10D&D.post (1).ppt - Lecture 9 1 Mental Illness(finish...

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Unformatted text preview: Lecture 9: 1. Mental Illness (finish) 2. Long Term Care 3. Death and Dying Course of Schizophrenia Highly Highly variable variable long-term long-term outcome outcome •20-25% improve completely •10% remain impaired •50-70% some improvement •Pre-schizophrenic children - more academic difficulties, lower IQ •Most evolve into a nonpsychotic state with chronic negative symptoms •Most function in the community (i.e., not institutionalized) •10% commit suicide Schizophrenia: Cause • 1980’s-major shift in understanding – Critical mass of studies led to current view of SP as a neurodevelopmental disorder – Long-term consequence of an early (most likely prenatal) abnormality in neural development – Lies silent until affected brain regions (most likely DLPFC) are called upon to function Schizophrenia- Genetics • General Population: 1% – Sibling: 8% – Parent: 12% • Concordance rates: (twin studies) – 45% MZ – 14% DZ • Estimate that 60-70% of liability may be genetic – No single gene has been identified, most researchers assume polygenic model (NIMH) • Vulnerability/Stress Model – Neurodevelopmental factors (non-genetic) interact with a genetic predisposition Shared Genetic Roots • Autism, ADHD, bipolar disorder, major depression and schizophrenia were associated with genetic variation at the same four chromosomal sites. – These included risk versions of two genes that regulate the flow of calcium into cells. Major Mental Disorders in Adulthood: Personality Disorders Cluster A •Schizoid: lack of interest in social relationships •Schizotypal: odd behavior or thinking •Paranoid: irrational suspicions and mistrust of others Cluster B •Borderline: instability in relationships, self-image, identity and behavior •Histrionic: attention seeking behavior, shallow/exaggerated emotions •Narcissistic: grandiosity, need for admiration, and a lack of empathy •Antisocial: disregard for the law and the rights of others Cluster C •Avoidant: social inhibition, feelings of inadequacy, extreme sensitivity to negative evaluation, avoidance of social interaction. •Dependent: pervasive psychological dependence on other people •Obsessive-compulsive: rigid conformity to rules, moral codes and excessive orderliness Personality Disorders Maturation Hypothesis Aging Aging associated associated with with decrease decrease in in ““immature immature”” personality personality types types Improvement Improvement in: in: Worsening Worsening of: of: •Borderline (B) •Histrionic (B) •Narcissistic (B) •Antisocial (B) •Obsessive-compulsive (C) •Schizoid (A) •Paranoid (A) Treatment Issues: Considerations with Psychotherapeutic Medications for Older Adults •Take longer to clear excretory system •Polypharmacy risk However However •Medications have effectiveness rate of 50-70% •Particularly when combined with psychotherapy Treatment Issues: Therapy Specific Concerns of Work with Older Adults Generational Generational differences differences •Older adults more skeptical about process •Sensory and cognitive impairments in client •Therapist younger than client •Older take longer to benefit However, therapy can yield positive outcomes Death and Dying: Key Points • Attitudes towards death • End of life decision making – Advanced Directives – Palliative Care/Hospice Care – Physician Assisted Suicide/Euthanasia Technical Perspectives on Death Definition of death •Irreversible cessation of circulatory and respiratory functions •All structures of brain have ceased to function Complicated by: Persistent Persistent vegetative vegetative state state •Subcortical areas intact •Lack of conscious awareness Medical Aspects of Death Physical symptoms of imminent death •Asleep most of time •Disoriented •Irregular breathing •Hallucinations •Reduced vision •Changes in autonomic bodily functions •Anorexia-cachexia syndrome- loss of appetite and muscle atrophy Mortality Facts and Figures Compression of Mortality WORLD WORLD ••Decreases Decreases in in under-5 under-5 rates rates ••Increases Increases in in over-65 over-65 rates rates Due to largest changes in developing countries Mortality Facts and Figures Changes in Mortality Rates ••Fewer Fewer deaths deaths of of under-5 under-5 ••More More deaths deaths of of over-65 over-65 LEAST LEAST DEVELOPED DEVELOPED Mortality Facts and Figures Changes in Mortality Rates DEVELOPED DEVELOPED ••Over-65 Over-65 already already high high ••Middle-aged Middle-aged will will show show greatest greatest decrease decrease Mortality Facts and Figures Compression of morbidity • Healthy lifestyle associated with shorter period of disability before death – Risk-free group (no smoking, physically active, normal weight) close to 0 disability for decade prior to death (Hubert et al., 2002) cultural perspectives …history of attitudes in Western society Tame Tame death death End End of of self self Early Later 1700s middle ages middle ages Remote Remote death death 1800s Beautiful Beautiful death death 1950s+ Invisible Invisible death death cultural perspectives …history of attitudes in Western society Tame Tame death death End End of of self self Early Later 1700s middle ages middle ages Remote Remote death death 1800s Beautiful Beautiful death death 1950s+ Invisible Invisible death death cultural perspectives …history of attitudes in Western society Tame Tame death death End End of of self self Early Later 1700s middle ages middle ages Remote Beautiful Remote Beautiful death death death death 1800s 1950s+ Invisible Invisible death death cultural perspectives …history of attitudes in Western society Tame Tame death death End End of of self self Early Later 1700s middle ages middle ages Remote Remote death death Beautiful Beautiful death death 1800s 