Transcript Back_to_Basics_Pall_Care_03_13_2012_Final_Dr Bush

Palliative Care: Back to Basics
Dr Shirley H. Bush
Assistant Professor, Division of Palliative Care,
Department of Medicine
March 30, 2012
Luke Fildes: The Doctor 1891
Oil on canvas, © Tate (tate.org.uk)
Overview of Session
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Online Knowledge Quiz: Fluid Survey links will open during class
In-class discussion of answers
Palliative Care overview
End of life (EOL) care
– For MCC objectives “The Dying Patient”
• Resources on One45
– Opioid Equivalency tables
• Don’t forget: The Pallium Palliative Pocketbook from Integration
Unit
Objectives - I
• At the end of this session, students will be able to:
• Describe models of hospice palliative care and the principles on
which these are based.
• Discuss interprofessional collaboration in palliative and end-oflife care as a fundamental concept.
• Identify “total pain” incorporating the roles that psychological,
social, emotional and spiritual concerns, along with physical
symptoms, play in producing the pain experience.
• Identify the components of a holistic, interprofessional
assessment and plan of care for a terminally ill patient.
Objectives - II
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Describe 3 illness trajectories.
Identify signs of approaching death.
Describe common signs of the natural dying process.
Describe preparing the patient, family and caregivers, when
death approaches.
• Describe the pharmacological and non-pharmacological
management of patients at the end of life.
[Unit name – Lecture title – Prof name]
Palliative Care Knowledge Quiz
• Test your own knowledge:
• Questionnaire in English https://app.fluidsurveys.com/surveys/pgrassau/2012-englishpalcare-know-4y-survey/
• Questionnaire in French https://app.fluidsurveys.com/surveys/pgrassau/2012-frenchpalcare-know-4y-survey/
[Unit name – Lecture title – Prof name]
And now the Answers……
• These will be discussed in class
[Unit name – Lecture title – Prof name]
WHO Definition of Palliative Care - 2005
• “Palliative Care - an approach that improves QOL of
patients and their families facing the problem
associated with life-threatening illness, through the
prevention and relief of suffering by means of early
identification and impeccable Assessment and
Treatment of pain and other problems, physical,
psychosocial and spiritual”.
• http://www.who.int/cancer/palliative/definition/en/
• (Page not available in French)
• Effective palliative care requires a broad
multidisciplinary and interprofessional approach that
includes the family and makes use of available
community resources
• It can be successfully implemented even if resources
are limited
[Unit name – Lecture title – Prof name]
CHPCA Models of Palliative Care
(2002)
• Model
• Realistically
Bereavement
Care
Bereavement
Care
Therapy to cure or
control disease
Therapy to cure
or control
disease
Palliative
approach to care
Palliative
approach to care
Illness Trajectory
Illness trajectory
Dx
Death
Dx
Death
Aspects/Domains of Holistic Care
Physical, e.g.
-Disease management
-Pain & other symptoms
-Function
-Nutrition habits
-Physical activity
Social/Cultural, e.g.
-Finances
-Relationships
-Personal routines
-Recreation
-Vocation
-Rituals
-Legal issues
-Family caregiver support
-Practical
Psychological, e.g.
-Personality
-Psychological symptoms
-Emotions
-Control & dignity
-Coping responses
-Self image/ self esteem
-Loss & Grief
Spiritual, e.g.
-Meaning & values
-Existential issues
-Beliefs
-Spirituality
-Rites & rituals
-Symbols & icons
-Loss & Grief
-Life transitions
-Religions
Adapted from: “Domains of Issues Associated with Illness and Bereavement” in A Model to Guide Hospice Palliative
Care: Based on National Principles and Norms of Practice. CHPCA, March 2002, page 15.
Interprofessional (IP) Team Work
• Patients and families are experiencing a variety of needs representing the
different facets of their reality.
• In order to meet these needs which are often complex, the perspectives,
skills and resources of a variety of professionals are required.
– Physician collaborates with…….
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Nurse (RN, RPN, APN, PCA – Personal Care Assistant)
Dietician/ Speech Language Pathologist (SLP)
Pharmacist
Physiotherapist/ Occupational therapist (PT/OT)
Psychologist
Recreation therapist
Social worker
Spiritual care professional/ Chaplain
Volunteer
Patient and family
Medical Care of the Dying, 4th ed. Victoria Hospice Society; 2006
Conceptual Model of level of need within the population of
patients with a life limiting illness
A Guide to Palliative Care Service Development: a population based
approach . PCA 2005. Available at: http://www.palliativecare.org.au
Episode of Care scenarios to meet Palliative Care needs
A Guide to Palliative Care Service Development: a population
based approach . Palliative Care Australia (PCA) 2005.
