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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. Physiologicalincluding 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