Etiology, clinical manifestations, complications, pathophysiology,
diagnosis, treatment, precautions.
These are the class of Drugs that are used to treat and prevent cardiac arrhythmias by blocking ion channels involved in cardiac impulse generation and conduction. Class I drugs like quinidine and procainamide block sodium channels to prolong the action potential duration, while Class IB drugs like lignocaine shorten repolarization. Class III drugs like amiodarone block potassium channels to prolong the action potential. Calcium channel blockers like verapamil inhibit calcium influx. Other drugs include adenosine for paroxysmal supraventricular tachycardia, beta blockers for supraventricular arrhythmias, and atropine for bradycardias. Adverse effects vary between drugs but include arrhythmias, heart block and QT prolong
These lecture slides, by Dr Sidra Arshad, offer a simplified description of the physiology of insulin and glucagon.
Learning objectives:
1. Describe the synthesis and release of insulin
2. Explain the mechanism of action of insulin
3. Discuss the metabolic functions of insulin
4. Elucidate the effects of insulin on adipose tissue, skeletal muscle, and liver
5. Enlist the factors which stimulate and inhibit the release of insulin
6. Explain the mechanism of action of glucagon
7. Discuss the metabolic functions of glucagon
8. Elucidate the role of insulin and glucagon in glucose homeostasis during the fasting and fed states
9. Discuss the role of other hormones in the glucose homeostasis
10. Differentiate between the types of diabetes mellitus
11. Explain the pathophysiology of the features of diabetes mellitus
12. Discuss the complications of diabetes mellitus
13. Explain the rationale of oral hypoglycemic drugs
14. Describe the features of hyperinsulinemia
Study Resources:
1. Chapter 79, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 24, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 39, Berne and Levy Physiology, 7th edition
4. Chapter 19, Human Physiology, From Cells to Systems by Lauralee Sherwood, 9th edition
5. Chapter 3, Endocrine and Reproductive Physiology, Bruce A. White and Susan P. Porterfield, 4th edition
6. Insulin and Insulin Resistance, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1204764/
7. Complications of diabetes mellitus,
https://pdb101.rcsb.org/global-health/diabetes-mellitus/monitoring/complications
Factors influencing growth & development:
Growth & development depend upon multiple factors or determinants. They influence directly or indirectly by promoting or hindering the process.
The determinants can be grouped as Heredity & environment..
Heredity or genetic factors are also related to sex, race, & nationality. Environment includes both pre natal & post natal factors.
1. I n t e g r a t i n g P a l l i a t i v e
C a r e i n t h e
E m e r g e n c y D e p a r t m e n t :
A P a r a d i g m S h i f t
Maria Fidelis Manalo, MD, MSc.
Palliative Care
The Medical City
2. P r e s e n t a t i o n
o u t l i n e
TOPICS TO BE DISCUSSED:
• How can early identification of the end-of-life state
reduce low-value emergency care?
• How can we integrate discussions about goals of
care, shared decision-making, and advance care
planning with the families of resuscitation patients?
• How can we optimize emergency treatment
planning to help reduce inappropriate CPR
attempts?
3. Choosing And Doing Wisely: Triage Level I Resuscitation A Possible New Field For
Starting Palliative Care And Avoiding Low-value Care –
A Nationwide Matched-pair Retrospective Cohort Study In Taiwan
Methods
• A matched-pair retrospective cohort study was conducted to examine the association between
palliative care and outcome variables using multivariate logistic regression and Kaplan–Meier
survival analyses.
• Between 2009 and 2013, 336 ED triage level I resuscitation patients received palliative care services
(palliative care group) under a universal health insurance scheme.
• Retrospective cohort matching was performed with those who received standard care at a ratio of
1:4 (usual care group).
• Outcome variables included:
• Number of visits to emergency and outpatient departments
• Hospitalization duration
• Total medical expenses
• Utilization of life-sustaining treatments
• Duration of survival following ED triage level I resuscitation
Lin, CY., Lee, YC. BMC Palliat Care, 2020
4. Choosing And Doing Wisely: Triage Level I Resuscitation A Possible New Field For
Starting Palliative Care And Avoiding Low-value Care –
A Nationwide Matched-pair Retrospective Cohort Study In Taiwan
Results
• The mean survival duration following level I resuscitation was less than 1 year.
• Palliative care was administered to 15% of the resuscitation cohort.
• The palliative care group received significantly less life-sustaining treatment than did the usual care
group.
