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Palliative Care

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April 15, 2008 Jenny Legassie, PGY5 Palliative Care Anne Boyle, MD CCFP Case 3 Reevaluating Mrs. Taylor s Goals Urgent Laparotomy Lysis of adhesive band Viable ... – PowerPoint PPT presentation

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Title: Palliative Care


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

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
  • Its Just Good Medicine.

Giving a Prognosis
Physiotherapy
Caring for Families
Wound Care
Rehab
Outlining Disease Trajectory
Optimizing Function
Listening
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
Nutrition
Saying Good-Bye
Mouth Care
Saying you dont 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. Smiths Delirium
10
Case 1 Mr. Smiths 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. Smiths Delirium
  • Mr. Smith still has pain from his bone mets. How
    are you going to manage Mr. Smiths 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. Smiths 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. Smiths 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. Smiths Delirium
  • What Do you Do Now?
  • Change his morphine to 15mg IV q4h and 5-7mg IV
    q4h as long as patients RR gt 10 and no myoclonus
  • Mr. Smith settles quickly with pain management
    and re-orientation.

16
Case 2 Mr. Browns Delirium
17
Case 2 Mr. Browns 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. Browns 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. Browns 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. Browns 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. Browns 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. Browns Delirium
  • You change Mr. Browns 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. Taylors Goals
25
Case 3 Reevaluating Mrs. Taylors 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. Taylors Goals
27
Case 3 Reevaluating Mrs. Taylors Goals
28
Case 3 Reevaluating Mrs. Taylors Goals
29
Case 3 Reevaluating Mrs. Taylors 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. Taylors 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. Taylors 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. Taylors 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. Taylors Goals
34
Case 3 Reevaluating Mrs. Taylors Goals
  • Urgent Laparotomy
  • Lysis of adhesive band
  • Viable small bowel
  • Patient recovered well, tolerated regular diet,
    alert, responsive

35
Case 3 Reevaluating Mrs. Taylors Goals
  • Palliative Care and Comfort Care are not only
    applicable to actively dying patients.
  • Patients dont 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 youre not comfortable with
    these, dont avoid them, consult.

45
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