Download
april 15 2008 jenny legassie pgy5 palliative care anne boyle md ccfp n.
Skip this Video
Loading SlideShow in 5 Seconds..
Palliative Care PowerPoint Presentation
Download Presentation
Palliative Care

Palliative Care

411 Vues Download Presentation
Télécharger la présentation

Palliative Care

- - - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript

  1. April 15, 2008 Jenny Legassie, PGY5 Palliative Care Anne Boyle, MD CCFP Palliative Care

  2. Objectives • Develop an understanding of what palliative care is. • Develop an approach to opiate use in hospitalized patients. • Explore role for palliative care in surgical patients

  3. What is Palliative Care?

  4. What is Palliative Care? • Palliative care is an approach that improves the quality of life 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. WHO, 2002

  5. What is Palliative Care? • Palliative care: • provides relief from pain and other distressing symptoms; • affirms life and regards dying as a normal process; • intends neither to hasten or postpone death; • integrates the psychological and spiritual aspects of patient care; • offers a support system to help patients live as actively as possible until death; • offers a support system to help the family cope during the patients illness and in their own bereavement; • uses a team approach to address the needs of patients and their families, including bereavement counseling, if indicated; • will enhance quality of life, and may also positively influence the course of illness; • is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications. WHO, 2002

  6. What is Palliative Care? • It's just good medicine.

  7. What is Palliative Care? Planning for Discharge Giving a Prognosis Caring for Families Physiotherapy • It’s Just Good Medicine. Wound Care Rehab Listening Outlining Disease Trajectory Optimizing Function Setting Goals Discussion of Recesutation Wishes Acknowledging Death Control of Vomiting Antibiotics Treatment Of Dyspnea Identifying Patients Wishes Reassessing Goals Diagnosis Special Mattress Financial Care/Planning Spiritual Care Pain Control Saying “Good-Bye” Nutrition Mouth Care Saying you “don’t know” Addressing Care Giver Burnout Bowel Care Discussing Feeding Tubes Education Answering Questions Honestly Acknowledging that Patient Cannot Return Home

  8. What is Palliative Care? • Patients are NOT Palliative • Patients may have a terminal or incurable illness • Patients may opt for a palliative goal of care • Palliative Care provided for one patient is not appropriate for all patients

  9. Case 1 - Mr. Smith’s Delirium

  10. Case 1 – Mr. Smith’s Delirium • 78 year old male with prostate cancer. Mets to Bone identified 6 months ago. Disease currently stable with hormonal therapy. • PHX: cholesystectomy 1976 • Presents to Hospital with nausea and vomiting times 2 days. Exam and imaging are consistent with SBO. • Current Meds are: • Oxycontin 60mg po BID (for bone mets) • Oxycocet 2-3 tabs po q4hprn (takes about one dose per day) • Colace 200mg BID • Senekot 3 tablets BID • Hormonal therapy q3months

  11. Case 1 – Mr. Smith’s Delirium • Mr. Smith still has pain from his bone mets. How are you going to manage Mr. Smith’s pain in hospital? • What Drug? • What Dose?

  12. Case 1 – Mr. Smith's Delirium • Mr. Smith is given morphine 5mg IV q4h prn • 24 hours after admission, nursing staff call you to say Mr. Smith is confused, calling out, combative, tremulous, trying to climb out of bed. • He has had a total of 5mg morphine every 6 hours since he came to hospital (30mg in 24 hours). • What is your approach to his change in behavior and level of confusion?

  13. Case 1 – Mr. Smith’s Delirium • Physical Exam confirms that Mr. Smith is confused, tremulous, combative. Looks uncomfortable. • Infection workup is negative. • No metabolic abnormalities. • So why is he confused and combative?

  14. Case 1 – Mr. Smith’s Delirium • Opiate Withdrawal • At home using Oxycontin 60mg po bid • Conversion Oxycontin 10 approx.= Morphine 15 • Total daily Morphine dose 180mg po • Conversion Morphine 2mg po = Morphine 1mg SC/IV • Total daily Morphine dose 90mg SC/IV • SC/IV Morphine dosed q4h • Morphine 15 mg SC/IV q4h • Morphine 5-7 SC/IV q2h prn for breakthrough pain

  15. Case 1 – Mr. Smith’s Delirium • What Do you Do Now? • Change his morphine to 15mg IV q4h and 5-7mg IV q4h as long as patient’s RR > 10 and no myoclonus • Mr. Smith settles quickly with pain management and re-orientation.

  16. Case 2 – Mr. Brown’s Delirium

  17. Case 2 – Mr. Brown’s Delirium • 78 year old male with prostate cancer. Mets to Bone identified 6 months ago. Disease currently stable with hormonal therapy. • PHX: cholesystectomy 1976 • Presents to Hospital with nausea and vomiting times days. Exam and imaging are consistent with SBO. • Current Meds are: • Tylenol 3 1-2 tabs q4h prn (patient does not take these as feels pain is well controlled) • Colace 200mg BID • Senekot 3 tabs BID • Hormonal therapy q3months

  18. Case 2 – Mr. Brown’s Delirium • Mr. Brown has significant pain from his SBO. How are you going to manage this in hospital? • What Drug? • What Dose?

  19. Case 2 – Mr. Brown’s Delirium • Mr. Brown is given morphine 5mg IV q4h prn • 24 hours after admission, nursing staff call you to say Mr. Brown is confused, calling out, combative, tremulous, trying to climb out of bed. • He has had a total of 5mg morphine every 6 hours since he came to hospital (30mg in 24 hours). • What is your approach to his change in behavior and level of confusion?