Conclusion
• Among patients who underwent level I resuscitation, palliative care was inversely correlated with
the scope of life-sustaining treatments.
• Furthermore, triage level I resuscitation status may present a possible new field for starting
palliative care intervention and reducing low-value care.
Lin, CY., Lee, YC. BMC Palliat Care, 2020
5. People Enter The ED
In Search Of Help
When A Medical Or
Surgical Emergency
Arises
- Boyle S.
https://www.capc.org/blog/palliative-pulse-the-palliative-pulse-december-2018-integrating-
palliative-care-in-the-emergency-department-a-paradigm-shift/
•They arrive suffering from pain, respiratory
distress, with symptoms of a stroke or heart
attack, or as the victim of a motor vehicle
accident.
•These are the patients that ED physicians
and nurses have been trained to stabilize
and resuscitate; this is where the
adrenaline kicks in and the team jumps into
action.
•While ED staff are trained to save lives, all
too often they are also faced with
situations where the usual approach—
do everything and anything to prolong
life—may add to suffering with little to no
likelihood of benefit.
6. Recognizing
"Actively Dying" or
"Imminent Death"
• It is important for healthcare providers to be
familiar with this process:
– so they know what to expect when providing
direct care to patients during this time
– so they can guide the family in understanding what
to expect during this process and providing support
as needed
• The timeline for each patient is variable.
A patient may experience these signs and
symptoms over 24 hours or for longer than 14
days.
Oates JR, Maani CV. Death and Dying. [Updated 2021 Aug 30]. In: StatPearls [Internet].
7. • Early stage: Loss of mobility and becoming bed bound; loss of interest or ability to drink and
eat; cognitive changes to include increased time sleeping or experiencing delirium. Delirium
can be a hyperactive or agitated state or a hypoactive state. The trademark point of delirium
is there is an acute change in the level of arousal.
• Middle stage: Further decline in mental status to becoming obtunded or slow arousal with
stimulation and only brief periods of wakefulness. Patients often exhibit the "death rattle"
which a noisy breathing pattern caused by a pooling of oral secretions due to the loss of the
swallowing reflex.
• Late stage: Coma; fever, possibly due to aspiration pneumonia; an altered respiratory
pattern which can be periods of apnea alternated with hyperpnea or irregular breathing;
and mottled extremities due to the constriction of the peripheral circulation
Recognizing "Actively Dying" or "Imminent Death"
Oates JR, Maani CV. Death and Dying. [Updated 2021 Aug 30]. In: StatPearls [Internet].
10. As an entry point to care, the ED is uniquely positioned to
identify the real needs of the patient and the family
- Boyle S.
https://www.capc.org/blog/palliative-pulse-the-palliative-pulse-december-2018-integrating-palliative-care-in-the-emergency-department-a-paradigm-shift/
Historically, however, ED clinicians have avoided goals of care conversations about
what is most important to the patient and family, assuming these were the domain of
the primary care clinicians or their hospital colleagues.
ED staff, in turn, suffered from varying degrees of moral distress and frustration at
their inability to meet their patient’s true needs in situations where the usual
approach to disease treatment appears to be doing more harm than good—by adding
stress and suffering without meaningful gain in survival, function, or quality of life.
12. Palliative Care In The
Emergency Department:
An Oxymoron Or
Just Good Medicine?
13. What is Palliative Care?
• Palliative care is an approach to patient/family/caregiver-centered health
care that focuses on optimal management of distressing symptoms, while
incorporating psychosocial and spiritual care according to
patient/family/caregiver needs, values, beliefs, and cultures.
• The goal of palliative care is to
• Anticipate, prevent, and reduce suffering
• Promote adaptive coping
• Support the best possible quality of life for patients/families/caregivers, regardless
of the stage of the disease or the need for other therapies
14. What is Palliative Care?
Palliative care can begin at diagnosis; be delivered concurrently with
disease-directed, life-prolonging therapies; and facilitate patient
autonomy, access to information, and choice.
Palliative care becomes the main focus of care when disease-directed,
life-prolonging therapies are no longer effective, appropriate, or desired.
15. Palliative Care Is NOT Synonymous With
End-of-life Care or Hospice Care
• Whereas palliative can begin at any point along the cancer care
continuum, hospice care begins when curative treatment is no longer the
goal of care and the sole focus is quality of life.
• Palliative care can help patients and their loved ones make the transition
from treatment meant to cure or control the disease to hospice care by:
• preparing them for physical changes that may occur near the end of life
• helping them cope with the different thoughts and emotional issues that arise
• providing support for family members
• Hospice care is always palliative, but not all palliative care is
hospice care.
