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LIFE-LIMITING ILLNESS. SymptomsPatient and carer needsPsychological supportSpiritual needsSocial isolationCarer supportQuality of Life. PARALLEL SYMPTOMS. LethargyDecreased mobilityPainDyspnoeaAnorexiaNauseaDepressionAnxietyDecreased QOL. DIFFERENCES. Predicting mortalityTerminal ph
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1. END-OF-LIFE CAREHEART FAILURE and COPDDr Sally ReederSpecialty Doctor in Palliative Medicine
2. LIFE-LIMITING ILLNESS Symptoms
Patient and carer needs
Psychological support
Spiritual needs
Social isolation
Carer support
Quality of Life
3. PARALLEL SYMPTOMS Lethargy
Decreased mobility
Pain
Dyspnoea
Anorexia
Nausea
Depression
Anxiety
Decreased QOL
4. DIFFERENCES Predicting mortality
Terminal phase
Understanding of diagnosis and prognosis
Discussions about prognosis
End-of-Life discussions
Contact with health and social services
Financial support
Availability of specialist services in community
5. NON-CANCER PATIENTS Unpredictable illness trajectory
Acute events – hospital admissions
Patient attitude to diagnosis
Timing of death uncertain
?opportunities for End-of-Life discussions
Patient choice
Palliative specialist involvement limited
6. ILLNESS TRAJECTORIES 3 typical illness trajectories
-Steady progression eg: cancer
-Gradual decline eg: HF / COPD
-Prolonged gradual decline eg: dementia / old age
9. WHO DEFINITIONof PALLIATIVE CARE An approach that improves quality of life.
Life-threatening illness
Prevention and relief of suffering
Early identification
Impeccable assessment
Treatment – physical, psychological, spiritual.
11. WHO SHOULD DELIVER THIS PALLIATIVE CARE?
General Practitioners?
Cardiologists?
Specialist clinic staff?
WHEN AND WHERE SHOULD IT BE DELIVERED?
At diagnosis?
Clinic appointments?
Hospital admissions?
GP appointments?
12. SHOULD THE PALLIATIVE CARE TEAM BECOME INVOLVED,
AND WHEN?
Hospital-based Palliative Specialists
Hospice out-patient clinics
Day Hospice attendance
Hospice admission
13. BARRIERS to ACCESSINGSPECIALIST PALLIATIVE CARE SERVICES
14. From Cardiology Palliative care only for dying patients
Need to continue active intervention
Concerns medications will be stopped
Lack of understanding what SPC can offer
15. From Specialist Palliative care Floodgates will open / patient load
Stretch charitable funding
? Skills to manage these patients
Chronically ill - ? Exacerbation
? Block beds
16. From Patients I don’t have cancer
I’m not dying
Distressing
Lack of understanding – their disease
palliative care
17. COST
18. HEART FAILURE / COPD ?
19. AN EQUITABLE SERVICE All life-limiting illnesses under SPC umbrella
Early introduction to the service
Patient and carer education
End-of-Life discussions
PPC documents
Day hospice
20. END-STAGE HEART FAILURE Optimal treatment but still symptomatic
Principles of Symptom control
Assessment and investigation
Intervention to reversible factors
Palliation of irreversible factors
Rationalisation of medication
Renal dysfunction / Hypotension
21. MEDICATIONS Statins – stop
Aspirin / Clopidogrel – stop
ACE Inhibitors – reduce if renal dysfunction
Loop diuretics
Spironolactone
B Blockers
Digoxin – stop, unless in AF
22. BREATHLESSNESS Common
Assess for treatable causes
Infection ; Effusion: PE; underlying Ca; pulmonary oedema
asthma; COPD; anxiety
Oxygen - ?benefit
Opioids – careful monitoring
Anxiolytics
Non –pharmacological measures
breathing techniques; fan:pacing;
23. PAIN in HEART FAILURE Angina; - ct anti-anginal medication as long as possible
musculoskeletal;
arthritis;
Gout
WHO analgesic ladder
Avoid NSAIDs
Amitriptyline
24. NAUSEA Consider cause
Medication – opioids; digoxin toxicity; spironolactone
constipation;
renal failure
anxiety
Avoid Cyclizine – strong anticholinergic effects
Metoclopramide
Levomepromazine
Haloperidol
Syringe driver
25. OTHER SYMPTOMS Fatigue
Over-diuresis; hypokalaemia; poor sleep; anaemia; depression;
PND; periodic respiration; sleep apnoea
Depression
Avoid tricyclics
Itch
Good skin care of oedematous legs; SSRI
Constipation
Avoid bulking agents eg: fybogel
26. TERMINAL STAGE Not tolerating oral medication
Syringe driver
Analgesics
Antiemetics
Anxiolytics
Diuretic
Liverpool Care Pathway LCP
27. End-Stage COPD Difficult to diagnose
Persistent breathlessness despite optimum treatment
Severe airflow obstruction FEV1 <30%
Housebound
An increased frequency of hospital admissions
Fear / anxiety
28. STUDY of COPD PATIENTSNEEDS
Diagnosis and disease process
Treatment options
Prognosis
What dying might be like
Advance care planning
ie: identical to needs of cancer patients!
29. End – Stage COPD Respiratory and non-respiratory symptoms
BREATHLESSNESS Decreased mobility
Wheeze Depression
Cough Social isolation
Fatigue
Pain
Poor sleep
Worse standard of daily life than Lung Ca
30. MANAGEMENT Bronchodilators
Anticholinergics
Oxygen
Anxiolytics
Opioids
Coping strategies
purse-lip breathing; slow expiration; lean forward
Pyschological support – end-of–life planning
31. GOING FOR GOLD Equitable end-of-life care
ALL appropriate patients on palliative register
Avoid un-necessary hospital admissions
Advanced care planning
Patient choice
32. Domiciliary Visits Primary care team + Hospice Dr
Aim - to recognise end-stage
- respect patients choices
- control symptoms
- prevent hospital admissions
- strive for a “good death”
33. COPD PILOT Looking at providing an equitable service
Recognising the different illness trajectories
Meeting patients needs
Introduction to the Hospice
Acknowledging what's already available
34. COPD PILOT Joint clinic at St Johns Hospice
RLI Respiratory team
SJH Doctor / Day hospice nurse
Physio / OT / CT
COPD patients chosen by respiratory team
FEV1 < 30
> 3 admissions
6 week programme