  20. Case 2 – Mr. Brown’s Delirium • Physical Exam confirms that Mr. Brown is confused, combative, focal muscle twitching, pin point pupils. Looks uncomfortable. • Infection workup is negative. • No metabolic abnormalities. • So why is he confused and combative?

  21. Case 2 – Mr. Brown’s Delirium • Opiate Toxicity • Opiate Naive • Now on 30mg Morphine per day • Has myoclonus, pin point pupils and confusion • What would you do now?

  22. Case 2 – Mr. Brown’s Delirium • You change Mr. Brown’s prescription to morphine 0.5-1mg IV q4 hours plus 0.5mg IV q1h prn. • You reassess him two hours after last dose – he has not needed any breakthrough Reports pain is manageable. Confusion clearing.

  23. Take Home Points - Case 1 & 2 • We use a lot of opiates in hospital • Too much and too little opiate has the ability to cause side effects • A patients opiate requirements should be based on their previous opiate doses and experiences. • Opiate doses must be reassessed frequently.

  24. Case 3 – Reevaluating Mrs. Taylor’s Goals

  25. Case 3 – Reevaluating Mrs. Taylor’s Goals • 90 year old woman from retirement home • Admitted with nausea and vomiting for 2 days, abdominal pain for one day. • O/Ex: BP 80/65, HR 137, RR 24, Confused, RUQ pain, guarding and rigidity • PMHx: Angina, HTN, DM type II, OA

  26. Case 3 – Reevaluating Mrs. Taylor’s Goals

  27. Case 3 – Reevaluating Mrs. Taylor’s Goals

  28. Case 3 – Reevaluating Mrs. Taylor’s Goals

  29. Case 3 – Reevaluating Mrs. Taylor’s Goals • Patient felt not to be a candidate for surgery. • Team discusses goals with patient and family. Opt for comfort care only. • What does comfort care mean?

  30. Case 3 – Reevaluating Mrs. Taylor’s Goals • Comfort Care is not a standard type of care. Need to clarify with each patient. • Fluids • Feeds • Interventions such as NGs, decompressing PEGs, heparin for PE • Non-invasive ventilation

  31. Case 3 – Reevaluating Mrs. Taylor’s Goals • Mrs. Taylor and her family opt for focus on symptom control. • No IV • Oral intake as Mrs. Taylor tolerated. (Mainly ice chips and rice pudding.) • Opiates, antiemetics, antibiotics • Gave consent for NG if intractable vomiting. • No CPR, defib, intubation

  32. Case 3 – Reevaluating Mrs. Taylor’s Goals • 5 Days later, Mrs. Taylor doing well clinically. Pain minimal (uses Tylenol only). No nausea or vomiting. Up to chair with assistance. • Mrs. Taylor asks if she can return to her retirement home. • So what now?

  33. Case 3 – Reevaluating Mrs. Taylor’s Goals

  34. Case 3 – Reevaluating Mrs. Taylor’s Goals • Urgent Laparotomy • Lysis of adhesive band • Viable small bowel • Patient recovered well, tolerated regular diet, alert, responsive

  35. Case 3 – Reevaluating Mrs. Taylor’s Goals • Palliative Care and Comfort Care are not only applicable to actively dying patients. • Patients don’t always die when we expect them to. • Part of providing good care is reassessing our goals daily.

  36. Case 4 – Palliation for Katie

  37. Case 4 – Palliation for Katie • 38 year old woman with metastatic breast cancer. • Treatment to date includes modified radical mastectomy, adjuvant chemo, local rads, tamoxifen. Palliative chemo through two clinical trials after mets found in liver, lungs and bone. • Married, mother of three (ages 13, 9, 6 years). Independent of ADLs at home prior to admission. • Admitted for surgical repair of pathologic femur fracture

  38. Case 4 – Palliation for Katie • Day 2 post op Katie develops central chest pain and shortness of breath. • No cough • Low grade fever • RR 26 • O2 sat 90% RA • JVP Elevated • Pulsus of 30mmHg • What do you do now?

  39. Case 4 – Palliation for Katie • Chest X-ray negative for infiltrate but shows large heart • V/Q scan low risk for PE • Cardiac Echo shows moderate to large pericardial effusion with tamponade. • What Now?

  40. Case 4 – Palliation for Katie • Katie wants to get home to her kids. Opts for pericardiocentesis. • Three days later, fluid re accumulates. • After lengthy discussion, Katie opts for a pericardial window.

  41. Case 4 – Palliation for Katie • 3 days after insertion of pericardial window, Katie complains of SOB and pain in her left leg. • Left leg is grossly swollen, tender to palpation behind knee and decreased pulses • U/S is positive for large proximal clot • Katie is anticoagulated despite the increased risk of bleeding. • Still wants to get home to her kids. • Begins to Ambulate.

  42. Palliation for Katie • How could a palliative care consult benefit Katie? • Symptoms – Pain • - Dyspnea • - Ambulation • Discharge - Is discharge home feasible? • How much help does she need at home? • Are they prepared for increasing symptoms at home? • Are they prepared for death at home? • Psychosocial - What do her kids know? • Who will look after her kids after her death? • Who else provides emotional support? • Has she talked about death to anyone?

  43. Take Home Points - Katie • Patients do not have to be actively dying to benefit from Palliative Care • Patients can seek active treatment and still benefit from a palliative care consult.

  44. Take Home Points • Good Care requires assessment of each patient as an individual. • Reevaluation of your approach and the patient's goals needs to occur frequently. • Palliative Care is much more than care at the time of death. • Palliative Care and active treatment can occur at the same time. • Palliative Care can be provided by the primary care team. • Palliative Care involves some difficult discussions. If you’re not comfortable with these, don’t avoid them, consult.

  45. Questions/Comments?