Monday, 22 February 2016

Don’t forget about those dying with dementia says Professor Ibrahim

Professor Joseph Ibrahim and colleagues from SPHPM’s Department of Forensic Medicine have published new research on the limitation of care orders (LCOs) in patients with a diagnosis of dementia in the journal Resuscitation.

With the prevalence of dementia in the community growing due to an ageing population, and most people with dementia dying in hospital as a result of an acute illness, Professor Ibrahim explores the complexities of the issues surrounding LCOs and providing good end-of-life care in the acute hospital setting.

Dementia is the term used to describe the symptoms of a large group of illnesses which cause a progressive decline in a person’s functioning. It is a broad term used to describe a loss of memory, intellect, rationality, social skills and physical functioning.

Patients with a diagnosis of dementia are unlikely to benefit from aggressive life-prolonging treatments, yet they receive the same care in the acute setting, including resuscitation therapeutics, as any other patient without regard to their significant morbidities.

New statistics released by Alzheimer’s Australia this month reveal that dementia is now the second leading cause of death in Australia, after heart disease, and that the number of Australians living with dementia is expected to triple by 2050.

Professor Ibrahim said that LCOs such as ‘Do Not Attempt CPR’ and ‘Physician Orders For Life Sustaining Treatment’ (POLST) appear to be underused in patients with dementia, which means that these patients receive the same aggressive life-prolonging therapies as any other patients, despite drastically higher mortality.

“The systems and processes for obtaining and documenting LCOs need improvement at the individual, organisational and societal level. The issue is controversial amongst the public and poorly understood by clinicians,” Professor Ibrahim said.

He said that dementia is under-recognised as a terminal condition. Patients over 75 years of age with advanced dementia have a three-year mortality close to 50 percent.

The mortality rate is even higher following an acute hospital admission. More than 50 per cent of patients with moderate dementia admitted for fractured neck of femur or acute pneumonia die within six months, compared to 13 per cent of patients without dementia.

“There is no accepted gold standard measure to quantify the quality of life in the presence of dementia. However, what is clear is that patients with dementia should participate in the decision-making,” he said.

He has urged for a greater debate around the topic of, “who and how we determine the assessments of quality of life and treatment abatement decisions”, as contemporary clinical practice faces the challenges of an ageing population with more dementia patients than ever before.

“Clinicians should be aware that their quality of life judgements may not be accurate, and that patients with mild to moderate dementia are often able to report on their quality of life, and are often incorrectly assumed not to have capacity, and thus left out of discussions about limitation of care,” Professor Ibrahim said.

Take a look below at Professor Ibrahim's video 'To Resuscitate or not?' discussing a case study of an elderly patient with dementia who has arrested.

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