1 / 88

Palliative Care

Palliative Care. “How one might live before they die” Melissa Matulis, MD. . Cultural Attitudes. In the beginning, man did not fear death but instead accepted it as a natural process.

nodin
Télécharger la présentation

Palliative Care

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Palliative Care “How one might live before they die” Melissa Matulis, MD..

  2. Cultural Attitudes • In the beginning, man did not fear death but instead accepted it as a natural process. • The Middle Ages brought about a change in attitude from death as ordinary and accepted to death as something shameful. • In the 1930’s, historians noted that people were no longer dying at home surrounded by friends and family, but in hospitals or nursing homes alone and isolated. • Over the last 40 years, our society has become increasingly influenced by new technology that has led to a more scientific and less humanistic approach to caring for people. • The “art of medicine” has been replaced by the “science of medicine”.

  3. History of Palliative Care • In the early 1960’s and continuing into the 70’s, the concept of “death awareness” developed and palliative care was born. • Palliative care had its origins in the hospice movement which began in England in 1967. • The interest in the terminally ill in the United States was sparked by the book On Death and Dying (1969) by Elisabeth Kubler-Ross.

  4. Definition of Palliative Care • Palliative Care is defined by the World Health Organization as “the active total care of patients whose disease is not responsive to curative treatment.” • This definition encompasses several principles: 1. It affirms life and regards dying as a normal process. 2. It neither hastens nor postpones death. 3. It provides relief from pain and other distressing symptoms. 4. It offers a support system to help patients live as actively as possible until death. 5. It integrates the psychological and spiritual aspects of patient care. 6. It offers a support system to help the family cope during the patient’s illness and in their own bereavement.

  5. Influences changing our attitudes 1. Our aging population • by 2030, 21% of our population will be age 65 and older • 8.8 million people will be over the age of 85 2. Emergence of patient autonomy and informed consent 3. The Right-to-Die Movement 4. The high cost of dying

  6. SUPPORT Trial • In JAMA November, 1995, investigators published a controlled trial to improve care for seriously ill, hospitalized patients entitled The Study to Understand Prognosis and Preferences for Outcomes and Risks of Treatments (SUPPORT).

  7. SUPPORT Trial • SUPPORT was a study of symptom experience, decision-making, and prognosis in hospitalized adults with one or more of 9 high mortality diseases. • Patients were required to meet defined severity criteria to establish a 6-mos mortality rate of 47%.

  8. SUPPORT Trial

  9. SUPPORT Trial • RESULTS: • Phase I • 47% of physicians knew when their patients did not want CPR. • 46% of DNR orders were written within 2 days of death. • 38% of patients who died spent at least 10 days in an ICU. • For 50% of conscience patients who died in the hospital, family reported moderate to severe pain at least half the time.

  10. SUPPORT Trial • In Phase 2, authors hypothesized that increased communication and understanding of prognosis and preferences would result in earlier tx decisions, decreased time in undesirable states before death, and a decrease in hospital resource use.

  11. SUPPORT Trial • The intervention physicians received estimates of likelihood of 6-mos survival for every day up to 6-mos, outcomes of CPR, and functional disability at 2-mos. • A specially trained clinical nurse facilitated communication between physician, patient, and family using questionnaires.

  12. SUPPORT Trial • RESULTS: • Phase 2 • Patients experienced no improvement in patient-physician communication. • No improvement in incidence of timing of written DNR orders. (AR 1.02, CI 0.90-1.15) • No change in physician’s knowledge of the patients’ preferences not to be resuscitated. (AR 1.22, CI 0.99-1.49)

  13. SUPPORT Trial • RESULTS: • Phase 2 • No difference in the number of days spent in the ICU, comatose, or receiving mechanical ventilation before death. (AR 0.97, CI 0.87-1.07) • No change in level of reported pain. (AR 1.15, CI 1.00-1.33) • No reduction in the use of hospital resources. (AR 1.05, CI 0.99-1.12)

  14. Barriers to Palliative Care • Advance Directives • Confusion of the “Dying Role” and the “Sick Role” • Lack of Physician Education

