this lady is my grandmother she dies in July last year she was 95 years old and
July last year she was 95 years old and
July last year she was 95 years old and she suffered from severe heart failure
she suffered from severe heart failure
she suffered from severe heart failure for a long period of time she died in
for a long period of time she died in
for a long period of time she died in her own house surrounded by her loved
her own house surrounded by her loved
her own house surrounded by her loved ones she died in her own house not only
ones she died in her own house not only
ones she died in her own house not only because she wanted to but because she
because she wanted to but because she
because she wanted to but because she shared her wishes with her closest loved
shared her wishes with her closest loved
shared her wishes with her closest loved ones and with her doctor who of you has
ones and with her doctor who of you has
ones and with her doctor who of you has ever discussed your end-of-life wishes
ever discussed your end-of-life wishes
ever discussed your end-of-life wishes with your loved ones what’s the most
with your loved ones what’s the most
with your loved ones what’s the most important in your life quality of life
important in your life quality of life
important in your life quality of life or how long you have to live there may
or how long you have to live there may
or how long you have to live there may be circumstances in which you believe
be circumstances in which you believe
be circumstances in which you believe that life isn’t worth living anymore
that life isn’t worth living anymore
that life isn’t worth living anymore many of you might think I don’t have to
many of you might think I don’t have to
many of you might think I don’t have to think about the end of life I’m not 95
think about the end of life I’m not 95
think about the end of life I’m not 95 years old when I look around I believe
years old when I look around I believe
years old when I look around I believe that’s true but I’m going to show you
that’s true but I’m going to show you
that’s true but I’m going to show you today why it is important for you and
today why it is important for you and
today why it is important for you and your loved ones to discuss your
your loved ones to discuss your
your loved ones to discuss your end-of-life wishes in fact some of us
end-of-life wishes in fact some of us
end-of-life wishes in fact some of us will be elderly some of us will have a
will be elderly some of us will have a
will be elderly some of us will have a life-limiting illness but many of us
life-limiting illness but many of us
life-limiting illness but many of us will get a life-limiting illness
will get a life-limiting illness
will get a life-limiting illness somewhere in our lives maybe you have
somewhere in our lives maybe you have
somewhere in our lives maybe you have parents or grandparents or loved one
parents or grandparents or loved one
parents or grandparents or loved one with a life-limiting illness do you know
with a life-limiting illness do you know
with a life-limiting illness do you know their end-of-life preferences for
their end-of-life preferences for
their end-of-life preferences for example would they prefer treatment
example would they prefer treatment
example would they prefer treatment focusing on prolonging life when they
focusing on prolonging life when they
focusing on prolonging life when they had a stroke and if they are no longer
had a stroke and if they are no longer
had a stroke and if they are no longer able to communicate with you I would
able to communicate with you I would
able to communicate with you I would they prefer comfort care in such a
they prefer comfort care in such a
they prefer comfort care in such a situation we are all going to the
situation we are all going to the
situation we are all going to the you me and our loved ones nobody can
you me and our loved ones nobody can
you me and our loved ones nobody can tell us when that will be it can be when
tell us when that will be it can be when
tell us when that will be it can be when we are 95 years old just like my
we are 95 years old just like my
we are 95 years old just like my grandmother can also be tomorrow a
grandmother can also be tomorrow a
grandmother can also be tomorrow a century ago most deaths occur and
century ago most deaths occur and
century ago most deaths occur and suddenly due to accidents infections
suddenly due to accidents infections
suddenly due to accidents infections around childbirth people didn’t have
around childbirth people didn’t have
around childbirth people didn’t have time to think about such a thing as
time to think about such a thing as
time to think about such a thing as end-of-life care but nowadays
end-of-life care but nowadays
end-of-life care but nowadays demographic transitions like aging of
demographic transitions like aging of
demographic transitions like aging of the population and a shift in causes of
the population and a shift in causes of
the population and a shift in causes of death towards chronic diseases because
death towards chronic diseases because
death towards chronic diseases because the major exchange in the experience of
the major exchange in the experience of
the major exchange in the experience of dying and the experience of dying
dying and the experience of dying
dying and the experience of dying becomes increasingly a feature of old
becomes increasingly a feature of old
becomes increasingly a feature of old age because of the developments in
age because of the developments in
age because of the developments in modern medicine people often survive
modern medicine people often survive
modern medicine people often survive acute illnesses but they may live for
acute illnesses but they may live for
acute illnesses but they may live for many years with progressive chronic
many years with progressive chronic
many years with progressive chronic diseases they may have severe
