ࡱ> '`  (bjbjLULU ;x.?.?d@@@@  [[[[|\ $]:^]^]^]^]f>g/g $h@ iefii@@^]^]ȧmmmi@Z^] ^]mimml ^]] = 9[Fj~U*ާ0jZkZTZ ;gghm5hTh ;g;g;gZm(;g;g;giiii /9D" 9 @@@@@@   Section of Geriatrics & Palliative Medicine Geriatric Pager: contact 2100 on call Palliative Care Pager: 188-7255 PALLIATIVE CARE COMMUNICATION End of Life (EOL) & Death Successful Communication: PROVIDE THE BIG PICTURE CLARIFY PROGNOSIS PROVIDE TIME TO DIGEST INFO EMPATHY RELATIONSHIP BUILDING NEGOTIATION CLARITY IN COMMUNICATION   Cancer Syndrome Survival Estimate Malignant Hypercalcemia 8 weeks Malignant Pericardial Eff 8 weeks Carcinomatous Meningitis 8-12 weeks Multiple Brain Mets 1-2 mo no XRT 3-6 mo XRT Malignant Ascites <6months Malignant Bowel Obst. <6 months _______________________________ Cease Dialysis 8-12 days Cease Eating 14-21 days ADAPTED FAST FACT 13 WALTER PROGNOSTIC INDEX: For 1 year prognosis in patients age 70 and older Factor Points Male Gender 1 v ADL dependence at discharge In 1-4 2 v In all 5 Congestive Heart Failure 2 v Cancer Solitary 3 v Metastatic 8 Createnine >3.0 2 v Albumin 3.0-3.4 1 v <3.0 2 Total z v 1 YEAR MORTALITY: 1-4 points 4% 2-3 points 19% 4-6 points 34% >6 points 64% HOW TO USE THIS INDEX: For patients in the highest risk category, consider hospice or preparing for EOL care. Also consider omitting interventions that only have long term mortality benefit (like cancer screening). From: Walter et al. JAMA 2001 Death Phase Symtoms to Expect Days-Weeks Sleepy-Agitated Bed bound Hours-Days No oral intake Decreased Urine Final Hours Apnea, Rattled breathing Cool & mottled limbs  You will not be right 100% of the time! Ask open-ended questions Give big picture (Layman, 2-3 major points) Direct eye contact Sit rather than stand Acknowledging patient/family emotions Empathy (listen, reassurance, respect) Utilize support services (SW, chaplain, nurse) Determine patient ability to participate Establish surrogate for decisions if impaired. Divert stress of decision making away from surrogate by: 1) focusing on patients values & stated wishes 2) physician providing recommendations Clarify prognosis (weeks-months). Clarify treatment options. Discussion of patient values and QOL wishes.  