  15. Physician Education • Archives of Internal Medicine, 1995 • only 26% of residency programs offered a course on end-of-life care • 15% had no formal training at all • New England Journal of Medicine, 1997 • 38% of residents felt comfortable educating families about the dying process • 32% felt comfortable responding to patients who request assistance in dying • Academic Medicine, 1991 • only11% of medical schools offered full-term courses on death education

  16. Barriers to Palliative Care • Advance Directives • Confusion of the “Dying Role” and the “Sick Role” • Lack of Physician Education • The Health Care Delivery System • Narcotic Distribution Laws

  17. Role of the PCP • Comprehensive care of the patient AND the family. • Changing the focus of care from cure to palliation. • Prognostic Guidelines • National Hospice Organization • Fox et al., JAMA 1999

  18. Fox et al.--JAMA 1999 • Fox et al developed a study to evaluate the accuracy of the prognostic criteria in patients dying from COPD, CHF, and ESLD by developing a validation study. • Using the NHO guidelines and the SUPPORT trial population, they grouped 7 prognostic criteria into 3 different combinations to identify those patients with a survival prognosis of 6-mos or less.

  19. More on Fox et al.

  20. Fox et al. (con’t) COMBINATION CRITERIA • Broad Inclusion: 1 of the 7 criteria • Intermediate Inclusion: 3 of the 7 criteria • Narrow Inclusion: 5 of the 7 criteria • for example, if one had significant weight loss, low albumin, and cor pulmonale (3 criteria), then he would be included in the broad and intermediate groups, but not in the narrow.

  21. Fox et al. (con’t)

  22. SUPPORT Data Prognostic Model

  23. Operating Characteristic Comparisons

  24. Fox et al., JAMA 1999--Results • Each of the combination criteria had a high specificity, meaning they excluded those who lived over 6 mos.

  25. Fox et al., JAMA 1999--Results • However, the sensitivities were severely inadequate, meaning the criteria failed to identify those they intended--the dying pts whose prognosis was indeed < 6 mos.

  26. Fox et al., JAMA 1999--Results • Actual discharge to hospice was the most powerful predictor of death within 6-mos.

  27. Role of the PCP • Comprehensive care of the patient AND the family. • Changing the focus of care from cure to palliation. • Prognostic Guidelines • National Hospice Organization • Fox et al., JAMA 1999

  28. “Breaking the News” Patients want: • Physicians to be truthful. • To be told in person with time to ask questions. • Assurance they will not be abandoned. • A promise of optimal pain control. • Access to appropriate resources and counseling. • Ongoing communication with their physician.

  29. Role of the PCP • Comprehensive care of the patient AND the family. • Changing the focus of care from cure to palliation. • Prognostic Guidelines • National Hospice Organization • Fox et al., JAMA 1999 • “Breaking the news”

  30. Bereavement • Patients and families begin the mourning process at the diagnosis of life-threatening disease. This is termed “Anticipatory grief”. • Kubler-Ross’ book On Death and Dying identifies 5 stages to describe the experience of dying: denial, anger, bargaining, depression, and acceptance. • Spousal loss is associated with increased morbidity and mortality in the survivor, therefore bereavement counseling should continue for 1 year after the death.

  31. Role of the PCP • Comprehensive care of the patient AND the family. • Changing the focus of care from cure to palliation. • Prognostic Guidelines • National Hospice Organization • Fox et al., JAMA 1999 • “Breaking the news” • Bereavement

  32. Active Care of the Dying • The physician’s primary goal is to assist the patient in achieving relief of emotional pain and to increase physical comfort. • To achieve this goal the physician must work with the patient and family to achieve a plan of care.

  33. Active Care of the Dying • The Plan of Care addresses: • pain control • symptom management • spiritual needs • social needs • wishes for interventions at the time of death • a method to meet these goals

  34. Active Care of the Dying • Pulmonary Symptoms • Dyspnea • “The Death Rattle” • Cough

  35. Active Care of the Dying • Pulmonary Symptoms - Dyspnea • Is there a reversible condition present? • Using low dose narcotics such as morphine to reduce “air hunger”. • Is there an anxiety component? • The use of corticosteriods • What about bedside fans, oxygen, mucolytics, or sedation?

