Transcript Document

Palliative Care for the
Critically-Ill Patient
Justin Engleka C.R.N.P.
Associate Chief of Nursing
VA Pittsburgh Health System
[email protected]
FRH
PALLIATIVE CARE
INITIATIVE
GOALS:
1.
Describe palliative care philosophy
2.
Discuss benefits to the patient and provider
3.
Identify ICU patients appropriate
for palliative care
4.
Discuss how palliative care can help the
ICU patient
Divisions by Health Status in the Population and
Trajectories of Eventually Fatal Chronic Illnesses
Divisions in the Population
Major Trajectories near Death
A
Group 2
death
“Chronic,
not
“serious”
High
B
Group 3
Chronic,
progressive,
eventually
fatal
illness
RAND document WP-137, Living Well at the End of Life:
Adapting Health Care to Serious Chronic Illness
in Old Age, which can be found online at:
http://www.rand.org/pubs/white_papers/WP137/. Used with permission
Time
Example
CHF patients
Function
“Healthy,” needs
acute and
preventive care
Example
Cancer patients
Low
death
Low
High
C
Function
Group 1
Function
High
Time
Example
Patients with Dementia
3
death
Low
Time
How Americans Die
20% of Americans die4in intensive care units,
part of the 50-60% who die in hospitals
Palliative Care Philosophy
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Palliative care aims to relieve suffering and improve
quality of life for patients with advanced illness and
their families.
Palliative care is provided by an interdisciplinary
team and offered in conjunction with all other
appropriate forms of medical treatment.
Palliative care programs structure a variety of hospital
resources to effectively deliver the highest quality of
care to patients with advanced illness.
Source: http://www.capc.org/building-a-hospital-based-palliative-care-program/case/definingpc
Palliative Care Goals
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Assist patients, families, and health care
providers with end-of-life decisions.
Promote quality of life and provide symptom
management regardless of individual goals or
prognosis.
Balance treatment options with therapeutic
palliation
Facilitate movement between various
healthcare settings or outpatient programs
Who is Eligible for Consultation?
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Any patient suffering with a serious chronic or
terminal illness
Frail patients at risk for death who would benefit
from code status discussions
Patients in the ICU who are facing difficult treatment
decisions
Patients with intractable symptom management issues
Patients and families desiring information on end-oflife resources
Patients who are actively dying and meet criteria for
inpatient hospice
ICU Disease States: Who’s
Appropriate?
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Multi-System organ failure
Metastatic cancers
Cardiac arrest/CRP
Pending decision for treatment
(trach/PEG/HD/surgery)
Prolonged ICU stays/ failure to wean
Prolonged hospital stay/ multiple readmissions
Advanced age
General frailty
Isn’t Hospice and Palliative Care
Just for Cancer Patients?
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Palliative Care is for any patient suffering
from a life-limiting illness or INJURY
Patients who survive the ICU stay may still be
at risk for death due to secondary
complications
Palliative Care can follow these patients
throughout their hospital stay and discuss
goals, options, code status, and D/C options
Is Palliative Care Simply Hospice in
the Hospital?
