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Palliative Care

Palliative Care. Dr Sharon Ryan Staff Specialist Palliative Care Service JHCH and CMN . What is Palliative Care?. Multi-dimensional approach “Palliative approach” vs. tertiary level palliative medicine Not all patients can be cured. Every living thing will die.

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Palliative Care

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  1. Palliative Care Dr Sharon Ryan Staff Specialist Palliative Care Service JHCH and CMN

  2. What is Palliative Care? • Multi-dimensional approach • “Palliative approach” vs. tertiary level palliative medicine • Not all patients can be cured. • Every living thing will die. • The transition of care with intent to cure to care with a palliative intent is a journey that is only very rarely clearly demarcated.

  3. Disease trajectory

  4. Possible Areas to discuss • Opioid use, drug conversions, routes of administration. • Management of common symptoms • Diagnosing dying and managing the terminal phase – including using syringe drivers • Identification and management of delirium • Difficult conversations, family conferences

  5. Switching opioids • Calculate daily requirement • Consider route of administration • Calculate dose conversion (convert current drug to daily oral morphine dose and convert to desired drug)

  6. Fentanyl patches • These are very potent – 25mcg patch = ~60-75mg oral morphine/24 hours • Carefully consider dose in opioid naïve pts • Not good for unstable pain • Take into account time to steady state

  7. Case 1 • 55 yo man with metastatic prostate cancer and severe pain from bone metastases • Currently on 60mg bd MS Contin • Persistently nauseated despite metoclopramide • You consider morphine induced nausea the most likely cause • What drug at what dose will you try next?

  8. Answer • Oral long-acting oxycodone a reasonable choice • Current opioid dose 120mg OME • = 80mg oxycodone • = 40mg bd OxyContin • Dose reduce slightly, so start on 30mg bd OxyContin

  9. Case 2 76 yo woman with metastatic breast cancer. On 120mg MS Contin bd (morphine) with occasional morphine for breakthrough. Presents to ED with persistent vomiting (hypercalcaemia). Her renal function is normal You think she needs an infusion. Chart her appropriate analgesia and antiemetic.

  10. Answer Morphine 80mg / metoclopramide 30mg sc over 24 hrs. Made up to 48 mLs in NS and run at 2ml/hr. Breakthrough analgesia : morphine 10mg q1 hr. sc prn.

  11. Case 3 83 yo woman who has been relatively well and living independently. Fall at home and found unconscious CT - large sub-dural haematoma. GCS consistently been 5-6 for last 7 hours. In accordance with her previous stated wishes, she is not for neurosurgery or aggressive management. Her family are in agreement. You are asked to write up medications for the end of life including a syringe driver order.

  12. Answer • This patient may NOT need a scsd • PRN medications • In opioid naïve pt, 2.5mg sc morphine q1h prn may provide excellent symptom control • Benzodiazepine – seizures/agitation • Antiemetic • Anticholinergic * Even if renal function poor, at end of life morphine may still be a good option

  13. Case 4 • 82yo man with acute on chronic renal failure (eGFR 14) and congestive cardiac failure. • He has not responded to maximal anti-failure therapy. • He is markedly breathless at rest on NRBM oxygen. He and his family are increasingly distressed. He has a documented NFR order • You think he needs an infusion. Chart this and appropriate prn medication.

  14. Answer • Pt has renal failure – • Would usually avoid morphine • BUT best evidence is for morphine for relief of dyspnoea • No right answer, but reasonable to start with morphine 10mg/24hours BUT watch for adverse effects • Reasonable to also use a benzodiazepine in scsd – say 5mg midazolam/24 hours • PRN meds morphine 2.5mg q1h, midazolam 2.5mg q1h, glycopyrrolate, haloperidol • REGULAR REVIEW.

  15. Case5 • 67 yo woman with metastatic breast cancer. • Admitted for 3 units of blood and imaging investigations. • She is on 50 mcg/hr. fentanyl patch changed every 3 days. Her renal function is normal. Her pain is reasonably well controlled but she does get breakthrough pain. • Chart her breakthrough analgesia.