Preparation for discussion Introductions Assess patient/family Understanding of condition & prognosis Assess expectations of disease, hopes of life Discussion of realistic goals of care (GOC) Address emotions and listen empathetically Establish /documentation GOC with additional focus on treatment priorities and plan. Adapted Von Guten , JAMA 2000  How long do we have? What if God intends a Miracle? Isnt this giving up? Do you really know who my mother/father is and what you are asking me to do? Should we go to ____ Treatment Center? Why didnt Dr.____ find this earlier? If my pain gets bad will you help me end this? What would you do if you were in my shoes? Do you understand my viewpoint?  Many patients Ive seen with similar stage disease live days-weeks, weeks-months. If a miracle is what you believe and what God intends it will happen irrespective of what we do. Gods miracles are His to decide and may differ from our hopes. God sometimes gives death as a miracle relief of suffering. We are not holding any care that will help or reverse this process. These decisions must be very difficult. There is no right or wrong choice. Though we cant cure her disease we can aggressively treat the symptoms of her disease. Our medical team will support you thru every step of your illness, making sure to control pain & suffering.  IDENTIFY patient (ID bracelet) Describe patient color and appearance Note lack of response to verbal stimuli Note size pupils and lack of reflex Look/listen for absent breath sounds Lack of carotid pulse, heart tones Note time of death pronouncement Dignify the patient: cover body/secretions Discontinue monitors, oxygen, alarms  Setting up: Read chart, Quiet setting Perception: Allow family to process of situation & clarify/reassure misperceptions. Invitation: Warning shot , assess support Knowledge: Convey info layman terms Mr. Smith died at 8:45 this evening. Emotions: Silence ok, let them tell patient story. Safety/Strategy of care: Safety/support of family Would you like to come to the hospital? When will you arrive? If not coming establish autopsy & special requests.  Verbal tone important: soft, not rushed Express sympathy: This must be difficult for you, Sorry for your loss. Listen ( Silence is ok). Ask if questions-lengthy explanations, medical jargon may be confusing and overwhelm. Assure support system and safety of family member before ending call.  