Available at: http://www.palliativecare.org.au
[Unit name – Lecture title – Prof name]
W.H.O. 3-step Analgesic Ladder
Non-opioid
e.g. paracetamol,
NSAIDs
+/– Adjuvant
STEP 1
Opioid for mild
to moderate
pain
+/– Non-opioid
+/– Adjuvant
Opioid for
moderate to
severe pain
+/– Non-opioid
+/– Adjuvant
STEP 3
STEP 2
Pain persisting or increasing
W.H.O. Analgesic “Ladder”
• Promoted 3 important concepts world-wide:
• By Mouth
• By the Clock
• By the Ladder
• N.B. not designed for use in isolation
• Is there still a role for Step 2?
Commencing Opioids
Common starting dose
Starting dose in frail, weak
patients or patients with
severe COPD
Morphine
5 – 10mg PO q4H straight
2.5 – 5mg PO q4H straight
Hydromorphone
1– 2mg PO q4H straight
0.5 – 1mg PO q4H straight
Oxycodone
2.5 – 5mg PO q4H straight 1 – 2.5mg PO q4H straight
(1) Discuss Opioid fears and misapprehension with patient: ‘Morphine Myths’
(2) Do also prescribe a ‘Rescue ‘ dose of IR (Immediate release) opioid for
‘breakthrough’ or ‘episodic’ pain: 10% of total daily dose
(3) Also see OPIOID EQUIVALENCY tables: on One45
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When Commencing Opioids: Manage Potential
Side Effects
• Discuss potential side effects and strategies with patients
• Constipation: occurs in majority of patients and does not
resolve spontaneously
– Regular laxative e.g. senna, lactulose
• Nausea: in up to 2/3 of patients, but usually subsides within
3-7 days
– Antiemetic e.g. metoclopramide, haloperidol
• Somnolence/ Sedation: usually temporary for a few days
– Advise patient not to drive following opioid initiation, opioid
switch, significant dose increase for at least 5-7 days,
or if uncontrolled pain
• Respiratory depression (RR less than 8/min):
• Extremely low risk if appropriate starting dose and appropriate
titration
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Illness Trajectories
[Unit name – Lecture title – Prof name]
Murray SA , et al. BMJ 2008,336,958-9
3 Triggers for Palliative/ Supportive Care
• (1) The ‘Surprise’ Question:
– Would you be surprised if this patient were to die in the
next 6 - 12 months?
• (2) Choice/Need
• (3) Clinical indicators: Specific indicators of advanced disease
for each of the 3 main EOL patient groups
• Prognostic Indicator Guidance from the Gold Standards
Framework ™
• Available @
http://www.goldstandardsframework.org.uk/Resources/Gold%20Standards
%20Framework/PDF%20Documents/PrognosticIndicatorGuidancePaper.pdf
[Unit name – Lecture title – Prof name]
Prognosis: “Doctor: How long do I have to live?”
• How frequently is the
patient observed to
decline?
The Thinker, Auguste Rodin, 1902
– Every Month: estimated
prognosis of months
– Every Week: estimated
prognosis of weeks
– Every Day: estimated
prognosis of days
– Every Hour: estimated
prognosis of hours
BUT with caveat: in setting of advanced cancer, patient’s condition
can change very quickly (Another disclaimer: life expectancy can be longer)
[Unit name – Lecture title – Prof name]
See Chapter 4 in Pallium Palliative Pocketbook
Goals of Care
• Establish patient’s Goals of Care
• Assess the patient and/or family’s knowledge of the illness
and prognosis
• Assess priorities
– Comfort – Allow a Natural Death
– Life-prolongation
– Special events
• Communication: Is everyone on the same page?
– Role for Family Meeting
• Detailed documentation, including ‘level of care’, code status
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See Chapter 3 in Pallium Palliative Pocketbook
The Normal Dying Process - The Last Days
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Weaker: need assistance with all care
Bed-bound
Reduced oral intake - food/ fluids
Difficulty swallowing oral medications
Drowsy or reduced cognition and difficulty concentrating
More time asleep
Some symptoms may increase e.g. delirium, dyspnea
• “Withdraw” - say their goodbyes
Signs that Death is Imminent: “days to hours”
• Explain these signs to the family and other caregivers:
• CNS: Refractory delirium (in up to 85% of patients @ EOL),
(N.B. exclude reversible causes e.g. urine retention, opioid toxicity),
Reduced consciousness
• RESP: Rate, pattern
– Altered breathing
• Cheyne-Stokes respiration
• Periods of apnea
• Agonal breathing
– Profuse upper airway secretions – “terminal respiratory
congestion” or “death rattle”
• CVS: Weak and rapid pulse, decreased capillary refill
• SKIN: Cold extremities, mottling of periphery (hands, feet, legs)
• GU/GI: Reduced output
[Unit name – Lecture title – Prof name]
Terminal Respiratory Congestion: “Death Rattle”
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Inability to clear secretions from oropharynx and trachea
Relaxation of pharynx
Noisy “rattling” respiration
Patients usually unconscious/ semi-conscious and too weak to
expectorate – likely not distressing to patient
– Explain to and reassure family
• Nursing care
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Nurse semi-prone
Nurse side to side
Maintain scrupulous oral hygiene
Suction rarely required
• Light oral suctioning may be needed – avoid deep suctioning
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Terminal Respiratory Congestion Management contd.
