Essential Option in Serious Illness

  • not all patients/families want aggressive interventions for disease.
  • always offer maximal symptom control and allowing natural disease progression.
  • be prepared to support patients decision
  • contact us for assistance with symptoms

Talk tip: “Although we may be able to manage this disease, you can always decide to focus on therapies to control your symptoms, and allow the disease to take its natural course.”

Intervention information for patients and families

Here’s what the patient and family needs to know.

1. How will the intervention affect:

  • length of life
  • ability to maintain current health
  • ability to think and function (i.e. cognitive impairment)

2. What is involved in the intervention:

  • potential complications
  • potential burden/suffering

CPR outcome statistics

Based on the patient’s current medical situation, CPR may or may not be recommended.

To inform discussion with patient/family:

Survival to discharge from hospital for in-hospital cardiac arrest

  • all conditions: 15-22%
  • pre-existing major trauma: 3.9%
  • pre-existing septicemia: 13.5%
  • pre-existing early metastatic cancer: 13.5%
  • pre-existing stroke: 4.1%
  • pre-existing dialysis: 3.9%
  • Of the patients discharged 28.1% had clinically significant neurological disability.

Talk tip: for patients who may not understand the percentage figures above, “Out of 100 patients in hospital who have a cardiac arrest, about 18 people will live to discharge. The other 82 people will die. And of those 18 people who leave the hospital, almost 5 will have brain damage.”

Talk tip: if CPR not recommended, “We’ll do everything we can to help you live as well as you can for as long as you can, but when you die, we’ll help you have a peaceful and natural death.”

Goals of care

Typical goals of care:

  • live longer or stay alive
  • improve or maintain function, quality of life, independence
  • be comfortable
  • achieve life goals
  • support family and loved ones

May be helpful to ask patient to identify which are the most important and why

Ask patient about specific life goals (e.g. live to daughter’s wedding, birth of grandchild)

Talk tip: See Communication section on Goals of Care discussion

Reconsider medications in advanced illness

Consider whether to continue or stop medications depending on the following questions for each medication:

What is the treatment target for medication?:

  • prevention/risk reduction of disease
  • life prolongation
  • prevention of morbidity/mortality
  • maintenance of current function/state
  • treatment of acute illness
  • symptom control

Is the treatment target in keeping with patient/family goals of care?

What is the time to benefit for the drug? (symptom control opioids=short, statins for prevention of stroke=several years)

Will the patient live long enough to benefit from this drug?

Request for hastened death

Canadian Medical Association recognizes practice of assisted death in Canada distinct from practice of palliative care.

Assessment framework:

  • Acknowledge the suffering occurring to cause patient’s request
  • Assess/address physical suffering
  • Assess/address potential depression/anxiety/delirium
  • Assess/address concerns about burden to others, loss of independence, meaning, dignity
  • Ensure patient aware of right to refuse, stop, withdraw any therapy causing distress
  • If persistent request by capable adult, free of coercion, with irremediable medical condition causing enduring intolerable suffering, in jurisdiction with legal physician-assisted death follow local guidelines.

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