END-OF-LIFE CARE

HEART FAILURE and COPD

Dr Sally ReederSpecialty Doctor in Palliative Medicine

LIFE-LIMITING ILLNESS

• Symptoms• Patient and carer needs• Psychological support• Spiritual needs• Social isolation• Carer support• Quality of Life

PARALLEL SYMPTOMS

• Lethargy• Decreased mobility• Pain• Dyspnoea• Anorexia• Nausea• Depression• Anxiety• Decreased QOL

DIFFERENCES

• Predicting mortality• Terminal phase• Understanding of diagnosis and prognosis• Discussions about prognosis• End-of-Life discussions• Contact with health and social services• Financial support• Availability of specialist services in community

NON-CANCER PATIENTS

• Unpredictable illness trajectory• Acute events – hospital admissions• Patient attitude to diagnosis• Timing of death uncertain

• ?opportunities for End-of-Life discussions• Patient choice

• Palliative specialist involvement limited

ILLNESS TRAJECTORIES

• 3 typical illness trajectories

-Steady progression eg: cancer

-Gradual decline eg: HF / COPD

-Prolonged gradual decline eg: dementia / old age

WHO DEFINITIONof

PALLIATIVE CARE

• An approach that improves quality of life.

• Life-threatening illness

• Prevention and relief of suffering

• Early identification

• Impeccable assessment

• Treatment – physical, psychological, spiritual.

LIFE-LIMITING ILLNESSES

PALLIATIVE MEDICINE

• WHO SHOULD DELIVER THIS PALLIATIVE CARE?General Practitioners?Cardiologists?Specialist clinic staff?

• WHEN AND WHERE SHOULD IT BE DELIVERED?At diagnosis?Clinic appointments?Hospital admissions?GP appointments?

SHOULD THE PALLIATIVE CARE TEAM BECOME INVOLVED,

AND WHEN?

• Hospital-based Palliative Specialists• Hospice out-patient clinics• Day Hospice attendance• Hospice admission

BARRIERS to ACCESSINGSPECIALIST PALLIATIVE CARE

SERVICES

From Cardiology

• Palliative care only for dying patients

• Need to continue active intervention

• Concerns medications will be stopped

• Lack of understanding what SPC can offer

From Specialist Palliative care

• Floodgates will open / patient load

• Stretch charitable funding

• ? Skills to manage these patients

• Chronically ill - ? Exacerbation

? Block beds

From Patients

• I don’t have cancer

• I’m not dying

• Distressing

• Lack of understanding – their disease

palliative care

COST

HEART FAILURE / COPD

?

AN EQUITABLE SERVICE

• All life-limiting illnesses under SPC umbrella• Early introduction to the service• Patient and carer education• End-of-Life discussions• PPC documents• Day hospice

END-STAGE HEART FAILURE

• Optimal treatment but still symptomatic

• Principles of Symptom control

Assessment and investigation

Intervention to reversible factors

Palliation of irreversible factors

• Rationalisation of medication• Renal dysfunction / Hypotension

MEDICATIONS

• Statins – stop• Aspirin / Clopidogrel – stop

• ACE Inhibitors – reduce if renal dysfunction

• Loop diuretics• Spironolactone

• B Blockers• Digoxin – stop, unless in AF

BREATHLESSNESS

• Common• Assess for treatable causes

Infection ; Effusion: PE; underlying Ca; pulmonary oedema

asthma; COPD; anxiety

• Oxygen - ?benefit• Opioids – careful monitoring

• Anxiolytics• Non –pharmacological measures

breathing techniques; fan:pacing;

PAIN in HEART FAILURE

• Angina; - ct anti-anginal medication as long as possible

• musculoskeletal;• arthritis; • Gout

• WHO analgesic ladder

• Avoid NSAIDs

Amitriptyline

NAUSEA

• Consider causeMedication – opioids; digoxin toxicity; spironolactoneconstipation;renal failureanxiety

• Avoid Cyclizine – strong anticholinergic effects

• MetoclopramideLevomepromazineHaloperidol

• Syringe driver

OTHER SYMPTOMS

• FatigueOver-diuresis; hypokalaemia; poor sleep; anaemia; depression;PND; periodic respiration; sleep apnoea

• DepressionAvoid tricyclics

• ItchGood skin care of oedematous legs; SSRI

• ConstipationAvoid bulking agents eg: fybogel

TERMINAL STAGE

• Not tolerating oral medication

• Syringe driver

Analgesics

Antiemetics

Anxiolytics

Diuretic

• Liverpool Care Pathway LCP

End-Stage COPD

• Difficult to diagnose

• Persistent breathlessness despite optimum treatment

• Severe airflow obstruction FEV1 <30%• Housebound• An increased frequency of hospital admissions

• Fear / anxiety

STUDY of COPD PATIENTSNEEDS

• Diagnosis and disease process• Treatment options• Prognosis• What dying might be like• Advance care planning

ie: identical to needs of cancer patients!

End – Stage COPD

• Respiratory and non-respiratory symptoms

BREATHLESSNESS Decreased mobility

Wheeze Depression

Cough Social isolation

Fatigue

Pain

Poor sleep

• Worse standard of daily life than Lung Ca

MANAGEMENT• Bronchodilators• Anticholinergics

• Oxygen• Anxiolytics• Opioids

• Coping strategiespurse-lip breathing; slow expiration; lean forward

• Pyschological support – end-of–life planning

GOING FOR GOLD

• Equitable end-of-life care

• ALL appropriate patients on palliative register

• Avoid un-necessary hospital admissions

• Advanced care planning

• Patient choice

Domiciliary Visits

• Primary care team + Hospice Dr

• Aim - to recognise end-stage

- respect patients choices

- control symptoms

- prevent hospital admissions

- strive for a “good death”

COPD PILOT

• Looking at providing an equitable service• Recognising the different illness trajectories• Meeting patients needs• Introduction to the Hospice• Acknowledging what's already available

COPD PILOT

• Joint clinic at St Johns Hospice

RLI Respiratory team

SJH Doctor / Day hospice nurse

Physio / OT / CT• COPD patients chosen by respiratory team

FEV1 < 30

> 3 admissions• 6 week programme