Did he suffer? Was he in pain? Did they delay hospitalization too long? Was he alone? Can I touch him? Can I stay with him? What will I do without him? Special considerations: Religious rituals  If you have knowledge of the patient being peaceful or without distress, state to family. Reiterate that death is unpredictable, this would have happened no matter what. Remind them they may hold hand or touch. Let family stay in room. Most hospitals 3-6 hr* Allow time to reflect and digest situation. Offer to contact family, call chaplain or SW.  Date and Time of Death Name of provider pronouncing death Brief statement of cause of death Absence of pulse, respiration, pupil response Note condition of body Family present, informed? Note family response if indicated Notification of attending, SW, pastoral care Note autopsy or donation request  SHIFT CARE TO FAMILY! Remove lines, monitors, tubes Establish care for family (answer questions, allow time in room, notify other family, chaplain) Establish donation and autopsy wishes Establish timing for morgue transfer Document death: chart, hospital forms Care for yourself: Talk, exercise, rest  Lists in sequential order below: Immediate cause of death (End disease complication which lead to death (pulmonary embolus), not mechanism (respiratory arrest) Conditions that resulted in the immediate cause of death (e.g., gunshot wound, DVT, lung ca) Other significant medical conditions (e.g. hypertension, atherosclerotic coronary artery) http://www.cdc.gov/nchs/data/dvs/blue_form.pdf  King DA, Quill T. Working with families in palliative care: one size does not fit all. J Pall Med. 2006; 9:704-715.  HYPERLINK "http://www.eperc.mcw.edu/EPERC/FastFactsandConcepts" http://www.eperc.mcw.edu/EPERC/FastFactsandConcepts  HYPERLINK "http://champ.bsd.uchicago.edu/documents/PCPocketCard2010.pdf" http://champ.bsd.uchicago.edu/documents/PCPocketCard2010.pdf  HYPERLINK "http://champ.bsd.uchicago.edu/PalliativeCare/index.html" http://champ.bsd.uchicago.edu/PalliativeCare/index.html http://www.medscape.com/viewarticle/716463_7 Developed By: Shellie Williams, M.D. University of Chicago Medical Center Section of Geriatrics and Palliative Medicine PROGNOSTICATION: DEATH CERTIFICATE: DEATH WORDS THAT MATTER: Notification-What Families Fear: WHAT FAMILIES WANT TO KNOW? EOL COMMUNICATION WORDS THAT MAY MATTER: WHAT FAMILIES WANT TO KNOW: DEATH CHART DOCUMENTATION: PHONE NOTIFY: NOTIFICATION: WORDS THAT MAY MATTER: PRONOUNCEMENT OF DEATH: SPIKES APPROACH TO NOTIFY: NOTIFICATION WORDS THAT MAY MATTER: RESOURCES: RRRERrRCARERESOURCES: AFTER DEATH CARE DEATH EOL COMMUNICATION 101: 7 STEPS TOWARDS GOALS OF CARE: UVwxzķqqqcUG8hFht^569CJ$aJ$hFht^56CJ$aJ$hFhD56CJ$aJ$hFh,56CJ$aJ$ *hqhD5CJ0aJ0 *hqh@MR5CJ0aJ0 *hqh?9W5CJ0aJ0 *hqh":p5CJ0aJ0 *hqhF5CJ0aJ0 *ht^5OJQJ^J *h^55OJQJ^Jht^h^5CJaJht^h@MRCJaJhFh^59jhFhKa?9UhG/Vwxyz ]^gdF$]^a$gdF$@ p]@ ^pa$gd":p$@ p]@ ^p`a$gd":p$@ p]@ ^pa$gd!$@ p]@ ^pa$gdKa?% (   $ , 5 Ү|j|j[I:hq59B*CJ,aJ,ph#hqhD59B*CJ,aJ,ph̙hq59B*CJ,aJ,ph̙#hqhD59B* CJ,aJ,ph3#hqht^59B* CJ,aJ,ph3hqhF59CJ,aJ,#hqhP 59B*CJ,aJ,ph#hqh?9W59B*CJ,aJ,ph#hqh,59B*CJ,aJ,ph#hqhD59B*CJ,aJ,phhFhD56CJ$aJ$hFht^56CJ$aJ$ , K ` }}}$a$gd":p$  @ p]@ ^pa$gd":p$@ p]@ ^p`a$gd":p $@ ]@ a$gd":p`]`gdq@ ]@ gdF]gdq0]0gdF`p`]`^p``gd":p@ ]@ ^`gdF5 K T ` i ̾}g[OCOC1#hqh5CJ OJQJ^JaJ hqh5CJ aJ hqhKa?5CJ aJ hqh?9W5CJ aJ +jhqhq5CJ UaJ mHnHuh":ph?9W5CJaJ hFh?9W5B* CJ$aJ$phf#hqh?9W59B* CJ,aJ,phf#hqhD59B* CJ,aJ,phfhqhF59CJ,aJ,#hqhD59B*CJ,aJ,phfhq59B*CJ,aJ,phf#hqhD59B*CJ,aJ,ph  G  Plh]^hgdq Plh]^hgdqgdq Hgdq$a$gd":p v |    ÷rgr\r\rPD8h(56CJ\aJhqh5CJ(aJ(hqh15CJ(aJ(h5CJ(\aJ(hq5CJ(\aJ(hqh5CJ(\aJ(&hqh5>*B* CJ(\aJ(phhqh5>*CJ(\aJ(&hqh5>*B* CJ(\aJ(ph3hFhq5CJaJh5CJaJhFh5CJaJ.jhFh5CJU\aJmHnHuh5CJOJQJ^JaJG }  < p < = wrrrrgdq Pl]gdq lh]^hgdq Plh]^hgdq P!#%h]^hgd Plt"(#`h]`^hgdq Plh]^hgdq = N \ ] ^ i j    * 5 6 ? J K V wlwldlwlwldlwlhgsCJ$aJ$hhF"CJ$aJ$ *hhF"B*CJ$aJ$ph *hgsCJ$aJ$ *hhqCJ$aJ$ *hhF"CJ$aJ$hhF"5CJ$aJ$hqhF"CJ aJ #hqhF"5>*B*CJ aJ ph#hqh5>*B*CJ aJ phh(hS 6CJ\aJh(h(6CJ\aJ'= N k  7 ? X v ]gdgs ]`gd ]`gdF"`gdqV W X t v  BZ˹|qh_VB&hgshv85>*B* CJ(\aJ(ph3hv86CJaJh":p6CJaJh6CJaJhgshCJ aJ hgsCJ aJ hgshgsCJ aJ hgshF"CJ aJ hgshF"5>*CJ aJ hhF"5B*CJ(aJ(ph# *hhF"5B*CJ(aJ(ph *hhF"5CJ(aJ(hhqCJ$aJ$hhF"CJ$aJ$ *hhF"B*CJ$aJ$phJ=  & F P]gd & F P]gdgs Pdh]d^hgd?9W P!D]Dgdgs PD]Dgdgs|]|gd":]{ $<sʿʿʿʿʿʱʥsssg[Oghhr5CJ(aJ(hh?9W5CJ(aJ(hh?9W5CJ(aJ(hh?9W5CJ(\aJ(h?9W5OJQJ\^J,jh5OJQJU\^JmHnHuhh(6CJaJhgshv85CJ$\aJ$hgs5CJ(\aJ(hgshv85CJ(\aJ(&hgshv85>*B* CJ(\aJ(ph3&hgshv85>*B* CJ(\aJ(ph #Ipah^hgdr & F & Fgd?9Wh^hgdJ & Fgd & Fgd":p & F P]gd & F P]gd"JP`ad¶¤˜Œ­¶ƒwhYh=5CJOJQJ^JaJh ~5CJOJQJ^JaJhgshv85CJ(aJ(hgs5CJ(aJ(hh ~5CJ(aJ(hhr5CJ(aJ(h5CJ(aJ(hJ5CJ(aJ(hh5s5CJ(aJ(hh?9W5CJ(aJ(hh":p5CJ(aJ(hh?9W5CJ(\aJ(hhr5CJ(\aJ(h5CJ(aJ( (>Lr~%LTijkmnops¶xsniZKZjh5UmHnHuh5CJOJQJ^JaJ hv85 hF5 h?9W5h(h ~6CJaJh(hr6CJaJh(h5s6CJaJh(h ~5CJ(aJ(h(hr5CJ(\aJ(h(hr5CJ(aJ(hrh5 hr5hrh?9W5h?9W5CJOJQJ^JaJ1jhr5CJOJQJU^JaJmHnHu(ZkLjklmnoqrstuvw ^`gd5sh^hgd ~ & Fgd ~h^hgdr & Fgdrsvw3"#Tty  3սthhhhhh_h_h_h_h_h_h5CJ(aJ(h(hk0X5CJ(aJ(1jh5CJOJQJU^JaJmHnHuh=5CJOJQJ^JaJ#h(h(5CJ(OJQJ^JaJ(h(5CJ(OJQJ^JaJ(h=5CJ(OJQJ^JaJ(h(5CJ(aJ(h(h ~5CJ(aJ(h5CJOJQJ^JaJh5CJOJQJ^JaJ%w5[  !