diseases they may have severe
diseases they may have severe limitations in performing their daily
limitations in performing their daily
limitations in performing their daily life activities impaired quality of life
life activities impaired quality of life
life activities impaired quality of life and maybe they are going in and out of
and maybe they are going in and out of
and maybe they are going in and out of the hospital because of acute episodes
the hospital because of acute episodes
the hospital because of acute episodes of the chronic disease or maybe they are
of the chronic disease or maybe they are
of the chronic disease or maybe they are living in a nursing home because of a
living in a nursing home because of a
living in a nursing home because of a high level of care dependency a medical
high level of care dependency a medical
high level of care dependency a medical care is still mainly focusing on
care is still mainly focusing on
care is still mainly focusing on prolonging life and the likelihood that
prolonging life and the likelihood that
prolonging life and the likelihood that a patient will die because of his or her
a patient will die because of his or her
a patient will die because of his or her disease is often ignored and dying is
disease is often ignored and dying is
disease is often ignored and dying is often seen as a failure of medicine and
often seen as a failure of medicine and
often seen as a failure of medicine and I will never forget a family meeting
I will never forget a family meeting
I will never forget a family meeting which I had when I was a 24 year old
which I had when I was a 24 year old
which I had when I was a 24 year old doctor in the nursing home one of my
doctor in the nursing home one of my
doctor in the nursing home one of my patients a very old lady with dementia
patients a very old lady with dementia
patients a very old lady with dementia was deteriorating fast and actually I
was deteriorating fast and actually I
was deteriorating fast and actually I had no idea what was wrong with her I
had no idea what was wrong with her I
had no idea what was wrong with her I spoke to the family and I told him a
spoke to the family and I told him a
spoke to the family and I told him a list of possible diagnoses which he
list of possible diagnoses which he
list of possible diagnoses which he might have which could explain why she
might have which could explain why she
might have which could explain why she was deteriorating the family was
was deteriorating the family was
was deteriorating the family was listening to me very patient and at the
listening to me very patient and at the
listening to me very patient and at the end of my extensive list they quietly
end of my extensive list they quietly
end of my extensive list they quietly said to me doctor she’s just worn out
said to me doctor she’s just worn out
said to me doctor she’s just worn out this family was ready for her dying I
this family was ready for her dying I
this family was ready for her dying I ambitious doctor I wasn’t and I will
ambitious doctor I wasn’t and I will
ambitious doctor I wasn’t and I will always remain grateful for what this
always remain grateful for what this
always remain grateful for what this family taught me autonomy becomes
family taught me autonomy becomes
family taught me autonomy becomes increasingly important in our society
increasingly important in our society
increasingly important in our society and the expectations about the end of
and the expectations about the end of
and the expectations about the end of life change we want to influence
life change we want to influence
life change we want to influence everything in our lives but we also want
everything in our lives but we also want
everything in our lives but we also want to influence the end of life but to be
to influence the end of life but to be
to influence the end of life but to be able to do this timely discussions with
able to do this timely discussions with
able to do this timely discussions with our loved ones and our doctors about
our loved ones and our doctors about
our loved ones and our doctors about what’s important in our lives and about
what’s important in our lives and about
what’s important in our lives and about our treatment references are important
our treatment references are important
our treatment references are important and these discussions are named advanced
and these discussions are named advanced
and these discussions are named advanced care planning discussions advanced care
care planning discussions advanced care
care planning discussions advanced care planning improve scare at the end of
planning improve scare at the end of
planning improve scare at the end of life for patients and their loved ones
life for patients and their loved ones
life for patients and their loved ones and we know now that people who had Lee
and we know now that people who had Lee
and we know now that people who had Lee discuss these discussions are more
discuss these discussions are more
discuss these discussions are more likely to receive care according to
likely to receive care according to
likely to receive care according to their preferences as an elderly care
their preferences as an elderly care
their preferences as an elderly care physician and of life discussions are
physician and of life discussions are
physician and of life discussions are now part of my daily work however these
now part of my daily work however these
now part of my daily work however these conversations never become easy and even
conversations never become easy and even
conversations never become easy and even for elderly patients with advanced
for elderly patients with advanced
for elderly patients with advanced illnesses focus facing the end of life
illnesses focus facing the end of life
illnesses focus facing the end of life can be very challenging and a while ago
can be very challenging and a while ago