Image courtesy of http://www.ersj.org.uk/content/32/3/796.full
- https://www.cancer.gov/about-cancer/advanced-cancer/care-choices/palliative-care-fact-sheet
16. When Is Palliative Care Used In Patient Care?
EARLY IN THE ILLNESS PROCESS
17. Who Gives Palliative Care?
• Palliative care should be provided by the primary
care team and augmented as needed by
collaboration with an interprofessional team of
palliative care experts.
• Palliative care specialists have received special
training and/or certification in palliative care.
- https://www.cancer.gov/about-cancer/advanced-cancer/care-choices/palliative-care-fact-sheet#when-is-palliative-care-used-in-cancer-care
18. Palliative Care Skills Relevant to ED Practice
- Quest TE, Lambda S.
https://www.uptodate.com/contents/palliative-care-for-adults-in-the-ed-concepts-presenting-complaints-and-symptom-management
19. - Quest TE, Lambda S.
https://www.uptodate.com/contents/palliative-care-for-adults-in-the-ed-concepts-presenting-complaints-and-symptom-management
Palliative Care Skills Relevant to ED Practice
20. Palliative Care Skills
Relevant to ED Practice
- Quest TE, Lambda S.
https://www.uptodate.com/contents/palliative-care-for-adults-in-the-ed-concepts-presenting-complaints-and-symptom-management
21. M a n a g i n g T h e p a l l i a t i v e c a r e
P a t i e n t W h o P r e s e n t s T o T h e E D
22. Palliative Care Referral
• Limited treatment options
• Concerns about decision
making capacity
• Need for clarification of goals
of care
• Resistance to engage in
advance care planning
• High risk of poor pain
management
• High non-pain symptom
burden
• High distress score
• Need for invasive procedures
• Frequent ER visits or hospital
admissions
• Need for ICU-level care (multi-
organ failure or prolonged MV
support)
24. Pain
Assessment
O P Q R S T
O - Onset
P - Provocative factors, Palliative factors
Q – Quality
R – Radiation, Referral pattern, Location
S - Severity or Intensity
T – Timing: onset, duration, course, persistent, or intermittent
Q – Quality
27. DYSPNEA CRISIS
COMFORT: Mnemonic Summarizing Key Palliative Management
- An Official American Thoracic Society Workshop Report: Assessment and Palliative Management of Dyspnea Crisis, Mularski RA et al, 2013
C: CALL for help.
Calming voice and
approach among
patient and caregivers
O: OBSERVE
closely and assess
dyspnea for ways to
respond
M: MEDICATIONS
to be tried
(recommendations
from providers for
opioid/other use)
F: FAN to face
may decrease shortness
of breath
O: OXYGEN therapy
as previously found
useful
R: REASSURE
and use relaxation
techniques
T: TIMING interventions
to reduce dyspnea–
work together–
reassess–repeat
Treat Distressing Symptoms
28. • Comfort care is often used in a misleading or
imprecise manner — for example, when such
care is automatically considered equivalent to a
Do-Not-Resuscitate order and, perhaps even
without discussion with the patient, is
extrapolated to mean the exclusion of a full
range of palliative measures appropriate for
the patient.
• Rather than simply writing orders for “comfort
care” (or “intensive comfort measures,” the
term that we prefer), the medical team should
review the entire plan of care and enter explicit
orders to promote comfort and prevent
unnecessary interventions.
- Craig D. Blinderman, CD, Billings, JA, Comfort Care for Patients Dying in the Hospital, N Engl J Med, 2015
U n d e r s t a n d i n g
C o m f o r t C a r e
29. U n d e r s t a n d i n g
C o m f o r t C a r e
• Infrequently, a focus on comfort care may
include the use of potentially life-
sustaining measures, when these are
consistent with a patient’s goals (e.g.,
when the patient wants to be kept alive
with mechanical ventilation until a loved
one can visit from afar or when
withdrawing a treatment conflicts with
the patient’s religious beliefs or cultural
norms).
• In addition, the use of invasive
interventional procedures, such as
thoracentesis for the treatment of
symptomatic pleural effusions, can
promote comfort.
- Craig D. Blinderman, CD, Billings, JA, Comfort Care for Patients Dying in the Hospital, N Engl J Med, 2015
30. An Official American Thoracic Society Statement: Update on the
Mechanisms, Assessment, and Management of Dyspnea
31. O p i o i d s a n d D y s p n e a
• Opioids have been the most widely studied agent in the
treatment of dyspnea.
