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Current Advances in Palliative Care i.e. not in the Palliative Care Handbook 6th Edition

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Current Advances in Palliative Care i.e. not in the Palliative Care Handbook 6th Edition

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    1. Current Advances in Palliative Care (i.e. not in the Palliative Care Handbook 6th Edition) Chris Higgs May 2010

    2. Symptom control ‘New’ drugs Dorothy House development projects End of Life Care

    3. Symptom control

    7. Physiological including autonomic dysfunction (?HR ?BP dry mouth, insomnia) Cognitive Emotional Behavioural

    8. Mechanism of fatigue Central or peripheral? The evidence is for a central mechanism with ? brain-muscle coupling. Any peripheral problem = weakness rather than fatigue, although fatigue can lead to deconditioning of muscles.

    9. Management of fatigue Correct treatable causes Treat associated symptoms – dry mouth, insomnia Pharmacological - ? Dexamethasone (2-4mg od) ?? Methylphenidate (10-20mg od before food) Fatigue management education Understanding / coping Exercise training Rest & sleep

    12. Acute-phase protein rise – e.g. ? CRP Anorexia, malaise and fatigue Skeletal muscle wasting Lipolysis Bone marrow suppression Increased resting energy expenditure Increased body temperature

    13. It is not due to starvation/malnutrition due to competition by tumour reversed by nutritional support

    14. Treatment Correct other problems – e.g. pain, anxiety, oral thrush, gastric stasis, constipation

    15. NIPPV for MND For hypoventilation – often presenting as breathlessness, morning headaches etc there is more portable and user friendly NIPPV (Nasal Intermittent Positive Pressure Ventilation) Can extend useful quality of life for some months.

    16. NIPPV images

    17. ‘New’ drugs

    18. Short acting fentanyl preparations for breakthrough cancer pain (BTcP)

    19. Short acting fentanyl preparations for BTcP

    20. Treatment of BTcP Check that opioid sensitive Oramorph remains first choice Consider new products when Intolerance of oramorph swallowing/absorption problems Rapid onset + short duration of BTcP All require titration

    21. Preparations for opioid induced constipation Targinact (oxycodone + naloxone 2:1) Relistor (methylnaltrexone)

    22. Approximate costs for 4 weeks treatment Zomorph 40mg bd £14 Oxycontin 20mg bd £50 Targinact 20/10 mg bd £70 Movicol 1 sachet nocte £6 Relistor per injection £21

    23. 1st / 2nd line drugs for neuropathic pain amitriptyline or ? nortriptyline, dosulepin, mirtazapine and / or gabapentin or pregabalin? ?? 5% lidocaine plasters (Versatis)

    24. Dorothy House development projects

    25. A-Z of Information Available at www.dorothyhouse.co.uk Advice on where to find help and support for problems, with contact telephone numbers or website links to organisations that provide information.

    26. Carer support Fortnightly lunchtime meetings for carers of Dorothy House patients List of carer support agencies in Wiltshire, Somerset and BaNES available

    27. COPE Rehabilitation 6 week course Includes exercise and relaxation, breathlessness management, fatigue management, practical advice Currently at Dorothy House and Midsomer Norton (further outreach centres planned)

    28. End of Life Care

    29. National End of Life Care Strategy 2008 End of Life Care Strategy – Quality Markers 2009 RCGP End of Life Care Strategy 2010

    31. EoLC Quality Markers for Primary Care (1) All GP practices to demonstrate the following: Action plan for EoLC Assessment and recording of needs and wishes of EoLC patients Assessment and recording of needs and wishes of their carers Discussion of the above at MDT meetings (preferably monthly)

    32. Provision of relevant information to Out of Hours Services Nomination of Key Worker Relevant practice staff have training in communication skills, assessment and care planning, advance care planning, and symptom management A care pathway for those in the dying phase Audit of quality of care provided after death. EoLC Quality Markers for Primary Care (2)

    33. Triggers to looking ahead Significant shift in treatment focus Prognostic indicators Increasing dependency Questions from patient/family The surprise question

    34. 1 Year 6 months Few weeks Few days Advance Care Planning (ACP) ACP + ? DS1500 ACP + ? CHC + Integrated/Liverpool Care Pathway. Just In Case boxes

    35. Advance Care Planning ACP is a process of discussion about: Needs and wishes Personal goals for care Understanding of illness and prognosis Preferences for types of care or treatment in the future Etc…

    36. Planning for your Future Care: A Guide

    37. ACP Recording Various documents are available. In Somerset, an Advance Care Planning guide contains: straightforward guidance the Preferred Place of Care document prompts about making a will and funeral arrangements information about Lasting Power of Attorney an ADRT, a DNAR/AANDO Any of which can be used as relevant.

    38. Information Exchange (1) Information about: Needs assessment Symptom control Shift from intensive treatment Advance Care Planning Wishes and preferences, DNAR/AANDO forms

    39. Should be shared between: (with the consent of patient or representative) Relevant hospital team GP practice Community teams Out of Hours services Ambulance services Via EoLC Register ? Information Exchange (2)

    40. Pathway? EoLC Triggers Needs assessment Advance Care Planning (discussion & record) Gaps? Arrange support Key Worker Sharing of information Regular review LCP / Just In Case boxes as required Bereavement support

    41. Triggers to Specialist Palliative Care Referral Poorly controlled symptoms Needs or problems that require additional help Help required with issues raised in advance care planning or needs assessment If preferred place of terminal care is a hospice

    42. Questions?

    43. References Gold Standards Framework – Prognostic Indicators Guidance www.goldstandardsframework.nhs.uk National Council for Palliative Care (2005) Planning for your Future Care: A Guide www.ncpc.org.uk/downloads/publications/PlanningYourFutureCare.pdf Royal College of Physicians (2009) Concise Guidance to Good Practice, National Guidelines, Number 12, Advance Care Planning www.rcplondon.ac.uk/clinical-standards/organisation/Guidelines

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