can be very challenging and a while ago I was caring for an 82 year old
I was caring for an 82 year old
I was caring for an 82 year old gentleman with advanced lung disease and
gentleman with advanced lung disease and
gentleman with advanced lung disease and he was bound to a wheelchair it used the
he was bound to a wheelchair it used the
he was bound to a wheelchair it used the high doses of oxygen and he couldn’t
high doses of oxygen and he couldn’t
high doses of oxygen and he couldn’t perform any physical activity because of
perform any physical activity because of
perform any physical activity because of severe breathlessness he spoke to me
severe breathlessness he spoke to me
severe breathlessness he spoke to me about a recent experience in the
about a recent experience in the
about a recent experience in the hospital and that he felt that he was
hospital and that he felt that he was
hospital and that he felt that he was going to die we discussed his fear for
going to die we discussed his fear for
going to die we discussed his fear for suffocation and how palliative care can
suffocation and how palliative care can
suffocation and how palliative care can prevent suffering and the dying faced
prevent suffering and the dying faced
prevent suffering and the dying faced one day later his wife called me she was
one day later his wife called me she was
one day later his wife called me she was very upset actually she was very angry
very upset actually she was very angry
very upset actually she was very angry with me she was very angry that I spoke
with me she was very angry that I spoke
with me she was very angry that I spoke with her husband about dying I try to
with her husband about dying I try to
with her husband about dying I try to explain to her that I discussed this as
explain to her that I discussed this as
explain to her that I discussed this as part of a hope for the best but prepare
part of a hope for the best but prepare
part of a hope for the best but prepare for the worst approach but after this
for the worst approach but after this
for the worst approach but after this moment any conversation with the couple
moment any conversation with the couple
moment any conversation with the couple about the end of life became impossible
about the end of life became impossible
about the end of life became impossible a few weeks later he was discharged home
a few weeks later he was discharged home
a few weeks later he was discharged home and two months later we heard that he
and two months later we heard that he
and two months later we heard that he died in the hospital I don’t know
died in the hospital I don’t know
died in the hospital I don’t know whether he wanted to die in the hospital
whether he wanted to die in the hospital
whether he wanted to die in the hospital or whether he would have preferred to
or whether he would have preferred to
or whether he would have preferred to die at home I don’t know this because
die at home I don’t know this because
die at home I don’t know this because his end-of-life preferences will never
his end-of-life preferences will never
his end-of-life preferences will never discussed for other patients preparing
discussed for other patients preparing
discussed for other patients preparing for the end of life is very important
for the end of life is very important
for the end of life is very important and last summer as 60 year old gentleman
and last summer as 60 year old gentleman
and last summer as 60 year old gentleman was admitted to my unit he had severe
was admitted to my unit he had severe
was admitted to my unit he had severe lung disease for many years and he was
lung disease for many years and he was
lung disease for many years and he was not only using oxygen therapy but also
not only using oxygen therapy but also
not only using oxygen therapy but also non-invasive ventilation before he came
non-invasive ventilation before he came
non-invasive ventilation before he came to my unit he was living at home alone
to my unit he was living at home alone
to my unit he was living at home alone and every morning the home care nurse
and every morning the home care nurse
and every morning the home care nurse came and she helped him with washing
came and she helped him with washing
came and she helped him with washing dressing and P Bertha’s breakfast in the
dressing and P Bertha’s breakfast in the
dressing and P Bertha’s breakfast in the afternoon events with his scooter to see
afternoon events with his scooter to see
afternoon events with his scooter to see some friends and during a coffee every
some friends and during a coffee every
some friends and during a coffee every day the same this was the only thing he
day the same this was the only thing he
day the same this was the only thing he could do but he was satisfied with his
could do but he was satisfied with his
could do but he was satisfied with his life when he came to my units he was bad
life when he came to my units he was bad
life when he came to my units he was bad bound he needed help with performing all
bound he needed help with performing all
bound he needed help with performing all his daily life activities and he was
his daily life activities and he was
his daily life activities and he was uses using his non-invasive ventilation
uses using his non-invasive ventilation
uses using his non-invasive ventilation mouse for almost 24 hours a day he was
mouse for almost 24 hours a day he was
mouse for almost 24 hours a day he was very clear to me if he was not going to
very clear to me if he was not going to
very clear to me if he was not going to improve his level of functioning and if
improve his level of functioning and if
improve his level of functioning and if he couldn’t be discharged home again his
he couldn’t be discharged home again his
he couldn’t be discharged home again his life wasn’t worth living anymore we
life wasn’t worth living anymore we
life wasn’t worth living anymore we started with intensive therapy but