&^gd( & F  !&gd(Dt4d:jh^hgdq:gdq: & Fgdq:h^hgdt^ & Fgdt^h^hgd & Fgdh^hgdk0Xgdk0X & Fgd ~:hnXq   67oq  ͹yypypypyphv85CJ(aJ(h(hq:5CJ(\aJ(h(hJ5CJ(aJ(hb5CJ(aJ(h(h ?5CJ(aJ(h(hq:5CJ(aJ( hq:5jhq:5UmHnHu hv85 hS 5h(hS 5CJ(aJ(h(ht^5CJ(aJ(h(h ~5CJ(aJ(h5CJ(aJ(,)Mr    6i & Fgdv8 & Fgdq:gd=^gd ? & Fgd & Fgdq:gd ?h^hgdq: @t,y23gd ? & Fgd ?h^hgd8l & Fgdv8 & Fgdq:h^hgdq: & Fgdv8h^hgdv8 & Fgdq:?@Fux,7`b01245ufM1jh8l5CJOJQJU^JaJmHnHuhF5CJOJQJ^JaJhv8hF5CJ(aJ(hJ5CJ(aJ(h(h8l5CJ(aJ(#h(hb5CJ(OJQJ^JaJ(1jhq:5CJOJQJU^JaJmHnHuhq:5CJOJQJ^JaJhv8h5CJ(aJ(h(hq:5CJ(\aJ(hv85CJ(aJ(h(hq:5CJ(aJ(346789:Z1d: & F gdJh^hgdb & F gdb & F gd ? & F gd8lgd ?59:15s  9fghijklmnƭҡ҉zk^Qh5>*B* \ph3h(5>*B* \ph3hJ5CJOJQJ^JaJhF5CJOJQJ^JaJhEH5CJOJQJ^JaJhJ5CJ(aJ(h(hb5CJ(aJ(1jh5CJOJQJU^JaJmHnHuhv8h8l5CJ(aJ(h(h8l5CJ(aJ(#h(h8l5CJ(OJQJ^JaJ(h8l5CJOJQJ^JaJ:ijklmnpq  2 U gdEHT]TgdF & F7$8$H$gdJ & F7$8$H$gd h7$8$H$^hgd PT]TgdFgd ? & F gd ?noq    0 1 2 T V W q ȹȹȹȪȪȹȪȹȪȏqbShS 5CJOJQJ^JaJhv85CJOJQJ^JaJhF5CJOJQJ^JaJhJhFB*CJ(aJ(phh5B*CJ(\aJ(phhJB*CJ(aJ(phhJ5B*CJ(\aJ(phh(hB*CJ(aJ(ph#h(h5B*CJ(\aJ(phhhB*CJ(aJ(ph+jhB*CJ(UaJ(mHnHphu !!!!!!!!!!";#<#=#>#l#׼|nbVD#h(h,56B*CJaJph333hv8hv85CJ(aJ(h(h=5CJ(aJ(h(hEH5>*CJ(aJ(h1T5CJOJQJ^JaJ1jh1T5CJOJQJU^JaJmHnHuhF5CJOJQJ^JaJhv85CJ(aJ(h(hEH5CJ(aJ(h5CJOJQJ^JaJhEH5CJOJQJ^JaJ1jhEH5CJOJQJU^JaJmHnHu !A!g!!!!!!!!!"*"W""""# & FgdEH hh^h`hgdEH & F gdEHgdEH#>#m#n#o#p#q#s#t#u#v#w#####i$j$$$w%x%%%gdgd,qgdqGWh^hgdDgdF"gd ? hh^h`hgdv8l#m#n#q#r#u#v#w###########2$δymy^ymyRmAR jh(hF"5CJ$UaJ$h(hF"5CJ$aJ$h(hk0X56CJ$]aJ$h(hqGW5CJ$aJ$h(hk0X5CJ$aJ$h(hF"CJ(OJQJaJ(hF"B*CJOJQJaJph333hDB*CJOJQJaJph3333jhDB*CJOJQJUaJmHnHph333uhS B*CJOJQJaJph333hy5CJOJQJ^JaJ#h(hy56B*CJaJph3332$3$4$g$h$i$j$k$$$$$$$$$<%=%>%u%v%w%x%%%ۼۼېkXLh(h,q5CJ$aJ$$h(hqGW0J5B*CJ$aJ$ph&j8h(hqGW5CJ$UaJ$ jh(hqGW5CJ$UaJ$h(hD5CJ$aJ$&jh(hF"5CJ$UaJ$h(hqGW5CJ$aJ$h(hF"5CJ$aJ$$h(hF"0J5B*CJ$aJ$ph jh(hF"5CJ$UaJ$&jZh(hF"5CJ$UaJ$%%%%%% &'&8&9&L&Q&R&S&d&e&f&g&&&&&&&&&' ' 'øxoxfxx]xTHhh5CJ0aJ0h5CJ0aJ0h(5CJ0aJ0hJ5CJ0aJ0h5CJ0aJ0hh,5CJ0aJ0hF"h1T5 h1T5hh1T5CJ0aJ0hqh5CJ0aJ0h,hqh,CJ$aJ$hqh,CJ(aJ(#hqh,5CJOJQJ^JaJhq5CJOJQJ^JaJh(hF"5CJ$aJ$h5CJOJQJ^JaJ%%%%%% &!