Transcript Palliative Care

End Of Life Care in ICU
(Palliative Care)
Consultant Professor : Dr Yekefallah
Seyedeh Hedyeh Banihashemi & Mahtab Salehi
Master students of critical care nursing
(entrance Mehr 92)
Automn 1392
objectives
 Explain the meaning of palliative care & its type
 Know the ethical & legal issues related to end of life
care
 Describe the common symptoms
We will [not] achieve more
comfortable or peaceful
deaths
by trying to persuade our
patients that comfort care is their best option
when they still have what many perceive as
reasonable odds for longer survival.
AINSLIE. ANN INTERN MED 1997
“Doctor, I Want Everything ”
What is palliative care ?
 “Palliative care seeks to prevent, relieve, reduce or
soothe the symptoms of diseases or disorders
without effecting cure…
 Palliative care may be needed at any time in the
disease trajectory and bereavement.
… Palliative care
 It may be combined with therapies aimed at
reducing or curing the illness, or it may be the total
focus of care.
 Care is delivered through the collaboration efforts
of an interdisciplinary team including the
individual, family and others involved in the
provision of care.
 Where possible, the palliative care should be
available in the setting of personal choice.”
What Palliative Care is NOT
 A mutually exclusive alternative to life-prolonging,
restorative care
 A way to “periodically cleanse the hospital of its long
stay outliers”
The term ‘‘palliative care’’ was coined by a surgeon,
Balfour Mount,
Care for patients and families facing
serious and complex illness, focused on:
 Alleviation of distress
 Communication about treatments and care goals
 Alignment of plan with preferences
 Smooth and continuous transitions across settings
 Provided simultaneously with medical treatment for
cure, disease-modification, life-prolongation
 Incorporated in comprehensive critical care for all
patients, including those pursuing life-prolonging
treatments
 Not simply a sequel to failed intensive care, but a
synchronous, synergistic, component of ICU
treatment
How Palliative Care Reduces
Length of Stay and Cost?
 Clarifies realistic and appropriate goals of care with
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patients and families
Helps families to select medical treatments and
care settings that meet their goals
Coordinates care across multiple specialties and
disciplines
Facilitates transitions within and from hospital
Enhances continuity across venues of care
Better symptom control
Benefits of Palliative Care in the ICU
 Intensive care unit/hospital length of stay
 Use of nonbeneficial treatments
 Duration of mechanical ventilation
 Family satisfaction/comprehension
 Family anxiety/depression, PTSD
 Conflict over goals of care
 Time from poor prognosis to comfort goals
 Symptom assessment/patient comfort
What is Palliative care?
 Euthanasia
 Physician assisted suicide
 Discontinuing care
 Palliative sedation
Euthanasia
 It means one person killing another person with the
intention of alleviating in most countries.
 It is illegal in most countries .
 In Europe , Belgium is the second country after the
Netherland to approve a law on eunesthesia.
Physician-assisted suicide
The prescription or supply of drugs with the explicit
intention of enabling the patient to end his or her
own life .
Palliative sedation
The intentional administration of sedative drugs in
dosages & combinations requiring to reduce the
consciousness of a terminal patient as much as
necessary to adequately relieve one or more
refractory symptoms.
In most cases , thiopental for induction of deep coma
(alone or in combination with a muscle relaxant)
Nurses & Euthanasia
In a hospital setting , nurses are at the bedside of the
patient 24 hrs a day, as a consequence they are more
often confronted with the patient’s anxiety &
questions regarding prognosis or end of life issues
than physicians.
… Nurses & Euthanasia
Nurses are sometimes the first to sense a wish to die.
Nurses can have the significant & meaningful
contribution in finding a solution for the patients
request .
… Nurses & Euthanasia
The after care for the family members of the deceased
patient is most often given by nurses.
Nurses can provide assistance in administering lethal
medication by supporting the patient.
“Do everything” until “there is nothing more to be
done" and then give “comfort care only”
vs
Palliative Care initiated at the time of diagnosis,
independent of prognosis, and delivered in concert
with curative / life-extending efforts
 ICU care involves multiple specialists who provide
support for a particular defined organ system
 Intervene in each crisis with a goal to support life
until all options are exhausted
 ICU stays may stretch to weeks or months with
each new complication or crisis being addressed
and managed
 The palliative care referral, if there is one, occurs
when treatment options, insurance benefits, or
finances are exhausted
Strategies for Improving End-of-Life
Communications in the ICU
 Communication skills training for clinicians
 ICU family conference early in ICU course
Find a private location
Increase proportion of time spent listening to family
Value statements made by family members
Acknowledge emotions
Listen to family members
Understand who the patient is as a person
Assure family that the patient will not suffer
Focus on the goals and values of the patient
Use an open, flexible process
Anticipate possible issues and outcomes of the discussion
 Give families support and time
Palliative care in the ICU
 The focus on palliation in the ICU is recent & not well-
integrated in to the culture of most units .