1950s+ Invisible Invisible death death cultural perspectives …history of attitudes in Western society Tame Tame death death End End of of self self Early Later 1700s middle ages middle ages Remote Beautiful Remote Beautiful death death death death 1800s 1950s+ Invisible Invisible death death Cultural Perspectives Contemporary Attitudes in Western Society Changes Changes in in health health care care •Death associated with later life •Has become “invisible” •People rely on media images •Sentimental death •Death of famous person •Disasters Ageism Ageism •Fear of aging itself •Fear of loss of capacity Death Death with with Dignity Dignity •Physician-assisted suicide •Euthanasia The Dying Process: Stages of Dying Kübler- Ross 5 Stages of Dying Denial Refusal to accept diagnosis Anger Feeling cheated or robbed Bargaining Attempt to strike a deal with God Depression Sense of loss when death seen as inevitable Acceptance Finality of disease is no longer fought Acceptance Acceptance requires requires ability ability to to talk talk openly openly about about death death The Dying Process: Stages of Dying Criticisms of Kübler- Ross •Five stages have become interpreted as steps that MUST be followed •Theory written about relatively young patients •Ignores other emotions that might be experienced •Researchers unable to establish existence of the stages The Dying Process: Palliative Care Findings from the SUPPORT Study (1995) •Interviews with over 9000 patients and family members •Majority preferred to die at home but most died in hospital •Dying patients suffered from severe pain (40%), difficulty breathing, and confusion •Majority preferred palliative care but instead were given life-sustaining- known as overtreatment The Dying Process: Palliative Care/Hospice Care • Palliative Care • focus is on pain and symptom management • patient does not have to be terminal • may still be seeking aggressive treatment • Hospice • focus is on pain and symptoms management • patient has a terminal diagnosis with life expectancy of less than six months • not seeking curative treatment The Dying Process: Palliative Care/Hospice Care in Canada • Palliative Care: term coined by Balfour Mount, Canadian MD – Word “hospice” used in France for nursing homes – Created specialized ward in 1975, RVH Montreal • Current use in Canada – Estimated that 95% of deaths would benefit • Only ~ 30% of Canadians have access to palliative care/hospice • Most wish to die at home, yet ~75% of Canadians die in hospital/care facilities • Billing schedules focus on procedures; may discourage palliative care • Only 200 palliative care physicians – Most care provided by GP’s – Canadian Virtual Hospice ( ) End of Life Decision Making • CPR (Cardiopulmonary resuscitation): will almost always be started unless there is a DNR order. • DNR (Do not resuscitate): Order on medical chart stating that extraordinary measures should not be used to attempt to save life • Advance directives/living wills: directions given by a competent individual concerning what and by who decisions should be made in case of incompetence – instruction directives: establish what and/or how health care decisions are to be made • Eg: woman has signed document that states that, should she fall into a persistent vegetative state, she does not wish to receive artificial hydration or nutrition. – proxy directives: establish who is to make health care decisions. • Eg: a man has signed a document that states that, when he is incompetent, he wishes his wife to make all health care decisions on his behalf. Advance Directives/Living Wills • 80% of Canadians agree that people should start planning for end of life when they are healthy. • 70% of Canadians surveyed have not prepared a living will. • 47% of Canadians have not designated a substitute decisionmaker to make healthcare decisions for them if they are unable. • Fewer than 44% Canadians have discussed end-of-life care with a family member. • Although Canadians feel that end-of life care is an important discussion to have with a physician, only 9% have done so. • 31% of health care providers provide aggressive treatment despite patients AD expressing wishes to the contrary Canadian Hospice and Palliative Care Association (2010) Advance Directives/Living Wills • Significant costs for overtreatment – US: 2009: Medicare paid $55 billion for patients in last two months of life – Canada: 20% of all health spending occurs in the last year of life Advance Directives/Living Wills Terri Schiavo Case • • • • • • February 25, 1990, age 26: severe brain damage caused from cardiac arrest, – Cause: bulemia – Dx: PVS 1992: 1 million $ lawsuit; most spent on rehabilitation (not successful) 1998: husband petitions court to have feeding tube removed Law calls for courts to apply what Terri would have wanted March 18, 2005: feeding tube removed for the 3rd time Died on March 31, 2005 at the age of 41. Royal Society of Canada Expert Panel: End-of-Life Decision Making, November 2011 SUMMARY OF MAIN FINDINGS • Canada performs poorly in ensuring access to high quality palliative care. • Canada needs to resolve uncertainties about the legal status of withholding and withdrawal of potentially life sustaining treatment without the consent of the individual. • The legal uncertainties about palliative sedation should be resolved and practice guidelines should be developed and implemented. • Evidence from other jurisdictions does not support claims that decriminalization will result in vulnerable persons being subject to abuse. • Assisted suicide and voluntary euthanasia should be legally permitted for competent individuals who make a free and informed decision that their life is no longer worth living to them. The Dying Process: Issues in End-of-Life Care Terminology: Physician-assisted Physician-assisted