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Palliative care embraces the idea that some
treatment options are necessary despite
terminal status
Patients electing palliative care in the hospital
do not have to enroll in a hospice program
after discharge
Hospice may be an ultimate decision, but any
patient with serious illness can benefit from
palliative care services
A Bridge to Hospice for Hospitalized
Patients
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Acute care settings can be an optimal setting
for introducing hospice discussions
Palliative care consultants are experts in endof-life resources and hospice options
Palliative care clinicians will facilitate
discharge or transfer with hospital discharge
planners, physicians, and families
Benefits to the Patient
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Improved quality of life when symptoms are
managed
Ability to plan for the future when accurate,
but compassionate discussions on prognosis
and goals take place
Avoid unwanted treatments, therapies,
hospitalizations, or nursing home placement
Avoid excessive financial burdens on their
loved ones
Benefits to the Provider
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Palliative care clinicians work with the
primary team and other consultants to develop
common goals
Provide expertise on difficult symptom
management issues
Allows the primary team to focus on their
specialties while P.C. facilitates
communication with patients and families
Benefits to the Hospital and Health
System
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P.C. consultation may reduce unnecessary
utilization of ICU care when treatment goals
are clarified prior to “emergencies”
Facilitate timely discharge planning
Strengthen the health system palliative care
and hospice program through clear integration
Reduce frequent readmissions for patients with
terminal illnesses
Special Focus:Geriatric Trauma
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Western PA/Allegheny County demographics
8th leading cause of mortality for those over age 65
Older patients have worse outcomes despite lesser
injuries
Implications for long term decline in functional
measures
Trauma Patients Appropriate for
Palliative Care
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Elderly trauma patients: Geriatric Study
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Overall mortality in major trauma age 55=15%
Mortality increased to 20% at age 75
Mortality from all causes rose with age, but to a lesser
extend from falls, possibly due to low-level impact of falls
in the elderly
Finelli FC, et. Al. Major trauma in geriatric patients. J Trauma 1989;29:541-8
Predictors of Mortality
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Need for early intubation
Presence of shock (SBP<90)
Glasgow Coma Scale (GCS)
Severe head injury
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Research:
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Elderly patients with GCS<5: Mortality 79%
Younger patients with GCS<5: Mortality 38%
Pennings JL, et al. Survival after severe brain injury in the aged. Arch Surg
1993:128:787-94
Predictors of Mortality
Comorbidities and Complications
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Cardiovascular complications tripled mortality
Pulmonary complications doubled mortality
Injury severity scores predicted:
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ARDS
Pneumonia
Sepsis
GI complications
ARDS,sepsis, and MI are significant risk factors for
mortality
Tornetta P, et al. Morbidity and mortality in elderly trauma patients. J Trauma
1989;29:541-8
Defining Diminishing Functional
Status
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Karnofsky Score < 50%
Dependence in at least 3 of 6 ADLs
1.
2.
3.
4.
5.
6.
Bathing
Dressing
Feeding
Transfers
Continence of stool/urine
Ability to ambulate independently
Impaired Nutritional Status
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Unintentional progressive weight loss greater
than 10% over 6 months
Serum albumin less than 2.5 gm/dl
Progressive dysphagia
Decision not to pursue artificial feedings
Dementia
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Death usually occurs as result of other comorbidities
Should have all of the following:
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Unable to dress without assistance
Unable to bathe properly
Urinary or fecal incontinence
Unable to speak or communicate meaningfully
Dementia Related Complications
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Aspiration pneumonia
Pyelonephritis or upper urinary tract infection
Septicemia
Stage III-IV decubitus ulcers
Fever recurrent after antibiotics
Malnutrition/wt. loss over 6 months
Stroke/Coma/SDH
Coma or PVS > 3 days secondary to CVA
Post-anoxic event accompanied by severe
myoclonus 3 days post event
Comatose patients with any 4 of the following on
day 3 of coma have estimated 97% mortality
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Abnormal brain stem response
Absent verbal response
Absent withdrawal response to pain
Serum creatinine >1.5 mg/dl
Age>70
Stroke and Coma (..cont)
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Chronic stroke
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Age > 70
Karnofsky >50%
Poor nutritional status (>10% wt loss/ albumin<2.5mg/dl)
Dysphasia
Medical complications:
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Aspiration pneumonia
Upper UTI
Stage III-IV decubitus ulcers
Fever recurrent after antibiotics
Hospice Eligibility:
Terminal Prognosis
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Two MDs (Primary MD + Hospice Medical
Director) must certify that the patient’s
prognosis is < 6 months
Patients can eventually live > 6 months and
continue hospice
The MD/ Hospice team must show progressive
decline prior to enrolling into new benefit
periods
Signs of
Imminent Death
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Anuric - no dialysis (if primary dx)