 Such care need not be in opposition with life saving ,
curative care & should be viewed as a necessary part of
humane , patient-focused health care .
 Palliative care consults have been demonstrated to
decreased hospital lengths of stay & resource utilization
while improving multiple patient & family centered
outcome.
Ethical & Legal Issues
 Certain broad principles should be applied to all situations
when addressing decision making at the end of life . These
principles are the following :
 Autonomy : Individual should be self determining &
providers have a duty to respect the choices of patients.
 Nonmaleficence : First do no harm : i.e medical treatment
should help patients & not hurt them .
 Beneficence : Taking positive steps to actively help patients.
 Justice : Fair & equitable treatment even distribution of
resources & opportunities.
Who Should Make End of Life Decisions?
Who Should Make End of Life Decisions?
 The ethical right of patients to make autonomous
decision & the obligation of health care providers to
respect these decisions is well affirmed by medical
ethics .
 Advance Directors are legally decision makers for
incompetent patients.
Common symptoms in ICU patients at high risk of dying
Key symptoms :
Anxiety
Restlessness
Agitation
Dyspnea
Thirst
Sleep distribution
Pain
Delirium
… symptoms
 90 % of ICU patients complain of at least one
symptom during their stay in ICU.
 75 % had 10 or more symptoms
 The mean number of symptoms experianced by ICU
patients was 8.62
Symptom relief for the imminently dying patient
 Routine procedures such as taking v/s , drawing blood for lab
tests , reposition & ETT suctioning should be re-evaluated .
 These procedures are interfered with patients comfort &
indeed may cause unnecessary discomfort.
…Symptom relief for the imminently dying patient
 Some patients wish to remain awake & alert for as long as
possible . The critical care team need to manage the
difficult balance between having the patient awake but not
suffering .
 There is no limit to the doses of medication that can be
used to manage the patient symptoms however the risk of
hastening death as a consequence of use of necessary
analgesic or sedation is legally & morally acceptable in
these circumstances.
Pain
 It is the problem that most dying patients & their families
worry about most(40-63%)
 When it is inadequately managed , it can affect a person’s
ability to sleep , cope & relate to others .
 It dramatically affects quality of life & it will affect the patient’s
quality of death.
 Although many nondrug treatment such as massage … can
help reduce the patient’s pain , the mainstay of pain
management is drug therapy.
Pain Management Within the Palliative and Endof-Life Care Experience in the ICU
 All ICU patients experience pain and discomfort
regardless of prognosis or goals.
 For those dying in the ICU, a shift to comfort care
goals may be the most beneficial treatment.
 Communication and cultural sensitivity with the
patient-family unit is important for comprehensive
ICU care.
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 Ethical, (medical) and legal misconceptions about
the escalation of opiates should not be barriers to
appropriate care.
 Standardized instruments, performance
measurement and care delivery aids are effective
strategies for improving palliative care.
 Palliative care should address family and caregiver
stress associated with caring for critically ill patients
and anticipated suffering and loss.
 Pain occurs in up to 70% of patients with advanced cancer
and about 65% of patients dying of non-malignant disease.
 Much can now be done medically to make their last few
weeks or months relatively pain-free.
 Patients frequently express the desire to have open and
honest dialogue with medical carers about pain.
 The patient should be the prime assessor of their pain and
be encouraged to take an active role in their pain
management.
Pain tolerance
Pain tolerance is lowered by:
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Discomfort
Insomnia
Fatigue
Anxiety
Fear
Anger
Boredom
Sadness
Depression
Introversion
Social abandonment
Mental isolation
Pain tolerance is raised by:
Relief of symptoms
Sleep
Rest or physiotherapy
Relaxation therapy
Explanation/support
Understanding/empathy
Diversion
Listening
Elevation of mood
Finding meaning and
significance
 Social inclusion
 Support to express emotions
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 Adequate psychological support is critical, as
removing the fear of pain in itself will help to
optimise pain control.
 Nondrug measures to help psychological or spiritual
distress may be as important as medication in
relieving pain and suffering.
 Over 80% of cancer pain can be controlled with inexpensive oral drugs
given a good assessment of pain and systematic choices of analgesics.
 Provide information and instruction about the pain, agree on treatment
goals and encourage the patient to take an active role in their pain
management.