suicide suicide Euthanasia Euthanasia Individuals choose suicide and physician assists in ending life Physician’s action causes death Can be “passive” or “active” Terminology: Passive Euthanasia • Passive euthanasia: The deliberate disconnection of life support equipment, or cessation of any life-sustaining medical procedure, permitting the natural death of the patient. – Withholding of potentially life-sustaining treatment: failure to start treatment that has the potential to sustain a person's life. • Eg: not providing CPR – Withdrawal of potentially life-sustaining treatment: stopping treatment that has the potential to sustain a person's life. • Eg: removal of a ventilator Terminology: Passive Euthanasia • Palliative sedation: umbrella term used to explain intermittent and continuous as well as superficial and deep sedation. – Terminal Sedation/”Snow”: is potentially life-shortening deep and continuous sedation intentionally combined with the cessation of nutrition and hydration • Controversial; criminality based upon intent Assisted Suicide: Terms • Assisted suicide: intentionally killing oneself with the assistance of another. • Physician-assisted suicide: Doctor provides lethal drugs with which a dying person may end their life. • Competent/competency: capable of understanding and appreciating the relevant information and the nature and consequences of the decision to be made. – may be competent for one decision and not another – may be competent one day and not the next The Dying Process: Issues in End-of-Life Care The only places that today openly and legally, authorize active assistance in dying of patients, are: • Oregon (since l997, physician-assisted suicide only); • Washington (since 2008, physician-assisted suicide only); • Switzerland (1941, physician and non-physician assisted suicide only); • Belgium (2002, permits 'euthanasia' but does not define the method); • Luxembourg (since 2009, physician assisted suicide and euthanasia); • Netherlands (voluntary euthanasia and physician-assisted suicide lawful since April 2002 but permitted by the courts since l984). The Dying Process: Issues in End-of-Life Care • February, 2015: Supreme court of Canada ruled criminal prohibition of assisted death is unconstitutional – “Carter versus Canada” – Gave Parliament 1 year to draft legislation – Ruling applies broadly in cases of major illness, disease or disability that inflicts intolerable physical or psychological pain • June 17, 2016: – Physician assisted dying became law in Canada – Medical assistance is legal if the eligibility criteria are met and procedural safeguards followed Assisted Suicide in Canada: Eligibility Criteria (summary) • They are eligible for health services funded by a government in Canada; • They are at least 18 years of age and capable of making decisions with respect to their health; • *They have a grievous and irremediable medical condition; – May be physical or psychological • They have made a voluntary request for medical assistance in dying that was not made as a result of external pressure; and • They give informed consent to receive medical assistance in dying after having been informed of the means available to receive their suffering, including palliative care. *For details, see: Assisted Suicide in Canada: Procedural Safeguards (summary) • *Before providing assistance in dying, the medical practitioner must be of the opinion that: – the person meets all of the criteria and has made made a written request – the person has been informed that they may withdraw their request • And again immediately before – Be satisfied that they and the other medical practitioner making the request are independent – 10 clear days between request and decision *For details, see: The Dying Process: Issues in End-of-Life Care Physician-Assisted Suicide and Euthanasia Arguments in favor: •Individual’s right to make decision •Need to relieve suffering •Life can be extended beyond point of meaning Arguments opposed: •Promotes death as a solution to societies ills •Day to day variation in desire to end life •People who wish to end life are suicidally depressed •Not necessary with adequate pain control Individuals often site fear of resource-based decisions (BC) "The biggest fear is that we'll have the same situation as we have in the abortion situation," the Catholic Archbishop of Ottawa said this week. "We'd have teenagers deciding they don't want to live and they'd ask doctors to put them away," he added, even though the court has imposed restrictions on who may end their life with a doctor's help. Hmmm..? Let’s look at the evidence! The Dying Process: Issues in End-of-Life Care Oregon’s Death with Dignity Act ( ) • Requirements: – – – – Must be 18 Resident of Oregon Capable to make and communicate health care decisions Diagnosed with terminal illness that will lead to death in 6 months • Since 1998, 1,127 patients have died with physician assistance in Oregon The Dying Process: Issues in End-of-Life Care Characteristic of PAS Patients (1998-2016) • Sex – Male (51.6%) – Female (48.4%) • Median age (71) – Range (25-102) • Race – White (96.5%) • Marital Status – – – – Married (45.5%) Widowed (23%) Divorced (23.8%) Never Married (7.7%) • Education – – – – BA or higher (46.1%) Some college (26.7%) HS (21.5%) Less (5.6%) • Illness – Cancer (77.4%) • Lung: 17.1% – ALS (7.9%) – COPD (4.1%) – Heart disease (3.1%) Oregon Death with Dignity Act: (1998-2016) End of life concerns • Losing autonomy (91.4%) • Decreasing ability to participate in activities that make life enjoyable (89.7%) • Loss of Dignity (77%) • Losing control of bodily functions (46.8%) • Burden on family, friends/caregivers (42.2%) • Inadequate pain control (26.4%) • Financial implications of treatment (3.4%) ...
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