End of life/Palliative care issues in Internal Medicine

1. Dr Lynn Alison Lambert B.Sc. PhD, MB ChB, FRCP (Lond) DTM&H Internal Medicine, University of Calgary End of life/Palliative care issues in Internal Medicine

2. Disclosures • I have a vested interest in good end of life care – one day I will die too. • No sponsorship or financial links with any drug company • Most of the information in this workshop is from: • The Oxford Textbook of Palliative Medicine, 4th Edition 2010 • Hanks, G., Cherry, N., Christakis, N., ,Fallon, M., Kaasa, S., Portenoy, R. (Eds) • Palliative Medicine, A Case Based Manual , 3rd edition 2012 • Doreen Oneschuk, Neil Hagen and Neil MacDonald (Eds) • Discussions with my colleagues in Palliative care in Foothills Medical Centre, Calgary - with special thanks to Dr Jessica Simon. • Personal experience with many patients at the end of their lives

3. As Bob Dylan once said: “He who isn’t busy being born is busy dying”

4. What is Palliative Medicine? • “Palliative Medicine is no more , no less than the quality of care we should be offering all our patients every day - care tailored to their needs , skilled, compassionate” • quote from the late Sir Raymond (Bill) Hoffenberg, President of the Royal College of Physicians of London 1983-1989. Former Professor of Internal Medicine, University of Birmingham Medical School, Birmingham, England FromPalliative Medicine, A Case Based Manual, by Doreen Oneschuk (U of Alberta) Neil Hagen (U of C) and Neil MacDonald (McGill) So - Palliative Medicine is for everyone.

5. Palliative medicine • Is holistic care, taking into account a patients cultural, spiritual and individual needs • Respects a patients wishes • Even if they are not what we would choose • Informs a patient of what can be done • Treatment options – pros and cons • Communicates prognosis accurately • Communicates with the family/friends (provided the patient gives permission)

6. History • Dame Ciceley Saunders • Nurse, social worker, doctor • Founded St Christopher’s Hospice in London, 1967 • Wrote reports of a series of cases of terminally ill patients -340 1960, 1100 by 1967 • Realised that in terminal care there may be • Physical needs, emotional distress, social issues (housing, finance, family) • Championed pain management – regular not prn • Battled current ideas/fears re opiate addiction

7. History 2 • 1973- 1st International Symposium on Pain control • 1976 1st International Congress on the Care of the Terminally Ill – Montreal • 1987 Palliative Medicine recognised as a specialty in UK • 2006 ACGME and ABMS in US approved a new specialty in hospice and palliative medicine.

8. Is there a need for internal medicine physicians to know about palliative care if we have all these specialists? • Top 5 predicted causes of death in 2020 • IHD, • Cerebrovascular disease • COPD • Respiratory infection • Lung Cancer • So palliative medicine in non- malignant disease is important

9. Why internists need to be good at palliative care • Whole patient management/ whole person medicine • Care of Elderly with multiple problems • Not enough hospice places • Palliative medicine in non-malignant disease • Especially COPD and heart failure • Drug interactions • Care of younger patients with complex diseases

10. Is Palliative Medicine “Terminal Care” only? • Good Palliative care practice is the ability to recognise when the aim of a patient’s treatment is mainly that of symptom control rather than life prolongation. • This can be months or even years before the patients terminal phase. • Allows a patient to live with their disease and not just be dying from it.

11. Palliative care for the General Medical patient • Generally discussion is left too late • Often goals of care are discussed when the patient arrives in the Emergency Department with an acute complication of a terminal illness. • This is stressful for doctors , patients and relatives • To avoid this we need to engage with our patients in advance care planning

12. Signposts in Palliative Care • How to recognise that the time has come for some end-of-life / goals of care discussion • The Surprise Question: • “Would I be surprised if this patient were to die in the next 6 months?” • If the answer is “No” then you should look for cues from the patient that they wish to discuss this. Try some exploratory questions.

13. Communication at the end of life • What are the barriers?

14. Communication at the end of life • What are the barriers? • What can we do as clinicians?

15. Communication at the end of life • What are the barriers? • What can we do as clinicians? • How can we do better?

16. Canadian Pallium project • Communication resource with clinical scenarios • Allow us to observe examples of good communication skills • Access via You Tube

17. Palliative Medicine • Should be what we do every day as part of usual care in Internal Medicine • Is it?

18. Having a Goals of Care discussion-what you can do • Initiate the discussion of advance care planning • “are there any limitations on your treatment I should know about” • “do you have any specific wishes about your treatment?” • “Do you have a personal directive?” • Alberta “Conversations Matter” initiative • Booklet, videos • Family Meeting • Useful to get everyone “on the same page”

19. Goals Of Care – Calgary Region • R Resuscitative Care • M Medical Care (excluding resuscitative care) • C Comfort Care • More flexible than DNR versus no DNR

20. Rules for internal medicine • Ask yourself “what am I trying to achieve here?” • Don’t be caught up in a curative mode and fail to pick up on the patient’s anxieties • Be realistic (but not dogmatic) about the prognosis • With yourself • With the patient • Find Out • What the patient wants • Accept that: • referral to a palliative care specialist does not mean that you have given up on the patient

21. When to involve the palliative care team • Sooner rather than later • For symptom control when you are unsure what to do • To aid access to community services and hospice • When you recognise that you don’t have time to do it properly yourself • As a learning resource • (a phone call may be enough)

22. End of life care • The last days • How to die with dignity in hospital • Is this difficult? • How can we make it better? • Liverpool Care pathway (or similar)