&"&#&$&%&&&'&8&9&L&R&S&f&g&&&&&gd8lgdbgd1Tgd$a$gdH $  a$gdHgdD&&&&&& ' ''&'='>'V'W'r''''''''''''$a$gd?9WgdEHgdv8gdq:gdgd ~ '''$'%'&'<'='>'V'W'q''''''''''''''''' ( ( ( (ĸĠ}qh(hF"5CJ$aJ$hA{#hh,5CJ0OJQJ^JaJ0hF"hEH5 hEH5hhEH5CJ0aJ0hv8h,5CJ0aJ0hgshv85CJ(aJ(h,hrh,5 h,5hh5CJ0aJ0hh,5CJ0aJ0h5CJ0aJ0hv85CJ0aJ0' ( ( ( (gdDgdr9&P1h0:p":p`' C! " # $ % ZDd  N  C *Auch_logobZ3i1pAL#;DnZ3i1pAL#;PNG  IHDRC{PLTEٌKḞpppyyyƒiextЩ-'<6٦ZUҗߵѳfffa]!tRNS!bKGD k= cmPPJCmp0712Hs$IDAThC[v:U$˒-[r689tz: mOBN%4^*ڣ8jLER-AZܾGzoMoD:J;̮ dֱk!澯hT:NugWOh6҅P&V ̮e\Uմ,ŰT' ๔切A٬4o9ɇD!?B7z?u -TYrDžj[fn֋Ps_@El,Ere c?H޷El; `9#6S˞CN/f$L1[8[/k-o9#C`x_!V.BNVmsbC{a)6 Mww^!o3gU?|7tB+(muT?릇XaLm>izmӺpjN6%u%SDY6vN`SN1y:i6٩y#ZE Tc5MAI,&W i|0d\k ~^^؀S"BhnCxp+iS&!Qx%< X0O :Dj]'̟WNͅE7O?4%XX;W[׶b$X2bv) ,Wz4¯Ɉ OlG:G!H7.@@xQAMWI-F~^8lSi ` Gڛi2<{`U LYm%~*> W61c-aOw]9i16ָD"y ,/UyQjc`%2%^T} ~2@P]*J֐"_<"}6@"ZB)D?sV4TM&lqKOc< Jܴܭ LHh,meJFAK}e`桪t nrՊCwMAѽl"Eq{!g ȵ(~ i04$xM٣,YGp3|22q\q6\-Q.[=̧Y8K2Ļj"^n襖Ոm(k5 Hpj3;J@Yi#hlmSnrppxtL1Gzp5~U+O/krPe|\3p`&|F{G ųf-)%5r.)"&&@(̰ìϨE_"݅亘]s!Q6$g\{Hg#A%:xwZ%6= .^9[~riNi$.*12JC.ԂN&͜"u("\Wt|ȭ .ʦkTay6U^R5dߺ<͜ ^x J z2zfUu%FUREEyFsÓ]GI"qDRJR" Ibzm1RF%>A;;̄( ! QDb)^[CrT`"Zj^O:)gPTa@-@VQ@S 0M\aˊ%7@N (\qO(rYW"֪ܟ(hL[j1t0NfrW,ޕNXΌ;"|Qp<ƕ` D]NHY[2J?J2OFNӋSy&R!xT[vm46(M\w]|X,vL(AbꟿAL BRѶ֥&5A@ۿ|S'THL>uT4=ڳlON'Rz zLV ?j_PIENDB`]DyK 4http://www.eperc.mcw.edu/EPERC/FastFactsandConceptsyK http://www.eperc.mcw.edu/EPERC/FastFactsandConceptsyX;H,]ą'cDyK =http://champ.bsd.uchicago.edu/documents/PCPocketCard2010.pdfyK http://champ.bsd.uchicago.edu/documents/PCPocketCard2010.pdfyX;H,]ą'cmDyK 8http://champ.bsd.uchicago.edu/PalliativeCare/index.htmlyK http://champ.bsd.uchicago.edu/PalliativeCare/index.htmlyX;H,]ą'c@@@ @MRNormalCJ_HaJmH sH tH FBF D Heading 4dd@&[$\$5\DA@D Default Paragraph FontRiR  Table Normal4 l4a (k(No List6U@6 ! Hyperlink >*B*phB^B D Normal (Web)dd[$\$88 Dsmall1CJOJQJaJo(b"b JDefault 7$8$H$-B*CJOJQJ^J_HaJmH phsH tH Tw3T XTable Colorful 2:V0 j% jj0  j @56\]56B*\]`Jph56\]jCj jf Table Grid7:V00aQ0 qGW HTML Cite6]FVaF qGWFollowedHyperlink >*B*ph`d {|}~)Fc*BCc #a_ZYJIcQPNK^F H{|}~)Fc*BCcf      x/Vwxyz,K`G}<p <=Nk7?XvJ= # I p a  ( Z k  L j k l m n o q r s t u v w  5 [ Dt4d:j)Mr    6i @t,y2346789:Z1d:ijklmnpq2UAg*W>mnopqstuvwijwx !"