Confusion/delirium with no obvious cause
No or minimal intake
Chyene-Stokes resp., mottled skin, cool
extremities
Pooled oropharyngeal secretions (death rattle)
Comatose or extreme lethargy
Discontinuation of all life-prolonging therapies
Various Levels of Hospice Care
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Home Hospice
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Most typical experience for patients “going home”
Curative treatments are stopped
Palliative treatments can be continued
Prognosis is less than 6 months
Patients can remain on hospice longer than 6
months if still declining
Is often arranged from the acute care setting, MD’s
office, or when requested from home
Home Palliative Care
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In the community:
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Home Palliative Care
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Six months prognosis not necessary
Delivered by hospice nurses
Treatment can still be an option
Must still meet skilled care needs set by insurances for
home nursing care
Often for the patient who is “not ready for hospice”
Palliative Care Intervention
Study: Part 1
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Within 24 hours of admission to TICU:
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Bereavement and psycho-social support
Interdisciplinary Palliative Care assessment
Prognosis discussions
Advanced directive discussion
Pain and symptom management interventions
Family needs assessment
Mosenthal AC, Murphy PA. Changing the Culture Around End-of-Life Care in the Trauma
Intensive Care Unit. Journal of Trauma. 2008;64:1587-1593
Integrating Palliative Care
Into the ICU
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Within 72 hours of admission to TICU:
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Interdisciplinary meeting with MD/nurse
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End-of-life care for the dying
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Communicate likely outcomes
Goals of care discussion
Assess family understanding
Palliative Care order set
Ventilator withdrawal guideline
Integration of Palliative Care performance into M&M
conferences with peer review
Mosenthal AC, Murphy PA. Changing the Culture Around End-of-Life Care in the Trauma Intensive Care
Unit. Journal of Trauma. 2008;64:1587-1593
Palliative Care Integration:
Results
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Timing of DNR orders from admission to DNR:
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20 days in the control vs. 7 days in the intervention
No change in mortality rate
Shorter length of stay for dying patients:
 Reduced by 1.5 ICU days
Family meetings held in 62% of deaths
Conflicts around end-of-life decisions documented only in
2.4% Of meetings
Discussion on pain/symptoms during rounds increased:
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35% control vs. 55% during intervention
Mosenthal AC, Murphy PA. Changing the Culture Around End-of-Life Care in the Trauma
Intensive Care Unit. Journal of Trauma. 2008;64:1587-1593
Terminal Weans
“ 1. Morphine drip
2mg/hour..titrate to comfort”
“2. Extubate patient”
Purpose
1. To prevent respiratory distress/dyspnea
as treatment is withdrawn
2. To minimize the patient’s pain and
suffering
3. To minimize the patient’s fear and anxiety
4. To provide maximal patient and family
emotional/spiritual support at end of life
Three General Principles on
End-of-Life Symptom
Management
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Any given symptom is as distressing to the patient as
that person claims it to be
All treatments, their risks, benefits & alternatives
need to be discussed in context of the dying person’s
values, culture, goals, and fears
When death is near, the exact cause of any given
symptom is irrelevant, and investigations are usually
pointless
(Ian Anderson Continuing Education Program in End-of-Life Care)
Definitions
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Ventilator Support Withdrawal- The act of
removing ventilator support from a patient after it
has been clearly determined that the goals of
care are comfort-focused only. It is accepted
that the act of removing support will likely end
with death within a relatively short period of time.
Two methods have been described (von
Gunten, 2001): Immediate extubation and
terminal weaning.
von Gunten C and Weissman D.E. Fast Facts and Concepts #33: Ventilator Withdrawal Protocol, January, 2001. End-of-Life
Physician Education Resource Center www.eperc.mcw.edu.
Definitions
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Ventilator Wean- The process of reducing
the amount of ventilator support over a
given period of time. The goal is to
ultimately achieve a respiratory state
where the patient can breathe
independently or with supplemental
assistance from devices other than a
ventilator.
Case Example
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Mrs. B: 77 y.o. with advanced COPD
Plan for terminal wean after previous failed
attempts to wean from ventilator
Discussions with family about comfort care,
and terminal wean
Assured the family that the patient would be
comfortable
Case Example (Cont.)
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Orders:
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Morphine drip 2mg titrate q 15 minutes to comfort
Morphine 2mg IV q 1hour prn
Extubate
Case Example (Cont.)
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Outcomes:
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After extubation: patient with labored respirations,
and moderate to severe secretions
MD paged after extubation, and another order
obtained for Morphine 2mg IV now and q 30
minutes prn
Daughter at bedside extremely distraught by sight
of respiratory struggle
Patient died 15 minutes post-extubation
Case Example
How could this be avoided?