23. Liverpool Care Pathway - used when patient has hours or days left to live • Useful in hospital or at home • Documents discussions with relatives • Notes an advance directive (if done) • Assesses • Pain, nausea, vomiting, agitation, breathlessness, skin condition, constipation • Anticipates need for drugs for: • Pain, agitation, respiratory secretions, nausea vomiting, dyspnoea,

24. Liverpool Care Pathway • Has a section for discontinuation of routine: • blood tests, glucose monitoring, vital signs, oxygen, iv antibiotics • Documents • patients wishes re care after death • E.g. who washes body, need for burial within 24hours • Discussions with relatives and information given • Information leaflets, death certificate, post mortem request

25. Patients at the end of life- Cases • Elderly person • Cancer patient • Heart Failure • Renal Failure • Liver disease • Complex case

26. Palliative care for the elderly patient • Holistic care • Looks at social, Personal and spiritual issues • Removal of unnecessary treatments • Discussion of Goals of Care for the future • Sometimes operative treatment is the best palliation – e.g. repair of fractured NOF

27. How to assess patients prognosis?

28. Patient with COPD • Mr Murray is a 74 year old retired oil worker, ex smoker, is on his fourth admission to hospital this year with COPD • Last time he went to ICU and was ventilated for 2 weeks • He hasn’t left the house since • He has home oxygen and a nebuliser • He is readmitted with breathlessness, wheeze and cachexia

29. Mr Murray • What is his prognosis? • What will you do for him? • What are you going to discuss? • How will you do it?

30. Prognosis • Gold classification of COPD • O normal spirometry, • I Mild COPD • II Moderate • III Severe • IV Very Severe • ADO Index • BODE index

31. Prognosis- BODE Index • BMI, Airflow Obstruction, Dyspnoea, Exercise Capacity • BMI 19 • FEV1 38% predicted • MMRC dyspnea scale • Too breathless to leave house • 6 min walk < 149 m • Score 9 25% 4 year survival

32. Prognosis • GOLD III –Severe • ADO (age, dyspnea, FEV1) • 3 year mortality 47.2% • BODE • 4 year mortality 75%

33. What will you do?

34. What are his goals of care?

35. Points to consider • Discuss goals when patient is well if possible • Pre-discharge • In clinic • And document it • Discuss interventions which will be accepted and those which he does not want • Involve family • Advance directive

36. Complex Case • “Please see this 76 year old Eastern European in ED lady whose potassium is high (5.9)” • Gynae oncology consult • 3 months ago- rectal cancer • Biopsied - adenocarcinoma • Declined operation • 1 month ago vaginal bleeding • New gynae cancer (ovarian) • 2 weeks ago DVT – is on warfarin

37. Complex Case Continued • Having radiotherapy to perineum to control bleeding • Felt “unwell” sent to ED • Had a brief cyanotic /apnoeic attack • (bagged and recovered) • Is tachycardic, breathless and in pain • She has vomited and it is blood streaked • Hb is 72 g/L • ECG new –RBBB • Abdo looks distended

38. What do you do next? • She is “R1 goals of care” (for everything) • How far do you go? • Discuss

39. Issues • Potassium • Pain • Abdomen • Vomiting (hematemesis?) • Anemia • Breathlessness • Goals of care • Patients values • Family

40. Liver Case • 53 year old night club manager • Admitted to medical team yesterday • Jaundice, ascites and dehydration • Seen in liver clinic 6 months ago • told to stop drinking • Wife left 3 months ago • Hit the bottle even harder • Sister brought him to ED when he went yellow

41. Liver case continued His bilirubin is 220, INR 1.8, WCC 12 albumin 28 His urine output is poor (Urea 10, Creat 140) He has tense ascites and is uncomfortable His creatinine is rising and he keeps trying to pull out his iv He is mildly encephalopathic The nurses have tied his hands to the bed His mother is on her way to the hospital His daughter, inVancouver, is 8 months pregnant Hepatology say he is not a candidate for transplantation

43. What are you going to do? • What is his prognosis? • What do you need to do now? • Discuss

44. Prognosis • Severe alcoholic hepatitis can have a mortality of 50% at 30 days • 1 year after an admission for alc. Hep • 40% of patients are dead • Patients over 50 do worse than younger ones • Glasgow Alcoholic hepatitis score

45. Glasgow Alcohol Hepatitis score • Age over or under 50 • White count < 15, >=15 • Urea <5mmol/L> • INR <1.5, 1.5-2, >2 • Bilirubin <125, 125-250, >250umol/L • Day 1 Score is 9 • predicts Day 28 outcome as 46% survival and Day 84 as 40% survival • Day 7 score was 12 • 37% chance of survival at Day 84

46. Liver case – 4 weeks later • Bilirubin continues to rise (480 umol/L) • Creatinine is 420 umol/L • INR is 2.1 • He is only intermittently lucid and often in pain • What can you do for him?

47. What to do? • Prognosis • MELD Score is 41; 3 month mortality is 90% • (MELD – Model for End Stage Liver disease) • If already dialysed (& even if creatinine lower) mortality is 100% • Glasgow score also poor • Now what do you do?

48. Palliative Care Team • Can be involved even if you are still hoping for recovery • Can help with symptoms, support family • Can educate us • May have more time to talk

49. Take home message • Think about goals of care in both acute and chronic diseases • Try to get a prognostic indicator • Give the patient a chance to have a conversation about the future • Involve the palliative care team sooner rather than later

50. And if you have been.. • ....thanks for listening.