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  1. PALLIATIVE CARE IN SEVERE COPD AND PLANNING END OF LIFE ALEV GURGUN, MD Ege UniversitySchool of MedicineDepartment of ChestDiseases

  2. Outline • EndStage COPD • Supportive & PalliativeCareforEndStageCOPD SymptomControl 3. End-of-life in COPD: • When ? • Where ? • How ? 4. Conclusion

  3. End stageCOPD Disabling dyspnea at rest FEV1,< 30% of predicted Admission to ICU or hospitalizations Hypoxemia at rest on room air Hypercapnia Right heart failure Weight loss Resting tachycardia

  4. MajorProblemsin COPD Physical • Poor symptom control • Limited functional capacity, • Poor domestic life • Social • Limited social life • Psychological/ emotional • Living with crisis dying • Family sharing? • Prepare himself

  5. PrognosticIndıcators in End-Stage Lung Disease Mortality predictors ( ½ year – 1year) for COPD are imprecise. FEV1, PaO2, admissions, dyspnea, BMI, BODE Recent RCT of 609 patients with severe COPD: age, oxygen utilization, physiologic measures ( RV, TLC), exercise capacity, emphysema distribution. Am J Respir Crit Care Med 2006; 173:1326-34

  6. Emerging Profile of Dying COPD Patient ( Within a Year) • Best FEV1 < 30% of predicted • Declining performance in ADL • Uninterrupted walk distance < a few steps • 1 urgent hospitalization in past year • Left-heart and/or other comorbid diseases • Older age • Depression • Unmarried Hansen-Flaschen J. COPD: The Last Year of Life. Respiratory Care, 2004; 49(1): 90-98.

  7. Lancet 1998; 351 (suppl II): 21-29 23% 4.4% 3.5% Death from respiratory causes accounts for 35% of all deaths in the EU

  8. “Patients did not generally realize that they were approaching the ends of their lives.” Compared to lung cancer patients, COPD patients were worse functionally and physiologically, but survived longer. Even in the last month of life, prognostic algorithm predicted reasonable survival (30% 6-month).

  9. LifeLine in COPD Cancer “Poor QOL” COPD Death

  10. Eur Respir J 2008; 32: 796–803 Usual care COPD Death of a patient often occurs with an exacerbation and can appear sudden and unexpected. The timing of when to start palliative care can be difficult Among my COPD patients whois an end of life patient ? Is this the last exacerbation before death ?

  11. COPD is an important risk factorfor COPD “COPD, heart disease and sedatives in men were survival predictors”. J Am Geriatr Soc 56:68–75, 2008.

  12. How can we serviceAccordingtotheDiseaseSeverity

  13. Clarification of Terms End of Life care Patients with progressive irreversible advanced disease Patients living with the condition they may die from- weeks/months/ years ‘Ante-mortal’ care like ante-natal care Supportive Care Helping the patient and family cope better with their illness Preferred by some specialists- ‘everyone needs supportive care’ Palliative care Physical psychological, social, spiritualcare General orspecialist palliative care Some regard as overlapping with or following curative treatment Terminal care Diagnosing dying-care in last hours and days of life 13 Terminal Care Death End of Life Care Supportive Care Palliative Care

  14. Controlling Symptoms Supportive & PalliativeCareforEndStage COPD

  15. Palliative Care Clinical Practice Guidelines for Quality Palliative Care; National Consensus Project. www.nationalconsensusproject.org Symptom control Social issues and practical needs are addressed Care of the patient is truly coordinated among disciplines Both the patient and the family are prepared for the dying process

  16. Palliative Respiratory Therapy Palliative care is comfort care! What will be comfortable for your patients? • Nebulized bronchodilators? • Oxygen therapy – device and liter flow? • Chest physiotherapy? • CPAP/IPPB? • ABGs? • NT suctioning? • Patient positioning?

  17. Agenda Size of the problem When Where Hospital Home How Hospital symptoms Home when ventilated palliation

  18. symptoms Arch Intern Med. 2007;167(22):2503-2508 DYSPNEA IS THE MOST COMMON PROBLEM IN TERMINA STAGE

  19. symptoms Severity of COPD symptoms3 days prior to death Lynn J,Teno, JM et al. Perceptions by family members of the dying experience of older and seriously ill patients. Ann of Intern Med 1997;126(2): 97-106.