started with intensive therapy but
started with intensive therapy but despite this he did not improve and he
despite this he did not improve and he
despite this he did not improve and he would need his fancy latian mosque for
would need his fancy latian mosque for
would need his fancy latian mosque for 24 hours a day and he couldn’t be
24 hours a day and he couldn’t be
24 hours a day and he couldn’t be discharged home again we had open
discharged home again we had open
discharged home again we had open discussions about his life goals about
discussions about his life goals about
discussions about his life goals about his prognosis and about his treatment
his prognosis and about his treatment
his prognosis and about his treatment options and he decided to forego any
options and he decided to forego any
options and he decided to forego any life-prolonging treatment he knew that
life-prolonging treatment he knew that
life-prolonging treatment he knew that he was going to die and he prepared for
he was going to die and he prepared for
he was going to die and he prepared for it he finished everything he wanted to
it he finished everything he wanted to
it he finished everything he wanted to do he found closure and a few weeks
do he found closure and a few weeks
do he found closure and a few weeks later he died peacefully and the
later he died peacefully and the
later he died peacefully and the presence of his loved ones a few weeks
presence of his loved ones a few weeks
presence of his loved ones a few weeks later I spoke with his family and of
later I spoke with his family and of
later I spoke with his family and of course they were very sad but even more
course they were very sad but even more
course they were very sad but even more they were very grateful about valuable
they were very grateful about valuable
they were very grateful about valuable time they spent together
time they spent together
time they spent together in his final weeks of life these two
in his final weeks of life these two
in his final weeks of life these two patients clearly show us that people
patients clearly show us that people
patients clearly show us that people differ and how they want to feel face
differ and how they want to feel face
differ and how they want to feel face the future people differ in their needs
the future people differ in their needs
the future people differ in their needs and desires for hope and explicit
and desires for hope and explicit
and desires for hope and explicit prognostic information but to achieve a
prognostic information but to achieve a
prognostic information but to achieve a good death advanced care planning is
good death advanced care planning is
good death advanced care planning is necessary and in the past advanced care
necessary and in the past advanced care
necessary and in the past advanced care planning was mainly seen as preparing
planning was mainly seen as preparing
planning was mainly seen as preparing advanced directives documenting wishes
advanced directives documenting wishes
advanced directives documenting wishes concerning life-sustaining treatments
concerning life-sustaining treatments
concerning life-sustaining treatments one of these life-sustaining treatments
one of these life-sustaining treatments
one of these life-sustaining treatments is CPR cardiopulmonary resuscitation
is CPR cardiopulmonary resuscitation
is CPR cardiopulmonary resuscitation when your house stops beating there’s no
when your house stops beating there’s no
when your house stops beating there’s no time of opportunity to discuss your
time of opportunity to discuss your
time of opportunity to discuss your preferences regarding CPR but chest
preferences regarding CPR but chest
preferences regarding CPR but chest compressions should be started as soon
compressions should be started as soon
compressions should be started as soon as possible or should not be started at
as possible or should not be started at
as possible or should not be started at all but why would anyone even consider
all but why would anyone even consider
all but why would anyone even consider to forego CPR CPR was quite successful
to forego CPR CPR was quite successful
to forego CPR CPR was quite successful isn’t it at least that’s what we see on
isn’t it at least that’s what we see on
isn’t it at least that’s what we see on television together with a colleague
television together with a colleague
television together with a colleague I’ve watched 68 episodes of ER house and
I’ve watched 68 episodes of ER house and
I’ve watched 68 episodes of ER house and grey’s anatomy and we saw 47 CPR
grey’s anatomy and we saw 47 CPR
grey’s anatomy and we saw 47 CPR attempts 51% were successful
attempts 51% were successful
attempts 51% were successful thirty-eight percent were not successful
thirty-eight percent were not successful
thirty-eight percent were not successful and it was not shown an 11 presents but
and it was not shown an 11 presents but
and it was not shown an 11 presents but these are real life data when you don’t
these are real life data when you don’t
these are real life data when you don’t have a chronic disease and you need CPR
have a chronic disease and you need CPR
have a chronic disease and you need CPR while you are in the hospital you have
while you are in the hospital you have
while you are in the hospital you have seventeen percent chance that you will
seventeen percent chance that you will
seventeen percent chance that you will survive until discharge if you have a
survive until discharge if you have a
survive until discharge if you have a chronic lung disease of cancer your
chronic lung disease of cancer your
chronic lung disease of cancer your chances are even lower and moreover only
chances are even lower and moreover only
chances are even lower and moreover only five to seven percent will be discharged
five to seven percent will be discharged
five to seven percent will be discharged home and the other survivors will be