  16. Answer • Morphine mixture 15mg q 1 PO hr. prn Or • Oxycodone 10mg q 1 hr. PO prn (endone or oxynorm)

  17. Syringe drivers Maintenance of symptom control in the setting of: • Terminal phase of illness • Persistent nausea and vomiting e.g. malignant bowel obstruction • Dysphagia e.g. carcinoma of the oesophagus • Coma • Poor absorption of oral drugs (rare) • Opioid adverse effects (rare) • Non-availability of intravenous access

  18. Delirium • Identify • hyper-active, hypo-active, mixed • Signs – grasping, plucking, myoclonus, irritability, hyper-vigilance, distractibility • Assessment • Reversible causes • Intervention • Re-assessment • Terminal delirium

  19. Difficult discussions

  20. Warning signs that you are about to have a difficult discussion • Pt – lengthy admission, needing nursing “special”, unrelieved symptoms, outside 2 SDs • Family – long-standing conflict between family members, D&A issues, mental health issues, • Staff – “passions running high”, multiple treating or consulting teams

  21. How to prepare • Be well-informed • Attend with a calm state of mind • Optimise environment • Agree goals of discussion early • Create finite time for each participant to speak uninterrupted • Identify “out-liers” and include them • Schedule follow up meeting • Carefully document discussion and outcomes

  22. Difficult discussions - During active management • Raising poor prognosis • Initiating advance care planning discussion • Limits to interventions and investigations • With-holding requested interventions and investigations • Unrelieved suffering

  23. Difficult discussions at the end-of-life: • What about supplemental oxygen? • What about i.v. or sub-cut fluids? • What about antibiotics? • What about steroids? • What about a blood test or chest x-ray? • Can you speed the process up?

  24. Palliative Medicine as a career

  25. Skills - Palliative Medicine • Medical Expert/Clinical Decision Maker – Pathophysiology of disease, Pharmacology, Appropriate clinical decisions • Communicator – Expert Communication skills with patients (whatever their location), carers, multidisciplinary colleagues • Collaborator - Consultation with other physicians & health care professionals; and contribution to inter-disciplinary activities. • Manager – Health Care Resources, Human resources • Health Advocate – Patients, Palliative Care issues in institutions and the community • Scholar – MOPS, Teaching, Research • Professional – Quality Care, Integrity, compassion,

  26. Training in Palliative Medicine “Diversity” LATERAL ENTRY Approved Non RACP Fellowship RACP Basic Training completed Written exam passed Clinical exam passed Advanced Training 3yrs Specialist in Palliative Medicine Fellowship + FAChPM Palliative Medicine Consultant (Physician/Paediatrician) FRACP + FAChPM

  27. Eligibility for ACHPM Advanced Training • Australian and New Zealand College of Anaesthetists (FRANZCA) • Australian College of Rural and Remote Medicine (FACRRM) • Royal Australasian College of Surgeons (FRACS) • Royal Australian and New Zealand College of Obstetricians and Gynaecologists (FRANZCOG) • Royal Australian and New Zealand College of Psychiatrists (FRANZCP) • Royal Australian and New Zealand College of Radiologists (FRANZCR) • Royal Australian College of General Practitioners (FRACGP) • Royal New Zealand College of General Practitioners (FRNZCGP) • Australasian Faculty of Rehabilitation Medicine (FAFRM) • Faculty of Pain Medicine (FFPMANZCA) • Joint Faculty of Intensive Care Medicine (FJFICM)

  28. Advanced Training • Six months in each of: • Palliative Medicine Unit or Hospice • Community Setting • Teaching Hospital Consultation Service • Discretionary Palliative Medicine • Six months Clinical Oncology (Medical, Radiation, Haematology) • Six month elective term – research, other specialties • 1 Case Report and 1 Research Project • RACP PREP programme

  29. Clinical Diploma in Palliative Medicine • Through RACP – Chapter of Palliative medicine • Pre-requisites: • An approved undergraduate medical degree • Current registration with the Medical Board of Australia • 6 month supervised clinical attachment in an accredited training site (hospice/consultation/community service) • Log-book (50 cases) • 3500 word case report

  30. Other Issues • Hunter Palliative Care is based at the Calvary Mater • Staffing: 5 Staff Specialists (0.6 FTE Paediatric palliative care), 5 VMOs • Approved for Higher Professional Training; Study Afternoon in advanced training; paid Conference Leave (x1 / year) • Palliative Care service involved in research (PaCCSC, research staff) • Professorship with Uni of Newcastle Faculty of Health • Referrals 1000/yr (Outreach Team, 20 Hospice Beds, Day Hospice, Teaching, Research, Bereavement Programme) • Involvement in Specialist Organisation ANZSPM and the Palliative Medicine Education Committee

  31. What is good about working in Palliative Medicine? • Acknowledgement of the whole person • Wide Dimension (Pain and other symptom management, Family Support, Psychospiritual Issues) • Challenging pathophysiology • Clinical, Teaching & Research Roles • Collegiality – Diversity of Backgrounds / Good support • Ethics in practice • Recognition that communication is a core competency • Experiencing the “apolitical” • Openness of patients and families • Pride in the Profession in having this specialty.

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