Palliative Care: Back to Basics

Dr Shirley H. BushAssistant Professor, Division of Palliative Care,

Department of Medicine

March 30, 2012

Luke Fildes: The Doctor 1891Oil on canvas, © Tate (tate.org.uk)

Overview of Session

• 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

• 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-of-

life 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 - I

Objectives - II

• 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.

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Palliative Care Knowledge Quiz

• Test your own knowledge:

• Questionnaire in English - https://app.fluidsurveys.com/surveys/pgrassau/2012-english-palcare-know-4y-survey/

• Questionnaire in French - https://app.fluidsurveys.com/surveys/pgrassau/2012-french-palcare-know-4y-survey/

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And now the Answers……

• These will be discussed in class

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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

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CHPCA Models of Palliative Care (2002)

• Model • Realistically

Illness trajectory

Palliative approach to care

Therapy to cure or control disease

Death

Bereavement Care

Death

Illness Trajectory

Therapy to cure or control disease

Palliative approach to care

Bereavement Care

Dx Dx

Aspects/Domains of Holistic Care

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.

-Finances-Relationships-Personal routines-Recreation-Vocation-Rituals-Legal issues-Family caregiver support-Practical

Social/Cultural, e.g.

-Disease management-Pain & other symptoms-Function-Nutrition habits-Physical activity

Physical, e.g.-Personality-Psychological symptoms-Emotions-Control & dignity-Coping responses-Self image/ self esteem-Loss & Grief

Psychological, e.g.

-Meaning & values-Existential issues-Beliefs-Spirituality -Rites & rituals-Symbols & icons-Loss & Grief-Life transitions-Religions

Spiritual, e.g.

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…….

• 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

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A Guide to Palliative Care Service Development: a population based approach . Palliative Care Australia (PCA) 2005. Available at: http://www.palliativecare.org.au

W.H.O. 3-step Analgesic Ladder

STEP 1

STEP 2

STEP 3

Non-opioide.g. paracetamol,

NSAIDs+/– Adjuvant

Opioid for mild to moderate

pain+/– Non-opioid

+/– Adjuvant

Opioid for moderate to severe pain

+/– Non-opioid+/– Adjuvant

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

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(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

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

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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

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Prognosis: “Doctor: How long do I have to live?”

• How frequently is the patient observed to decline?– Every Month: estimated

prognosis of months– Every Week: estimated

prognosis of weeks – Every Day: estimated

prognosis of days– Every Hour: estimated

prognosis of hours

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The Thinker, Auguste Rodin, 1902

BUT with caveat: in setting of advanced cancer, patient’s condition can change very quickly (Another disclaimer: life expectancy can be longer)

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

[Unit name – Lecture title – Prof name] See Chapter 3 in Pallium Palliative Pocketbook

The Normal Dying Process - The Last Days

• 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

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Terminal Respiratory Congestion: “Death Rattle”

• 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– 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

– 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

• 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 quelquefoisSoulager souventConsoler toujours

To cure occasionallyTo relieve oftenTo comfort always

Death in the sickroom, Edvard Munch, 1895

• Any Questions…..

• Please feel free to contact me:• sbush@bruyere.org

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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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