  20. Control of Dyspnea & Anxiety Oral & Parenteral Opioids Morphine symptoms • Improveexercise tolerance without sedation • OPM may diminish response to hypoxia and hypercapnia at chemoreceptor level • May alter perception of breathlessness • May exert peripheral effect on opioid receptor in lungs 20

  21. symptoms Control of Dyspnea PalliativeCareforPatientswithRespiratoryDiseasesandCriticalIllnesses ATS TaskForce AJRCCM 2008; 177:912-928

  22. symptoms Control of Anxiety & Depression • Anxiolytics ? Antidepressants ? • Benzodiazepines - Not anxiolytics-Not recomended • Phenothiazine (Thorazine) – antipsychotic which may be used for severe agitation

  23. symptoms Cough Control • Establish level of distress (0/10) • Educate family • Warm humidified air • Expectorants and/or mucolytics of little value • Codeine 15-30 mg oral Q4 • Morphine 2.5 mg oral Q4 • Nebulized lidocaine 2 mls (1%, 2% or 4%) Q6 (wait 30 minutes post before eating – aspiration risk)

  24. where More than 68% of all COPD admissions in hospital occurred in the 3.5 years before death, indicating longer stays closer to death. Begin when frequent admission to the hospital

  25. where British Journal of General Practice, April 2008 H H home hospice home 2/3 of deaths occur in institutions most commonly in acute hospitals Urgent need for planning care of a large increase of ageing and deaths.

  26. Home care programs for end of life ? where British Journal of General Practice, January 2006 Journal of Social Work in End-of-Life & Palliative Care, Vol. 1(3) 2005 interdisciplinary home-based palliative care (58% cancer 19% COPD) caneffectively: increase the likelihood of dying at home with significant cost savings.

  27. How What Do Families Need? • Caring for dying patients necessitates caring for their families • Adequate communication • Feeling supported • Giving good care to loved ones

  28. What To Discuss for Chronic Respiratory Disease Identify current preferences for intubation, ventilation and CPR No mechanical ventilation at all Ventilation for short-term reversible situation Long-term mechanical ventilation Identify situations in which patient would forego life support Unable to live independently Unable to communicate with family Prolonged or indefinite life support How 28

  29. What kind of life-support do patients want? How p>0.05 all comparisons 29 Claessens, J Am Geratr Soc, 2000

  30. Communication With Physicians: Seriously Ill Hospitalized Patients How SUPPORT, JAMA, 1995; 274:1591 30

  31. Decision-making AboutEnd of Life Shared decision-making depends on good patient-physician communication Early evidence suggests that some interventions can make a difference PATIENT EDUCATION IS THE MOST IMPORTANT COMPONENT How

  32. Shared Decision-making About End-of-life Care Important factors Prognosis Level of certainty Roles Patient/family: patient values & preferences Physician: treatments that are indicated How Physician decision Family decision Carlet, Intensive Care Med 2004; 30:770 32

  33. Barriers to Communication About End-of-life Care for COPD Only 32% of patients report discussing end-of-life care with physician 15 barriers identified by patients Only 2 barriers applied to >50% of patients I would rather concentrate on staying alive than talk about death --75% I’m not sure which MD will be taking care of me if I get very sick-- %64 7 barriers identified by physicians Only 1 barrier applied to >50% of physicians There is too little time to discuss everything we should – 70% He is not ready to talk about what kind of care he wants if he gets sick-21% How 33 Knauft. Chest 2005; 127:2188

  34. Breaking bad news Physician Findings Diagnosis Prognosis Treatment Patient What’s wrong? What will happen? What can be done? 34

  35. Buckman’s “SPIKES” strategy 6-step strategy for breaking bad news Setting Perception Invitation Knowledge Empathy Strategy and Summary www.conversationsincare.org/web_book/chapter05.html 35

  36. Listening empathically –PEARLS techniques 36

  37. Best end-of-life care 5 components 2. Patients All 3 trajectories- cancer, organ failure ,frail elderly 5. Points in time Out of hours+supportat all timesfrom diagnosis 4. Places Home, hospitals, care homes, hospices, other 3. Providers Generalists-GSF, LCP, education, specialists etc 1. People Public Awareness, information, enablement- ‘Expert pt’, Self care, Carer support Advanced Care Planning 37

  38. CONCLUSION • Death from respiratory causes is high, but its importance has not beenrecognized yet • Death of a patient often occurs with an exacerbation and can appear • sudden and unexpected, thereforetiming is veryimportant • Control of dyspneandothersymptomsareveryimportant in the terminal stage hospitals • During end of life decisions perspectives of patients and families need to be respected • Inthetreatmentandfollow-up of COPD palliavitecareandend of life issuesshould be adressedmore