Palliative Care: What is it?

Transcription

1 Palliative Care: What is it? CSIM Annual Meeting 2014 Calgary Dr. Amanda Brisebois MSc MD FRCPC General Internal Medicine and Palliative Care

2 What has surprised me is how little palliative care has to do with death. The death part is almost irrelevant. Our focus isn t on dying. Our focus is on quality of life. - Dr. Balfour Mount

3 OBJECTIVES Demonstrate the importance of symptom management in acute care, when prognosis uncertain. Evaluate utility of various investigations and interventions in palliative care and end of life. Identify ways to coordinate palliative care discharges.

4 Patient Mrs. X Medical team called STAT to patient room Walked into room, patient in respiratory distress. Vital signs not concerning, but patient severely dyspneic. Residents doing physical examination, no acute findings. Goals of Care: Medical Management (no ICU) Management?

5 Patient Mrs. X Asked nursing staff to get a floor fan into the room Fan set up to blow onto patient s face Investigations revealed no etiology, no medication given in room. Patient much improved over 30 minutes. Returned to discuss with her later in the day Dr.Brisebois, I cannot tell you how much you have done for me That fan, it saved my life

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7 Patient Mr. A Transfer of Care Friday Morning Walked into room, patient in extreme respiratory distress. Family informs me that he has been in distress for 2 days. 92 years old. Admitted with pneumonia x 7 days, on IV antibiotics. 92% 3L 02. Vitals not concerning. Goals of Care: Medical management. Management?

8 Patient Mr. A Quickly discussed patient and family goals. Who is this patient and what are his values? Immediately obvious that he is suffering and he wants comfort, and investigations not priority Management?

9 Patient Mr. A Immediate relief required, and patient not responding to non-pharmacologic intervention Opioid naive How to select opioid? Organ function Rate of onset required Previous opioid exposure, patient/family concerns, previous side effects

10 Patient Mr. A Hydromorphone 1mg subcutaneous, ineffective after 10 min. Hydromorphone 2mg mild effect, dyspnea decreased from 10/10 to 8/10. Fentanyl 150ug decreased dyspnea to 7/10 (still in extreme distress). Continued discussion regarding level of consciousness and comfort, and time to initiate treatments. Comfort patient main priority. Midazolam 2.5mg subcutaneous. Excellent effect. Initiated hydromorphone 0.5mg q4hr subcutaneous ATC. Patient woke up, no longer in distress. Discharged home 2 weeks later.

11 Symptom Management ESAS- r (Edmonton Symptom Assessment Score- revised) This can be utilized at any stage of illness Know how symptoms are affecting your patients These assessments can be performed concurrently with active, aggressive care

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13 Symptom Management Resources Frasier Health (Hospice Palliative Care Symptom Guidelines) LEAP (Learning Essential Approaches to Palliative Care) Pallium.ca (Pallium pocketbook) Virtual Hospice ( Canadian Hospice and Palliative Care (chpca.net) Palliative.org Alberta: PEOLC Dashboard, website being created, symptom protocols

14 Symptom Management Random treatment selection vs regimented etiology based approach For example: Cochrane review (nausea) Medication selection based on mechanism of action Medication dosing: standard regimens vs much lower dosing and titration One medication ineffective, try another. Patient responses are extremely variable

15 Symptom Management: Innovative approach Think outside of the box if treatments ineffective. Get to know your patient Symptom assessments: OPQRSTUV (U= patient Understanding of symptom and why V= what the patient values are surrounding the symptom, triggers and affect on quality of life)

16 TOTAL PAIN SYNDROME SOCIAL EMOTIONAL SPIRITUAL PHYSICAL Can be used with all symptoms

17 Patient Y Head and neck cancer In Palliative Care Unit Severe nausea and vomiting Etiology of Nausea multifactorial Multiple medications tried without effect

18 Patient Y Sat down with this patient and listened Had a traumatic event years prior, his father blamed him for his mother and sister s death He had not spoken to his father in years Nausea score decreased from 10/10 to 2/10, the next day, without pharmaceutical intervention. Vomiting ceased.