 Use the World Health Organization (WHO) analgesic ladder to guide
systematic pain relief but remember other treatments (surgery, nerve
blocks, radiotherapy, etc) and nondrug treatments may also have a role.
Fatigue
Fatigue like pain is a subjective word to describe wideranging sensation ,examples include:
 Being easily tired or exhausted
 Having decreased energy
 Feeling generally weak
 Struggling to concentrate or remember
 Reacting in a more emotional way than usual
… Fatigue
 No matter how close your patient is to death or
which treatment he’s receiving , it’s important to
assess the causes & possible treatment of his fatigue.
 Drugs:
Corticosteroid , Megestrol acetate , omega 3 fatty acids
Dyspnea
 It becomes more likely & more distressing as the end of
life approaches.
 Between 50-70% of dying patients experienced it
sometimes with profound shortness of breath , copious
secretion , fatigue & coughing .
 Causes of dyspnea :
COPD
Heart Failure
Pleural Effusion
Pneumonia
Tumor or other obstruction
Nausea & Vomiting
 Arise in about 40% of terminally ill patients.
 Common cause of vomiting : radiotherapy &
chemotherapy
 Treatment
Nondrug : diet , hypnosis & imagery
Drug : antiemetics , antihistamin , cholinergics, corticosteroid
Anxiety
 53-63% moderate to severe
 Provide frequent gentle re-orientation
 Anticipate relates symptoms such as pain
 Provide the patient & family members with information
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that is clear & easily understood
Listen to patient’s feeling , doubts & fears
Use a calming presence & acknowledgement to help patient
manage panic
Use relaxation
Teach breathing , imagery or try music therapy
Sleep disturbance
 42-68% moderate to severe
 Minimize unnecessary interruptions
 Don’t bathe patient between 9 pm & 6 am , if necessary give a warm
bathe that may promote sleep afterward.
 Control noise through the use of earplugs to increase REM sleep
 Turn down alarms to the lowest audible level possible or use light
alarms instead of sound alarms
 If possible decrease room lighting at night & open window shade during
the day.
Thirst & dry mouth
 40-78% moderate to severe
 Oral care is essential
 Frequent cleaning using soft toothbrush & moistural foam
swabs
 Consider using oral cleansing (chlorhexidine) oral rinse
(Na-bicarbonate) & fluoride
 Administer ice chips to reduce mouth dryness
Delirium
 Adult ( 11-89%) children ( 5% or less)
 It associates with longer ICU & hospital length of stays &
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with higher mortalities .
Delirium is distressing for family members & patient
Informing patient & family of delirium manifestation prior
to & during the occurance maybe helpful & may reduce
delirium symptomatology.
Many nondrug approaches have been proposed , none of
them have been tested.
Hand restraint are used
Reducing noise level , ambient light , music & relaxation
Fear should be treated.
Case
An 87 year old female comes into the hospital after a
fall, and has a witnessed cardiac arrest while still in
the ED. CPR and the hypothermia protocol are
started, but after three days in the ICU, she is on a
ventilator, off sedation and unresponsive. Her son
wants to have her removed from the ventilator, but
her granddaughter does not want to “pull the
plug.”
The Process
 Complete all forms and documents
 Focus on the patient and the family will too
 Let other staff know what is happening
… the process
 Turn off monitors and alarms
 Allow for privacy
 Gather loved ones (if they wish)
 Hand holding, touching, prayer (if they wish)
 Don’t be secretive
 Be open and inclusive
 Talk about comfort
 “Her comfort is our priority”, “How can we help”
Ventilator Withdrawal
 Assess the patient’s ventilator status
 No patient effort of breathing
 IMV at 8 bpm, patient breathing 18 bpm
 Assess the patient’s comfort needs
 Completely non responsive, no sign of suffering
 Non verbal indicators of distress, suffering
 IV or Sub q access
 Rx: Morphine, Versed, Ativan
 O2: tubing, prongs, mask, trach mask
… ventilator withdrawal
 If family is present, be ready for the faint,
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screaming and cultural diversity needs
Suction PRN
Comfort the patient
Extubate
Clean the patient’s face
Tidy the bed linens
Take tubes and machines away quietly
After Withdrawal
 Continue palliative medications
 Oxygen and suction for comfort
 Involve the loved ones (if they wish)
 Keep a quiet peaceful environment
 Offer comfort to family
 “What can I do for you?”
Important Concepts
 Offer continuing care
 Patients and families fear abandonment
 Understand family dynamics
 Guilt, blame, anger should be comforted
 Remove any associated burdens
References
 The end of life care in the ICU /Groeme Rocker et al
/ 2010
 End of life (a nurses guide to compassionate care) /
lippincot publisher / 2007