Palliative Care An introduction

1
Palliative Care An introduction

• Dr Suresh Kumar
• Director
• Institute of Palliative Medicine
• Kerala, India

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The Nature of Suffering and the Goals of Medicine
- Eric J. Cassell

• The relief of suffering and the cure of disease
  must be seen as twin obligations of a medical
  profession that is truly dedicated to the care of
  the sick. Physicians failure to understand the
  nature of suffering can result in medical
  intervention that (though technically adequate)
  not only fails to relieve suffering but becomes a
  source of suffering itself.

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Most people with chronic diseases live and die
miserably

• Over 30 million people suffer unnecessarily from
  severe pain and other symptoms each year. So
  much is known in the management of these
  symptoms, but unfortunately this knowledge is not
  benefiting most of those in need of it. In spite
  of all the effort over the last two decades, the
  great majority of individuals with incurable
  diseases that need care are not getting it
• -Stjernsward J and Clark D Palliative
  Medicine-a Global Perspective in Oxford Textbook
  of Palliative Medicine, 3rd Edition Eds. Doyle D,
  Hanks G et al Oxford University Press,
  Oxford.2004 Chapter21, 20

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Symptoms at the End of Life

• Pain 67
• Trouble breathing 49
• Nausea and vomiting 27
• Sleeplessness 36
• Confusion 38
• Depression 36
• Loss of appetite 38
• Constipation 32
• Bedsores 14
• Incontinence 33
• Seale and Cartwright, 1994

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Palliative Care

• The active total care of patients whose disease
  is not responsive to curative treatment. Control
  of pain, of other symptoms, and of psychological,
  social, and spiritual problems, is paramount.
  The goal of palliative care is achievement of
  the best quality of life for patients and
  families.
• (WHO, 1990)

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Goals of care

• What are the potential goals of medical
  intervention?

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Potential Goals of Care

• Cure of disease
• Avoidance of premature death
• Maintenance or improvement in function
• Prolong life

• Relief of suffering
• Quality of life
• Staying in control
• A good death
• Support for families and loved ones

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Historically, a dichotomous division of goals of
care

• Focus on curing illness
• Little attention to relief of suffering, care of
  dying
• Palliative care arose in response to this need

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Multiple goals of care

• Multiple goals often apply simultaneously
• Goals are often contradictory
• Certain goals may take priority over others

10
Goals May Change when the disease becomes
incurable

• Some goals may take priority over others
• The shift in the focus of care
• is gradual
• is an expected part of the continuum of medical
  care
• Review goals with any change in
• health/functional status (e.g. advancing illness)
• setting of care
• treatment preferences

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Prognosis Can Be Difficult to PredictChronic
Progressive Illness Actively
Dying
12
Sudden death, unexpected cause

• lt 10, MI, accident, etc

Health Status
Death
Time
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Protracted life-threatening illness

• gt 90
• predictable steady decline with a relatively
  short terminal phase
• cancer
• slow decline punctuated by periodic crises
• CHF, emphysema, Alzheimers-type dementia

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Steady decline, short terminal phase
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Slow decline, periodic crises, sudden death
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Palliative Care

• Interdisciplinary care that aims to relieve
  suffering and improve quality of life for
  patients with advanced illness and their
  families.
• It is offered simultaneously with all other
  appropriate medical treatment.

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Palliative Care

• Relief from symptoms
• Emotional support
• Social support
• The approach and skills relevant in the
  management of all diseases, curable or incurable

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What Do Patients with Serious Illnesses Want?

• Pain and symptom control
• Avoid inappropriate prolongation of the dying
  process
• Achieve a sense of control
• Relieve burdens on family
• Strengthen relationships with loved ones

Singer et al. JAMA 1999281(2)163-168.
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What Do Family Caregivers Want?

• Study of 475 family members 1-2 years after
  bereavement
• Loved ones wishes honored
• Inclusion in decision processes
• Support/assistance at home
• Practical help (transportation, medicines,
  equipment)
• Personal care needs (bathing, feeding, toileting)
• Honest information
• 24/7 access
• To be listened to
• Privacy
• To be remembered and contacted after the death
• Tolle et al. Oregon report card.1999
  www.ohsu.edu/ethics

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Palliative Care...

• Focuses on relieving suffering, improving quality
  of life
• affirms life, sees death as a personal and
  natural process
• many diagnoses
• appropriate early in course of illness
• patient and family preferences respected
• may be combined with curative therapies or may be
  the focus of care

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...Palliative Care

• Interdisciplinary care of the patient and family
• Pain and symptom management
• May include disease-modifying treatments
• Psychological, social, spiritual support
• Bereavement support

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Benefits of Palliative Care The Evidence Base

• Reduction in symptom burden
• Improved patient and family satisfaction
• Reduced costs

23
Global need for Palliative Care

• All figures in million
• Annual Deaths globally 58
• Developing countries 45
• Developed countries 13
• Projected rise- in 2015 64
• in 2030 74
• Cancer burden- new cases/year-
• in 2003 10
• in 2020 16
• in 2050 24
• Elderly aged 60 and above
• in 2000 600
• in 2025 1200
• in 2050 2000
• AIDS -mortality projections-
• in 2003 3
• in 2015 4
• in 2030 6

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Communicable and non communicable Diseases

• What will be the common diseases of the
  twenty-first century? As a group, the
  non-communicable diseases (cancer,
  cardiovascular, diabetes) will increase from 27
  to 43 per cent of the global burden of diseases
  by 2020, while communicable diseases (infections
  and tropical and parasitic diseases) will
  decrease from 50 to 22 per cent.
• Sepúlveda, C., Marlin, A., Yoshida, T., and
  Ullrich, A. (2002). Palliative care the World
  Health Organizations global perspective. Journal
  of Pain and Symptom Management 24 (2), 916.

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Non Communicable Diseases in resource poor
countries

• Only 20 of chronic disease deaths occur in high
  income countries
• 80 occur in low and middle income countries
• The age-specific death rates from
  non-communicable diseases are higher in
  developing than developed countries.
• (Preventing chronic diseases a vital investment
  WHO global report. World Health Organization
  Geneva 2005)

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Cancer Care (National Cancer Control Programs
Policies and Managerial Guidelines. World Health
Organization)
27

• Roughly 80-90 of pain due to cancer can be
  relieved relatively simply with oral analgesics
  and adjuvant drugs in accordance with the World
  Health Organisation's guidelines. The remaining
  10-20 can be difficult to treat.

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Meaningful Palliative Care

• Meaningful palliative care requires a
  combination of socio-economic, cultural, and
  medical solutions. All three must be addressed.
  Not purely a medical issue, the cultural and
  socioeconomic factors determine what kind of
  death we face. Todays overemphasis on medical
  approaches can be balanced only by the people
  taking ownership Dr Jan Stjernsward

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The challenge

• The challenge before physicians anywhere in
  the world is to find a way to assure continuous
  and meaningful care to most of those who need it
• How successful are we in meeting this challenge?

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A proposed system of care for chronically and
incurably ill patients

• Specialists have a definite but small role
• Primary care physician in the periphery to be
  involved
• Massive involvement from the local community

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Thank you!!