19 Symptom Management: Multifactorial What is the source of the symptom and what non-physical factors are contributing? Protocol development: PEOLC (Alberta) Individualizing treatments, based on both physical and non-physical measures

20 COFFEE BREAK!!! Please return by 15:30

21 Symptom Management in Comfort Care: How aggressive should we be?

22 Aggressive Care at End of Life 32 year old male Pancreatic cancer, un-resectable, diagnosed on admission Presented with gastric varices Bleeding, with 8 units PRBC required Pregnant wife (due in 6 weeks), and 2 year old child Admitted to the Palliative Care Unit Management?

23 Aggressive Care at End of Life Function decreasing, but not ready to let go. Got to know the patient and family. Wanted to maximize time, with comfort as the priority. Repeated endoscopy, bleeding did not stop. 15 U PRBC given total. Multiple intra-abdominal clots (discussed Tranexamic acid). Discussion re: splenic embolization Successful embolization. Bleeding stopped for 7 weeks. Died after baby born, renewed wedding vows.

24 Transitioning to Comfort Care: What investigations to consider? Metabolic disorders (hyponatremia, hypercalcemia, renal function) Anaemia (CBC) Biliary obstruction (Ultrasound abdomen) Metastases amenable to radiation (CT head, chest CT) Pathologic fractures (Xray, bone scan) GI obstruction (Xray) Renal obstruction (ultrasound) Peritoneal disease (CT scan) Blood and urine cultures (variable utility) Clots (PE, DVT) (CT scans, Doppler) Cardiac: BNP, troponin

25 Transitioning to Comfort Care: What interventions to consider? Fluids (electrolyte disorders) Blood (fatigue) Stenting (renal, liver, bowel obstruction) Fluid removal (ascites, pleural effusions) Embolization (bleeding) Radiation (pain, etc) LMWH for clots Decadron (vomiting, nausea, appetite) Venting PEG (GI obstruction) Remember to discuss ICDs, if in place

26 Interventions at End of Life

27 Antimicrobial Use: End of Life 145 patients, 126 (86.9% antibiotic end of life) 88 (69%) had clinical evidence of infection 61% (45%) had positive cultures Comfort care pursued in 99 (78.5%), 35% continued to receive antimicrobials for average of 1.6 days On average, antimicrobials were stopped <1 day before death

28 Transitioning to Comfort Care If symptoms are a priority throughout life, it is easier to transition to comfort care at end of life. Care can still be aggressive, but intent is not to prolong life. Aggressive comfort care, often in tertiary setting, but can occur at home with proper supports.

29 Most studies involve ICU transitions from Full care to comfort care 1998 Study: 56 patients, 67% cared for at two different sites, and 9% moved 2-5 times among three different sites in the last month of life review: Adjustment to death is a process, family and patient need to be listened to, and remain in control.

30 Components of Transitions 2014 study: Contending with Advanced Illness: Patient and Caregiver perspectives. Meeker et al Vol 47 (5) p May 2014 Suffering: Emotional, psychological, spiritual and physical of patients and caregivers. Symptom distress Fighting: Choosing to live/choosing to fight/ Staying positive. Concept of Treat or die. Settling: Awareness of terminality, adjustment to limitations. Comfort care, ease and acceptance.

31 Components of Transitions

32 Transitioning to Comfort Care: Obstacles Patient uncertainty, changing opinions Goals of care not addressed early in disease trajectory Communication between various care sites (inpatient, LTC, primary caregivers, home care services) Lack of understanding of various resources available Acceptance of Palliative Care involvement Lack of understanding of definition of palliative care vs end of life care Difficulty prognosticating Lack of sense of patient and family control, communication key

33 Transitioning to Comfort Care: Know your local resources Palliative Care MDs in the community (primary care and speciality care) Palliative Care consult services (inpatient and outpatient) Palliative Home Care Hospice (and how to access) Respiratory therapy PEOLC : EMS treat in place, Inform Alberta: lists of local resources, Palliative Dashboard, Strategic Care Networks Cancer and Non-Cancer resources

34 CONCLUSIONS Palliative care includes diligent symptom management, even early in chronic illness Symptom management can follow protocols, but also needs individualization, including communication and nonpharmacologic treatments Aggressive interventions can still be undertaken in comfort care Early explanation of symptom management can facilitate transitions to comfort care Including palliative care, in your care plans, requires knowing local resources

35 Questions?