• Opioids treat dyspnea through many mechanisms:
–Reducing respiratory drive
–Reducing anxiety
–Altering central responses to exertion
–Cough suppression
- American College of Chest Physicians consensus statement on the management of dyspnea in patients with advanced lung or heart disease.
Chest 2010;
- Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: a clinical practice guideline
from the American College of Physicians. Ann Intern Med 2008;
- Randomised, double blind, placebo controlled crossover trial of sustained release morphine for the management of refractory dyspnea. BMJ
2003.
32. O p i o i d P a i n
M e d i c a t i o n :
S e p a r a t i n g M y t h
f r o m R e a l i t y
• Symptom-titrated opioids do not hasten death.
• With proper titration, clinically significant
respiratory depression does not occur because
pain is a powerful respiratory stimulant and
counteracts the narcotic-induced depression.
• Because pain is a stimulus to respiration,
clinically significant respiratory depression is
rare.
• Pain is nature's own antidote to respiratory
depression.
- Fohr, SA, Journal of Palliative Medicine, 1998
33. T r e a t D i s t r e s s i n g
S y m p t o m s
Delirium and agitation
Nausea and vomiting
Pruritus and sweating
Cough and hemoptysis
Constipation and malignant bowel obstruction
Chronic wounds, including malodorous or bleeding malignancy-related wounds
Acute urinary retention
34. If rapid decisions are required
regarding the use of life sustaining
treatments (e.g., intubation for
respiratory failure), whenever
possible, taking a few minutes to
clarify the patient’s goals and
preferences first, before discussing
actual decisions, can help others
engage in decision-making.
M a n a g i n g T h e
p a l l i a t i v e c a r e
P a t i e n t W h o
P r e s e n t s T o T h e E D
35. G u i d e F o r A n E f f i c i e n t D i s c u s s i o n O f
G o a l s O f C a r e I n T h e E D
1. Determine the legal decision maker.
If the patient is unable to make decisions, identify the appropriate
proxy/surrogate. Review any completed advance directives.
Adapted from: Weissman DE, Quill TE, Arnold RM. The family meeting: End of life goal setting and future planning. J Palliat Med 2010; 13:462.
36. G u i d e F o r A n E f f i c i e n t
D i s c u s s i o n O f G o a l s O f
C a r e I n T h e E D
2. Explain the prognosis. Discuss the "big picture."
Be clear; avoid vague language. If the condition is
incurable, say so.
•Frame the discussion as "hoping for the best
while preparing for the worst."
•Answer 2 key questions: What is wrong with the
patient? What will happen?
Adapted from: Weissman DE, Quill TE, Arnold RM. The family meeting: End of life goal setting and future planning. J Palliat Med 2010; 13:462.
37. Issues that naturally arise during
conversations about goals of care
include the following:
Resuscitation
orders/code status
Use of invasive and noninvasive
diagnostic tests or treatments
(e.g., mechanical and
noninvasive ventilation,
hemodialysis, intravenous [IV]
vasopressors, surgery, blood
products, antibiotics)
Prognosis and
trajectory of illness
Approach and
commitment to
controlling symptoms
Disposition and discharge
options, to include home,
hospice care,
hospitalization, initiation of
critical care
- Quest TE, Lambda S.
https://www.uptodate.com/contents/palliative-care-for-adults-in-the-ed-goals-of-care-communication-consultation-and-patient-death
38. G u i d e F o r A n E f f i c i e n t
D i s c u s s i o n O f G o a l s O f
C a r e I n T h e E D
3. Elicit patient values. Engage the patient or
surrogate with open-ended questions:
"What is most important to you in your (or your
loved one's) life right now?"
"What kind of results are you hoping for?"
"What do you hope to avoid at all costs?"
If appropriate: "Have you been with someone
who had a particularly good death or a
particularly bad death? Tell me about it."
Adapted from: Weissman DE, Quill TE, Arnold RM. The family meeting: End of life goal setting and future planning. J Palliat Med 2010; 13:462.
39. G u i d e F o r A n
E f f i c i e n t D i s c u s s i o n
O f G o a l s O f C a r e I n
T h e E D
4. Use appropriate language.
•Avoid negative statements, such
as: "Do you want us to withhold
aggressive treatment?"
•Frame the discussion positively:
•"We want to ensure that you receive
the kind of treatment you want."
•"Let us discuss how we can work
towards your wish to..." (e.g., stay at
home).
