Comments on: How do people with dementia die? http://www.kevinmd.com/blog/2009/11/people-dementia-die.html Tue, 14 Feb 2012 11:46:00 +0000 hourly 1 By: Primary Care Internisthttp://www.kevinmd.com/blog/2009/11/people-dementia-die.html#comment-118164 Primary Care Internist Thu, 12 Nov 2009 05:00:47 +0000 http://www.kevinmd.com/blog/?p=41232#comment-118164 I give reasonable prognostic information to ALL my patients' families with advanced dementia in a large nursing home in NY, with varying degrees of information absorption. I would say that once such patients stop eating and walking, life expectance is very short (even with PEG placement). Still I would say that if someone asked families after patients die, at least half would say that they hadn't been told what to expect.So I'd say the study is interesting, but probably misleading. The same is true of most ER docs I know (I don't know any of them that "sugarcoat" the prognosis).None of this will change without tort reform. There's just no downside to getting GI to do a PEG, getting a useless neuro consult, or sending the near-vegetative demented patient back & forth to the hospital with pneumonia. There is just only down-side to using good judgment in the unnecessary use of limited healthcare resources, and I am certain it is straining our hospital ERs. I give reasonable prognostic information to ALL my patients’ families with advanced dementia in a large nursing home in NY, with varying degrees of information absorption. I would say that once such patients stop eating and walking, life expectance is very short (even with PEG placement). Still I would say that if someone asked families after patients die, at least half would say that they hadn’t been told what to expect.

So I’d say the study is interesting, but probably misleading. The same is true of most ER docs I know (I don’t know any of them that “sugarcoat” the prognosis).

None of this will change without tort reform. There’s just no downside to getting GI to do a PEG, getting a useless neuro consult, or sending the near-vegetative demented patient back & forth to the hospital with pneumonia. There is just only down-side to using good judgment in the unnecessary use of limited healthcare resources, and I am certain it is straining our hospital ERs.

]]> By: weakanddizzyhttp://www.kevinmd.com/blog/2009/11/people-dementia-die.html#comment-118153 weakanddizzy Thu, 12 Nov 2009 01:55:42 +0000 http://www.kevinmd.com/blog/?p=41232#comment-118153 I deal with this every day as a hospitalist. Many families are clueless and I spend an enormous amount of time explaining that dementia is a terminal illness and there is little we can do to change the trajectory. I think it is reasonable to give antibiotics, a limited amount of IV fluid support, good general nursing care, speech evaluation and modification of diet when indicated. Some families can accept the inevitable and appreciate your efforts to help their loved ones, others are unreasonable and demand multiple subspecialist consultations ( eg. neurology, pulmonary, GI, you name it) with no real change in the plan or outcome but a whole lot more testing and interventions of dubious value. I for one am not likely to argue with families. If they demand a neurology consult for dementia or GI for a PEG tube ( even after I explain there has never been a study to show they prolong quantity or quality of life) I get the consult. After all dead patients never sue you, but their families can easily find a med mal lawyer willing to listen to their complaints about the care you provided ( or denied) to their loved ones. I deal with this every day as a hospitalist. Many families are clueless and I spend an enormous amount of time explaining that dementia is a terminal illness and there is little we can do to change the trajectory. I think it is reasonable to give antibiotics, a limited amount of IV fluid support, good general nursing care, speech evaluation and modification of diet when indicated. Some families can accept the inevitable and appreciate your efforts to help their loved ones, others are unreasonable and demand multiple subspecialist consultations ( eg. neurology, pulmonary, GI, you name it) with no real change in the plan or outcome but a whole lot more testing and interventions of dubious value. I for one am not likely to argue with families. If they demand a neurology consult for dementia or GI for a PEG tube ( even after I explain there has never been a study to show they prolong quantity or quality of life) I get the consult. After all dead patients never sue you, but their families can easily find a med mal lawyer willing to listen to their complaints about the care you provided ( or denied) to their loved ones.

]]> By: Ralphhttp://www.kevinmd.com/blog/2009/11/people-dementia-die.html#comment-118089 Ralph Wed, 11 Nov 2009 18:59:53 +0000 http://www.kevinmd.com/blog/?p=41232#comment-118089 Families are often unprepared to deal with the end of life issues even when the patient has a severe dementia. I have intubated several patients just because the family could not decide if they wanted to withhold care. Physician - family communication in an outpatient settings is very important to deal with this issue. Families are often unprepared to deal with the end of life issues even when the patient has a severe dementia. I have intubated several patients just because the family could not decide if they wanted to withhold care.
Physician – family communication in an outpatient settings is very important to deal with this issue.

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