#$%&'89LRSfg  &=>VWr 000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000@000@0000000 0 0 0 0 0 0 0 0 0 0 00 0 0 000000000 0 0 00 0 0 0 000000000000000 0 0 0 00 0 0 0 0 00000000000000000 00 00 00 00 00 00 000000000 0 0 0 0 0 0 0 000000000 0 00 0  0 0 0  0 0000000000 0 0 0 00 00000000 0 0 0 0 0 0 000000 00 0 0 0 0 00000000 0 0 0 0 0  0  0  0  0 0000000 0 0 00 0 0 0 000000 0 000 00 00000000000000000000000000000000000000000000000000000000000`00(0000000000000002/Vwxyz,K`G} <=Nk7?XvJ= # I p a  ( Z k  L j o q r v w  5 [ Dt4d:)Mr   6i @t,y46789:Z1d:ij2UAg*W>mnopqstuvwjwx 0000000000000@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@000@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@00@0@0@0@0@0@0@00000 0 0 0 0 0 0000 0 000000000 0 0 00 0 0 0 00000000 0 0 0 000 0 0 0 00000000000 00 0000 000 00000000 00 0 00 0 0 00000000 0 000 0  0 0 0 0000000000 00 0 00000000 0 0 0 0 0 0000000 00 000 00@ 0@ 0@ 0@ 0@ 0 @ 0 @ 0 0000 0 0 00 0 0 0 00000 0 000 00 0000000000000 001 0 0 05 005 V s5n l#2$% ' ( "$%'*-/12567: G =  w3: #%&' (!#&()+,.03489; (3gj=u XXX8cd@pc(   # ^#. STST#" ` h F S  "` h H S  "` h I S   "`  h J S   "`  b K C "` h N S  "` n P c $P "` h Q S  "` h Y S   "`   h Z S   "`   h ^ S  "`  h _ S  "`  h a S  "` h c S  "`  B S  ? o  4nq #g[ p@ah tFttHc$#tIht"tJDt"tP0!tNt"<tQ(#OtY(#tZ(# tc(#t^t_CtKxt _Hlt290028925 _Hlt290028926SS @@SS QQPQ$IQVQ+QlmQmQQQ`55B# # -   AJJ, 3 3   =*urn:schemas-microsoft-com:office:smarttags PlaceType= *urn:schemas-microsoft-com:office:smarttags PlaceName9 *urn:schemas-microsoft-com:office:smarttagsplace     ( X ]  g p $ ) X _ "y jq nr5=*6W^  333333333333333333333333333333RZ::{{$$ss!!'79QSSdeg  $%&<>Ujq  O|'HTΤB(|fBj GdGMPcX n)ޏ 2  :BBPjXQMsatC H}Hd/7:Zkޏ;`mȎ$ uoX\w>}~3fW|80^`OJQJo(hH^`OJQJ^Jo(hHopp^p`OJQJo(hH@ @ ^@ `OJQJo(hH^`OJQJ^Jo(hHo^`OJQJo(hH^`OJQJo(hH^`OJQJ^Jo(hHoPP^P`OJQJo(hH ^`OJQJo("  ^`OJQJo("  pp^p`OJQJo("  @ @ ^@ `OJQJo("  ^`OJQJo("  ^`OJQJo("  ^`OJQJo("  ^`OJQJo("  PP^P`OJQJo(" h ^`OJQJo( ^`OJQJo("  pp^p`OJQJo("  @ @ ^@ `OJQJo("  ^`OJQJo("  ^`OJQJo("  ^`OJQJo("  ^`OJQJo("  PP^P`OJQJo(" h ^`OJQJo( ^`OJQJo( pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo( ^`OJQJo( ^`OJQJo( ^`OJQJo( PP^P`OJQJo(h^`OJQJo(hH ^`OJQJo("  pp^p`OJQJo("  @ @ ^@ `OJQJo("  ^`OJQJo("  ^`OJQJo("  ^`OJQJo("  ^`OJQJo("  PP^P`OJQJo("  ^`B*o(ph. ^`hH. pLp^p`LhH. @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.h^`OJQJo(hH^`OJQJ^Jo(hHopp^p`OJQJo(hH@ @ ^@ `OJQJo(hH^`OJQJ^Jo(hHo^`OJQJo(hH^`OJQJo(hH^`OJQJ^Jo(hHoPP^P`OJQJo(hH hh^h`hH) ^`hH) 88^8`hH) ^`hH() ^`hH() pp^p`hH()   ^ `hH. @ @ ^@ `hH.   ^ `hH.h^`OJQJo(hH ^`OJQJo("  pp^p`OJQJo("  @ @ ^@ `OJQJo("  ^`OJQJo("  ^`OJQJo("  ^`OJQJo("  ^`OJQJo("  PP^P`OJQJo(" h^`OJQJo(hH ^`OJQJo("  pp^p`OJQJo("  @ @ ^@ `OJQJo("  ^`OJQJo("  ^`OJQJo("  ^`OJQJo("  ^`OJQJo("  PP^P`OJQJo(" h^`OJQJo(hH ^`OJQJo("  pp^p`OJQJo("  @ @ ^@ `OJQJo("  ^`OJQJo("  ^`OJQJo("  ^`OJQJo("  ^`OJQJo("  PP^P`OJQJo(" h^`OJPJQJ^J. ^`hH. pLp^p`LhH. @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.h^`OJQJo(hH ^`OJQJo("  pp^p`OJQJo("  @ @ ^@ `OJQJo("  ^`OJQJo("  ^`OJQJo("  ^`OJQJo("  ^`OJQJo("  PP^P`OJQJo(" h^`OJQJo(hH^`OJQJ^Jo(hHopp^p`OJQJo(hH@ @ ^@ `OJQJo(hH^`OJQJ^Jo(hHo^`OJQJo(hH^`OJQJo(hH^`OJQJ^Jo(hHoPP^P`OJQJo(hH ^`OJQJo( ^`OJQJo( pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo( ^`OJQJo( ^`OJQJo( ^`OJQJo( PP^P`OJQJo(h^`OJQJo(hH ^`OJQJo("  pp^p`OJQJo("  @ @ ^@ `OJQJo("  ^`OJQJo("  ^`OJQJo("  ^`OJQJo("  ^`OJQJo("  PP^P`OJQJo(" h^`OJQJo(hHh^`OJQJ^Jo(hHohpp^p`OJQJo(hHh@ @ ^@ `OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHohPP^P`OJQJo(hHh^`OJQJo(hH ^`OJQJo("  pp^p`OJQJo("  @ @ ^@ `OJQJo("  ^`OJQJo("  ^`OJQJo("  ^`OJQJo("  ^`OJQJo("  PP^P`OJQJo(" O :BM;`mBjB7:ZkdGMI $ uI MsaX H}Hd3fW|Q'H 2PKX\w)         2" Plaxc0RF0Ƌ1f}$Pvx"NF6Bz麞T#~PxN@^r&4)cm^z:NRi2xHVzR6 ~<9U&`аp          hb:\lN|4sZNv>0xPlaxc0RF0Ƌ1f}$Pvxk@[K@pBnv(X< nċ6Fz:_R&        x6 ܺmJU_ʕ4x        xN@^r&4)cm^z:NRi2xT6& >N`&~3         xE K\hǾsf~zr/U }J@6iy/S;"L#u lf/SZb}UN r][iE~r: L#u @e sN 6i4 xhSL#u \4E iE~h|zP-6i51 }J*n/S/b"UL#u 1iE~h_d?xhS>A|3d?e|){=xhS{{|3:mr]X^d?9L H &O?!|3\d?#b}U%xhS%h|w'L#u v-(xhSFOC(6i@)iE~v)B,e|)_@+ZRZuB,/1d?)2L#u O12d?? 3L#u N36i|3X {4b}U\4V7(/?2g>8v 9xhS>_9d?I:b}U6g,:6i+? }J(/?2g>8"A!ory[Ab}U3BL#u ]C!or'mkEH zmFb}U4J6i }JSrUuKxhSjM|3Or]O|3&O_@+zPxhS@e FzSh|\SL#u /S"q:wy+b@(. P@UnknownGz Times New Roman5Symbol3& z Arial7&  Verdana;Wingdings?5 z Courier New9Garamond"1hEDEDCl;5l;59  24d 2QHX ?@MR2  BSDISBSDIST             Oh+'0  0 < H T`hpx BSDIS Normal.dotBSDIS2Microsoft Office Word@F#@U*@9@9l;՜.+,D՜.+,@ hp  University of Chicago5'  Title< 8@ _PID_HLINKSAs78http://champ.bsd.uchicago.edu/PalliativeCare/index.htmlB=http://champ.bsd.uchicago.edu/documents/PCPocketCard2010.pdf.04http://www.eperc.mcw.edu/EPERC/FastFactsandConcepts  !"#$%&'()*+,-./0123456789:;<>?@ABCDEFGIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~Root Entry FU? 9Data =1TableHWordDocument;xSummaryInformation(DocumentSummaryInformation8CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q