Transcript To start – a patient who taught me

To start – a patient who taught me
• VG – age 57
• COPD with emphysema plus diabetes and
cataracts
• Referred by respiratory consultant because of
multiple hospital admissions with no benefit
Problems elicited
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Shortness of breath
Panic
Fear of going out
Poor sight – boredom
Repeated hospital admissions
Repeated calls to GP and health centre
Remedies
• Regular and p.r.n diazepam (following
discussion re prognosis)
• Respiratory retraining
• Direct access to GP
• (not to stop smoking)
• Cataracts done later that year
• Motorised wheelchair
• Council funded holiday
Results
• Panic attacks decreased
• Got out enough to visit family, shop and socialise
• SOB actually improved – able to cook a meal at
home
• GP contacts decreased – except at times of
stress
• No hospital admissions for next two years
• Sight much better
The Palliative Approach
- Can come to a decision that focus of care now palliative –
not able to correct much and prognosis poor
- Then think slightly differently – concentrate on
symptomatic treatment – non drug and drug
- Assessment of problems (in all domains)
- Plan for each problem - with prognosis in mind
- To coordinate care put into into an advance care plan
Which diseases?
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COPD and other causes of SOB
Heart failure
Renal failure
Neurodegenerative diseases
Prognostication – can we do it?
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Is medical treatment still working?
Is quality of life decreasing?
Is there significant co-morbidity?
The surprise question
• Put on a palliative register….
What does this do?
• Changes focus of care
• Alters risk to benefit ratio of treatments
• Should trigger a supportive needs
assessment - physical, psychosocial,
spiritual, information needs, legal, financial
issues…..
• Gives a problem list to work on
Leads to
• Problem list – which can try to address
systematically
• more solutions for problems
• Stop unnecessary treatments
• Advance care plan to co-ordinate care
COPD
• Prognostication?
• Opioids and benzodiazepines are Ok in
small doses
• Panic is a huge factor – so is depression
• Bronchodilators are addictive and difficult
to stop
• Fans are brilliant for some patients
Heart failure
• Palliative when can’t find balance between
oedema and renal failure
• Can make a joint heart failure and palliative
service
• Can use NSAIDs for general aches and pains
and leg ulcers
• Can stop all drugs with only long and medium
term benefits
• Terminally better to be a bit dry and in renal
failure than grossly oedematous
Renal failure
Three groups
- those where dialysis stopped
- Those where dialysis should be stopped
- those who choose supportive care and refuse
dialysis
- Again should be able to stop some drugs – but
more difficult
- Co-ordinated planning difficult
neurodegenerative
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Prognostication?
Difficult symptoms
Coping with illness
Speech and feeding difficulties
Advance planning
Social and respite services
Lesson of this lecture
Careful elicitation of problems
and thoughtful use of palliative remedies
together with careful advance planning
can really improve quality of life even in very ill
people.
And we can learn gradually how to do it better