• Discontinue parenteral fluids
• Anticholinergic drugs may be required….
– Reduce production of pharyngeal secretions
– ? Less effective on chest secretions compared with oral
secretions
– E.g. Glycopyrrolate 0.2 – 0.4 mg subQ q2-4 hr PRN
– E.g. Hyoscine hydrobromide (Scopolamine™) 0.2 – 0.4 mg subQ
q2-4 Hr PRN
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Still
Active Management of Symptoms
• Prepare patient and family (Difficulty with prognostication)
• Full nursing cares - for patient comfort and dignity
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Eyes: Artificial tears, lacrilube
Nose: Reassess nasal prongs, salinex
Oral hygiene: Regular mouth care, moisture spray, gels
GI: Suppository PRN
GU: Pads, Foley catheter PRN
Skin: Pressure area care (Including mattress)
• Ongoing review and relief of physical symptoms
–  delirium,  dyspnea @ EOL
• Psychosocial (settle affairs)/ spiritual and/or religious needs
Preparing for Death
• Communication with family: explanation and support
• Clinical management
– Vitals – discontinue
– Investigations – discontinue
– Life-prolonging treatments
• Evaluate benefit, role in ongoing symptom management
• Stop non-essential medications/ ? Discontinue oxygen
– Comfort treatments – continue/ institute
• Appropriate dosing & schedule
– Parenteral route for medications (subQ route generally) when
patient no longer able to swallow/ in anticipation of this
• Review role for Medically Assisted Hydration & Nutrition
• Deactivate Implantable Cardioverter Defibrillator (ICD)
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Review Venue of Care
• Knowledge of options available
• ? Hospital vs. Palliative Care unit vs. hospice vs. nursing home
vs. home
• Single room if possible
• If needed, urgent ambulance home
– Community palliative care team (24 hr cover) - PPSMCS
– Liaise with Family Physician – As Early as possible
– Supply of drugs with medication orders, hospital bed and
other equipment, ?Foley catheter, ??Oxygen
– Insert indwelling SubQ butterfly needle
Planning for Crises
• Community: Supply of emergency drugs at home
– E.g. SubQ opioid, neuroleptic, antiemetic, benzodiazepine
• Risk of Hemorrhage
• E.g. Carotid hemorrhage in Head and Neck (H&N) cancer
• E.g. Massive GI bleed, massive hemoptysis
– Discuss with family and staff
– Green towels
– Catastrophic order/ Crisis pack
• 5- 10mg subQ (or I.M.) midazolam, +/- Usual opioid rescue dose
and repeat q5 minutes PRN if needed
– Stay with patient (At home, family not to call 911)
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Essential Medications at EOL ……
• Cessation or subQ conversion of oral medications
– Consider continuous SubQ infusion
• ? Opioid (e.g. for pain, dyspnea)
• +/- Neuroleptic for delirium
– E.g. Haloperidol, methotrimeprazine (Nozinan™)
• +/- Sedative agent for refractory delirium, refractory dyspnea
at the end of life
– E.g. Midazolam, lorazepam, methotrimeprazine (Nozinan™),
phenobarbital
• +/- Antiemetic
• +/- Anticholinergic for respiratory secretions
– E.g. Glycopyrrolate, hyoscine
• Review parenteral fluids/ oxygen
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Caring for Patients - and Families - at the End of Life
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Address fears and concerns
Reassurance where appropriate
? Hearing and Touch last senses to go
Suggest notifying family/ friends, especially if overseas
Consider allied health support (social work, spiritual care,
psychology) if not already involved
• Ensure family members looking after selves (eating, drinking,
sleep)
• “Keeping vigil”: Give permission for family to leave room and
take breaks, or create a roster for family shifts
• Enquire if any cultural or religious/spiritual needs for end of
life care, and after death
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Guerir quelquefois
Soulager souvent
Consoler toujours
To cure occasionally
To relieve often
To comfort always
Death in the sickroom, Edvard Munch, 1895
• Any Questions…..
• Please feel free to contact me:
• [email protected]
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Orienting Ourselves for End of Life (EOL) Care
• Reflective Discussion Video – Orienting Ourselves for Hospice,
Palliative & EOL Care (5 minutes)
• From pallium.ca
• http://www.youtube.com/watch?v=sP4Fkjn3OwU
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