home and the other survivors will be
home and the other survivors will be discharged for example to a nursing home
discharged for example to a nursing home
discharged for example to a nursing home so documenting preferences regarding
so documenting preferences regarding
so documenting preferences regarding CPRS importance but we also know now the
CPRS importance but we also know now the
CPRS importance but we also know now the limitations of advanced directives
limitations of advanced directives
limitations of advanced directives life-sustaining treatments I’ll
life-sustaining treatments I’ll
life-sustaining treatments I’ll preferences are likely to change and
preferences are likely to change and
preferences are likely to change and moreover it is very difficult to make
moreover it is very difficult to make
moreover it is very difficult to make decisions in advance about future
decisions in advance about future
decisions in advance about future unknown scenarios and to illustrate this
unknown scenarios and to illustrate this
unknown scenarios and to illustrate this I
I
I want to use a quote of a loved one of a
want to use a quote of a loved one of a
want to use a quote of a loved one of a patient that I’ve written a paper from
patient that I’ve written a paper from
patient that I’ve written a paper from Quebec isidoro and this loved one said
Quebec isidoro and this loved one said
Quebec isidoro and this loved one said we got the DNR and writing but in making
we got the DNR and writing but in making
we got the DNR and writing but in making decisions which there were many this was
decisions which there were many this was
decisions which there were many this was just one and the first decision was
just one and the first decision was
just one and the first decision was whether to put him in a nursing home we
whether to put him in a nursing home we
whether to put him in a nursing home we were married for 30 years and I could no
were married for 30 years and I could no
were married for 30 years and I could no longer take care of him the second
longer take care of him the second
longer take care of him the second decision was whether to put him on a
decision was whether to put him on a
decision was whether to put him on a feeling cube because he had stopped
feeling cube because he had stopped
feeling cube because he had stopped eating and I wasn’t ready to let him go
so advanced care planning it’s not about
so advanced care planning it’s not about deciding everything in advance and
deciding everything in advance and
deciding everything in advance and signing lots of papers advanced care
signing lots of papers advanced care
signing lots of papers advanced care planning is about talking with your
planning is about talking with your
planning is about talking with your loved ones and your doctor’s about
loved ones and your doctor’s about
loved ones and your doctor’s about what’s important in your life and what
what’s important in your life and what
what’s important in your life and what quality of life means to you and this
quality of life means to you and this
quality of life means to you and this will help your doctors and your loved
will help your doctors and your loved
will help your doctors and your loved ones with making the best possible
ones with making the best possible
ones with making the best possible decisions for you when you are no longer
decisions for you when you are no longer
decisions for you when you are no longer able to participate in the
able to participate in the
able to participate in the decision-making process for example when
decision-making process for example when
decision-making process for example when you are lying in the ICU unconscious it
you are lying in the ICU unconscious it
you are lying in the ICU unconscious it will help them to offer you the
will help them to offer you the
will help them to offer you the treatments as you would have wanted
treatments as you would have wanted
treatments as you would have wanted taking and account your values and your
taking and account your values and your
taking and account your values and your life goals it allows you to lift the way
life goals it allows you to lift the way
life goals it allows you to lift the way you want but also to die the way you
you want but also to die the way you
you want but also to die the way you want it allows your family members to go
want it allows your family members to go
want it allows your family members to go on after your dad’s we know now that
on after your dad’s we know now that
on after your dad’s we know now that loved ones of patients who died who had
loved ones of patients who died who had
loved ones of patients who died who had advanced care planning discussions are
advanced care planning discussions are
advanced care planning discussions are less likely to suffer from anxiety and
less likely to suffer from anxiety and
less likely to suffer from anxiety and depression but to achieve this we have
depression but to achieve this we have
depression but to achieve this we have to talk about dying we have to be aware
to talk about dying we have to be aware
to talk about dying we have to be aware of the fact that we are all going to die
of the fact that we are all going to die
of the fact that we are all going to die we don’t know when but we can prepare we
we don’t know when but we can prepare we
we don’t know when but we can prepare we can overcome fears just by talking about
can overcome fears just by talking about
can overcome fears just by talking about it so when you go home today just think
it so when you go home today just think
it so when you go home today just think about it think about your end-of-life
about it think about your end-of-life
about it think about your end-of-life wishes discuss with your loved ones
wishes discuss with your loved ones
wishes discuss with your loved ones there and of life wishes be prepared
”
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