Adapted from: Weissman DE, Quill TE, Arnold RM. The family meeting: End of life goal setting and future planning. J Palliat Med 2010; 13:462.
40. G u i d e F o r A n E f f i c i e n t D i s c u s s i o n
O f G o a l s O f C a r e I n T h e E D
5. Reconcile the goals of care.
Sometimes a "time-limited trial" of therapy is needed to help the patient and family
cope with circumstances or reach a consensus about goals. If so:
• Outline the proposed treatment plan clearly.
• State the goals that you are hoping to achieve with the plan.
• Clarify how you will determine that these goals are being met.
• Establish a period of time for determining if the intervention works and is consistent with
goals of care.
Clinicians may need to set limits on unrealistic goals without making the patient feel
abandoned: "I understand your goal is not to be a burden to your family and you want
an assisted death. Unfortunately, I cannot do that. However, I can help you manage
distressing symptoms, and I can find ways to help you not be a burden."
Adapted from: Weissman DE, Quill TE, Arnold RM. The family meeting: End of life goal setting and future planning. J Palliat Med 2010; 13:462.
41. When decisions are made about
initiation of life-sustaining
interventions, it is often helpful
to present treatment options as
time-limited trials to see if they
will meet the care goals; if they
do not, this may set the stage
for possible withdrawal later
when they no longer meet the
patient’s care goals.
R a p i d
g o a l s o f c a r e
d i s c u s s i o n s
- Quest TE, Lambda S.
https://www.uptodate.com/contents/palliative-care-for-adults-in-the-ed-goals-of-care-communication-consultation-and-patient-death
42. Another productive tactic is to
portray life-sustaining
treatments as “bridges to
recovery,” thus implying that
life-sustaining treatment is not
intended to be indefinite therapy
and is only appropriate when the
patient has the potential for
recovery at some future time.
R a p i d
g o a l s o f c a r e
d i s c u s s i o n s
- Quest TE, Lambda S.
https://www.uptodate.com/contents/palliative-care-for-adults-in-the-ed-goals-of-care-communication-consultation-and-patient-death
43. G u i d e F o r
A n
E f f i c i e n t
D i s c u s s i o
n O f G o a l s
O f C a r e I n
T h e E D
6. Recommend a care plan based on the patient's goals.
a. Summarize the patient goal (e.g., "From what I
understand, your goal is to...")
b. Outline the plan (e.g., "In order to meet this goal,
we can...")
c. Be specific whenever possible ("I would/would not
recommend...")
•Discuss discontinuing interventions and therapies that
will not help meet the patient's goals.
•Diagnostic, treatment, and disposition plans are best
formulated and discussed with the patient's goals of
care in mind.
Adapted from: Weissman DE, Quill TE, Arnold RM. The family meeting: End of life goal setting and future planning. J Palliat Med 2010; 13:462.
44. M a n a g i n g T h e
p a l l i a t i v e c a r e
P a t i e n t W h o P r e s e n t s
T o T h e E D
45. M a n a g i n g T h e
p a l l i a t i v e c a r e
P a t i e n t W h o
P r e s e n t s T o T h e E D
46. M a n a g i n g T h e p a l l i a t i v e c a r e P a t i e n t
W h o P r e s e n t s T o T h e E D
47. M a n a g i n g T h e p a l l i a t i v e c a r e
P a t i e n t W h o P r e s e n t s T o T h e E D
48. M a n a g i n g T h e p a l l i a t i v e
c a r e P a t i e n t W h o
P r e s e n t s T o T h e E D
49. “There is nothing more that can be
done” does not exist in the lexicon
of palliative medicine.”
We do not abandon dying patients
and their families.
W e c o n t i n u e t o
p r o v i d e
c o m p a s s i o n a t e
c a r e e v e n w h e n
c u r e i s n o
l o n g e r p o s s i b l e
50. 1) To see the patient & the family through
the physical & emotional stages of terminal illness
2) To ease their burden along the way
to walk alongside, not to give orders from above
3) To be there
when symptoms arise, when hard questions
have to be faced, when fear & loneliness threaten
T A S K S O F T H E
M U L T I D I S C I P L I N A R Y C A R E
T E A M
51. T A S K S O F T H E
M U L T I D I S C I P L I N A R Y
C A R E T E A M
To apply to the care of
the seriously-ill,
the terminally-ill, and
the dying
the same high standards of clinical
analysis & decision-making as are
demanded in the care of patients
expected to get well