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Anticipate symptoms:
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Start opioid infusion at least 1-2 hours before extubation
Bolus 2-4 mg Morphine 15 minutes before extubation
PRN dosing should be q 15 minutes prn RR>24 or signs of SOB
Consider Benzodiazepine bolus 15-30 minutes pre-extubation
Administer anticholinergic (ie:Atropine) 30-60 minutes preextubation
Stop IV fluids and/or tube feedings several hours pre-extubation
Elevate HOB >45 degrees
MD should ideally be on unit or readily accessible by page
RN at bedside post-extubation and medications ready
Administer oxygen facemask or nasal canula
Ethical/Legal Issues
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Is this process euthanasia?
Hydration and nutrition questions/issues
Nursing perspectives
In terminal weans for non-terminally-ill
patients, only patients or POAs can provide
consent
Morphine Drips:
General Information
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Morphine drips can be a very useful tool to treat pain and
shortness of breath
When titrated carefully, there is no set limit to dosing
Dosing limits are determined by side effects
All actively dying patients do NOT need a morphine drip
Unrestricted “titrate to comfort” orders should be avoided
Clearly understand and discuss the intent of morphine drips
with families
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The goal is never to hasten death
BOLUS, BOLUS, BOLUS 1st, adjust drip rate later
Patients Previously on Opioids
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Establish 24 hour baseline requirements
Administer at least their hourly basal rate, and likely 50%
more
Example:
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Lung CA patient on MS Contin 100 mg TID
Equivalent: 300mg po/day or 100 mg IV/day
Baseline infusion 4-5 mg IV Morphine per hour
1-2 hour prns can be @ 10-15% of 24 hour dose and if needed,
interval can be every 15 min PRN for terminal weans
Why Not “titrate to comfort?”
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Patients do not receive acute pain relief
 Morphine half-life is 2-3 hours
 10-15 hours to reach steady-state
Patients end up with too much drug
Unwanted side effects from higher doses
Many patients can be maintained with prn dosing or stable infusion doses
Example of Morphine potency:
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Morphine drip 1mg/hr=(24 mg IV/day) OR (72mg po/day)
Morphine drip 5mg/hr=(120 mg IV/day) OR (360 mg po/day)
General Care Guidelines
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Stop unnecessary tests, procedures, meds
Do not restrict visitation
Increase communication and support
Confirm/establish goals & code status
Consider hospice or palliative care referral
Move focus to comfort
Consider move to private room if stable
Initiate discussions on “what to expect”
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Be prepared for the worst, but some patients can live for hours,
even days
General Care Guidelines
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Respiratory:
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Elevate HOB
Stop pulse-oximetry and monitors
Oxygen for comfort (use least invasive means possible)
Manage secretions (gentle oral suction, avoid deep suction)
 Atropine
 Scopolamine
 Levsin
 Lasix
Manage dyspnea
 Morphine (gold standard)
 Ativan
End-of-Life Communication
and
Goals of Care
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S
P
I
K
E
S
Setting
Perception
Invitation
Knowledge
Empathy
Summary/Strategy
Providing Real Facts about
CPR in the Elderly
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The portrayal of CPR on TV may lead the viewing public to have an
unrealistic impression of the chances of success of CPR
On one TV series, 75% of patients survive CPR with 67% appearing to survive to
discharge
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In real life for elderly patients
22% may survive initial resuscitation
10-17% may survive to discharge, most with impaired function
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1.
2.
3.
4.
Chronic illness, more than age, determines prognosis (<5% survival)
Annals Int Med 1989; 111:199-205
Diem SH, Lantos JD, Tulsky JA. Cardiopulmonary resuscitation on television – miracles and misinformation,
N Engl J Med 1996; 335:1578-1582.
W. T. Longstreth Jr; L. A. Cobb; C. E. Fahrenbruch; M. K. Copass. Does age affect outcomes of out-of-hospital
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cardiopulmonary resuscitation? JAMA. 1990;264:2109-2110.4.
EPEC Project RWJ Foundation, 1999
CPR: Poor Prognosis
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Unwitnessed Arrest
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Asystole
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Electrical-Mechanical Dissociation
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>15 minutes resuscitation
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Metastatic Cancer
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Multiple Chronic Diseases
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Sepsis
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Questions and Comments ?