  36. Active Care of the Dying • Pulmonary Symptoms - “The Death Rattle” • Drying agents such as atropine or scopolamine desiccate pulmonary secretions and relax the smooth muscle of the tracheobronchial tree. • Gentle suctioning.

  37. Active Care of the Dying • Pulmonary Symptoms - Cough • Is there an underlying cause? • The use of opioids.

  38. Active Care of the Dying • Gastrointestinal Symptoms • Nausea and Vomiting • Constipation and Ileus • Anorexia • Xerostomia

  39. Active Care of the Dying GI Symptoms - Nausea and Vomiting The Four Pathways to the vomiting center: • The Chemotrigger Zone • Peripheral Afferent Nerves • Cortical Structures • Vestibular Apparatus

  40. Active Care of the Dying • GI Symptoms - Nausea and Vomiting • The Four Pathways: • The Chemotrigger Zone (CRZ) • activated when offending agents such as opioids, NSAIDs, or uremic toxins cross the blood-brain barrier. • treatment includes removing the noxious agent, reversing pathology, or blocking the CRZ dopamine, acetylcholine, and/or histamine receptors.

  41. Active Care of the Dying • GI Symptoms - Nausea and Vomiting • The Four Pathways: • Peripheral Afferent Nerves • Stimulation of these nerves along the GI tract by mucosal irritation, viscous enlargement, or pain from irritation of other areas such as liver or pelvic organs. • Treatments include H2 blockers, laxatives or prokinetics, steroids or opioids.

  42. Active Care of the Dying • GI Symptoms - Nausea and Vomiting • The Four Pathways: • Cortical Structures • This pathway is associated with increased intracranial pressure as well as anxiety and preconditioning. • Treatment includes steroids and benzodiazepines

  43. Active Care of the Dying • GI Symptoms - Nausea and Vomiting • The Four Pathways: • Vestibular Apparatus • Associated with movement and vertigo • Treatment includes anticholinergic and antihistaminic agents as well as steroids for increased intracranial pressure.

  44. Active Care of the Dying • GI Symptoms - Constipation • Constipation is a common and predictable symptom secondary to the widespread use of narcotics in the dying patient. • The physician must prescribe a regular bowel regime with the institution of narcotics. • Bulk laxatives, stool softeners, as well as gut stimulants • If possible, adequate fluid intake and high fiber diet.

  45. Active Care of the Dying • GI Symptoms - Constipation • Impaction can also present as severe constipation or overflow incontinence with abdominal pain mimicking bowel obstruction. • Treatment includes a softening and stimulating suppository. Occasionally digital disimpaction is required.

  46. Active Care of the Dying • GI Symptoms - Constipation • Remember if a patient has significant nausea and vomiting with or without concomitant constipation, the diagnosis of ileus or bowel obstruction should be considered. • Patients can be managed using somatostatin instead of nasogastric suctioning.

  47. Active Care of the Dying • GI Symptoms - Anorexia • Anorexia can be very distressing to patient’s family for fear of their loved one “starving to death.” • Furthermore, many physicians are uncomfortable not providing nutrition and hydration to the terminally ill.

  48. Active Care of the Dying • GI Symptoms - Anorexia • Nutrition and hydration remain controversial, but recent information supports the conclusion that tube feeding or intravenous feeding seldom achieves the intended medical goal. • Furthermore, rather than prevent suffering, they can cause it.

  49. Active Care of the Dying • GI Symptoms - Anorexia • McCann et al. published a study in JAMA 1994 that found: • 63% of patients dying of cancer never experienced hunger • the 34% that did experience hunger only needed small amounts of food for alleviation

  50. Active Care of the Dying • GI Symptoms - Anorexia • McCann et al. also that found: - 62% experienced either no thirst or thirst only initially in their terminal illness and received relief with sips of water, ice chips, and mouth care.

More Related