Transcript What we need to learn

Care for End Stage Cancer
Patients
Dr. Peggy Lu
Determine the Level of Care
• Curative Care
• Palliative Care
• Comfortable care
Health Care Worker Attitudes
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We should be able to fix it or cure it
We must make people feels better
If a patient dies we fail
We have technology and drugs and there is
always more we can do
What we need to learn
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We will die
Life is finite
Not all technology works
How we want to die
• We must face our own mortality so we can help
others face theirs
Nearing the End of Life
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What’s going to happen to me?
Have I done everything I should have done?
What are my other options?
How much control will I have over my life and my
death?
• Will my wishes about my care be followed?
• How much pain and suffering will I have?
• What am I going to do about money?
“The Good End of Life”
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Preparation
Clear decision-making
Pain and symptom relief
Contribution to others
Completion
Affirmation
Self-Determined Life Goals
-Who I am and what I am leaving behind
-What are my most important needs
-Where do I want to die
Assist the patient in meeting their end of life goals
The Elderly
-It is essential to ask elderly patients their wishes
directly
-Medical personnel more often discuss these
matters with surrogates or family members,
neglecting to ascertain elderly patient’s opinions
and therefore misunderstand patient's needs and
wishes.
Why do you need an advance
directive?
• Your have a right to be informed and decided for
yourself
• Advance directives are for times you can’t speak
for yourself.
• Free loved ones from making difficult decisions
Choosing DNR/DNI
• They want quality of the life they have left
• They want to avoid risks and harms of CPR
• They accept their prognosis and death
When is Hospice Care Appropriate?
• Life expectancy of 6 months of less
• Curative care is no longer effective or desired
• Goals are transitioned to comfortable and quality
of life.
What can Hospice Care Provide?
• Minimized suffering
• Care is focused on pain and symptom
management
• Coordination of care: The patient and family are
supported by physicians, nurses, hospice aides,
social workers, volunteers
• Spiritual Care
• Respite Care
• Bereavement Care
Communication, Control, Support
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Honest communication
Allow as much control as possible
Maintain patient dignity
Address fear of unknown
Listen, listen, listen
Asses non-verbal cues
Empower love ones to provide support
Emotions as Patients Near the End of
Life
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Fear
Anger
Guilt and regret
Grief
Anxiety and depression
Feeling alone
Seeking meaning
Physical symptoms in the last 2-3
months of life
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Fatigue/weakness
Pain
Appetite changes
Problems breathing
Physical symptoms in the last 2-3
months of life
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Nausea/vomiting
Bowel obstruction
Bowel/bladder incontinence
Diarrhea or constipation
Delirium/agitation/confusion
Drowsiness and sleeping
Important Pain Management
Concepts
• Medications are given according to physician’s
orders and do not hasten the end of life
• Assess/reassess the duration and effectiveness
of pain management
• Assess non-verbal patients
• Correct medications make the dying process
more comfortable
• Always believe the patient’s report of pain.
Types of pain medications
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Long-acting time released forms
Short-acting forms
Patch
Lozenges
Liquid
Rectal suppositories
Pain medicine pump
Appetite Changes
• Happens to more than 8/10 of end stage cancer
patients
• It is normal in the last months of life for parts of
body to start slowing down and eventually shut
down.
• Avoid family food battles
Problem Breathing
• Even thinking about breathing problem can be
scary
• Patient may feel SOB or need breathe faster and
harder than normal.
• Most often, severe symptom happens while the
patient is unconscious and not aware.
• Things that can be done: Position, Oxygen,
Decongestion, Medicines to reduce anxiety,
Opioids
What Caregivers Can Do?
• Help patient turn and change position
• Try ice chips or sips of liquid if the patient is
having trouble swallowing.
• Do not push fluids. Near the end of life, some
dehydration is normal and also more comfortable
for the patient.
• Pad the bed beneath the patient with layers of
disposable waterproof pads.
What Caregivers Can Do?
• If patient is very restless, try to find out if they are
having pain and give breakthrough pain
medications if needed
• Gentle touching, caressing holding and rocking
are usually helpful and comforting.
• Always assume the patient can hear you and
continue to speak with and touch the patient to
reassure them of your presence.
Saying the Four Things
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Please forgive me
I forgive you
Thank you
I love you
• The 5th: Good bye
Signs that death has occurred
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Breathing stops
Blood pressure can not be heard
Purse stops
Eyes stop moving and may stay open
Pupils of the eyes stay large even in bright light
Control of bowels or bladder may be lost as the
muscles relax.
Life is pleasant.
Death is peaceful.
It is the transition that is troublesome.
Isaac Asimov (1920-1992)
Good Life and Good Death