Palliative Care and End of Life Issues: Transcending Pain and Suffering

1
Palliative Care and End of Life
IssuesTranscending Pain and Suffering

• Sandhya Lagoo-Deenadayalan
• Duke University Medical Center
• Durham, NC

2
Post-Operative Abdominal Pain

• Severe abdominal pain
• Tachycardia, hypotension
• Benign abdominal exam
• No blood per rectum
• ABGs metabolic acidosis
• No leucocytosis
• CT SMA occlusion

3
(No Transcript)
4
Intervention

• Exploratory laparotomy
• ? SMA thrombus
• ? Thrombectomy, repair of arteriotomy with vein
  patch
• ? Small bowel resection
• Anticoagulation
• Plan for second look laparotomy

5
(No Transcript)
6
(No Transcript)
7
(No Transcript)
8
Second look laparotomy

• Case scenario 1
• Patient stable, normotensive, minimum vent
  settings
• Bowel healthy, viable
• No further intervention needed
• Case scenario 2
• Patient acidotic, hypotensive, tachycardic,
  needs vasopressors, increasing ventilatory needs
• Second look laparotomy dusky small bowel , no
  transition point
• What should you do?

9
(No Transcript)
10
Demographics

• Transition in the leading causes of death
• From infectious diseases and acute illness to
  chronic disease and degenerative illness
• In the US, approximately 80 of all persons aged
  gt 65 years have at least one chronic condition,
  and 50 have at least two.
• JAMA, March 19, 2003

11
Demographics

• Only half of the hospitals in the US with 50 or
  more beds report a Hospital based Palliative Care
  Program
• Goldsmith B, 2008, J Palliat Med 2008,
  111094-1102

12
Challenges to Good Decision Making

• Less exposure to trajectories of end stage
  illness
• Multitude of specialist physicians
• Teaching focuses on disease and technical
  procedures, the great case
• Lack of emphasis on the emotions of the
  physicians and other providers, impact on family
• Weissman DE et al. Acad. Med. 1999 74 871-877.

13
Steinhauser et al. Ann Intern Med. 2000 132
825-832.
Palliative Care

• Pain and symptom management
• Clear decision making
• Preparation for death
• Completion (life review, resolving conflicts )
• Contributing to others
• Affirmation of the whole person

14
Regulatory Consideration - JCAHO

• The Joint Commission for the Accreditation of
  Healthcare Organizations (JCAHO) has issued a
  standard regarding care at the end of life.
• The patient at or near the end of his or her life
  has the right to physical and psychological
  comfort. The hospital provides care that
  optimizes the dying patients comfort and dignity
  and addresses the patients and his or her
  familys psychosocial and spiritual needs.
• Staff is educated about the unique needs of dying
  patients, their families and caregivers.

15
Transitions How Gravely Ill Becomes Dying

• For most patients, two fundamental facts ensure
  that the transition to death will remain
  difficult. First is the widespread and deeply
  held desire not to be dead
• Second is medicines inability to predict the
  future, and to give patients a precise, reliable
  prognosis about when death will come.
• Finucane, TE. JAMA. 1999. pg 1670.

16
Palliative Care in the Surgical ICU

• In the face of prognostic uncertainty, the only
  way to ensure good palliative care is to
  incorporate its principles and practice into the
  care of all critically ill patients, regardless
  of prognosisfor all, not just the dying.
• Each step is started based on time from
  admission, not on prognosis, eg,
  interdisciplinary assess within 24 hrs of
  admission
• Crit Care Med.2006 34S399-S403.

17
Palliative Care in the Surgical ICU

• Family meeting with MD and RN within 72 hrs of
  admission
• Order set for the imminently dying
• Integration of palliative care performance
  measures into morbidity and mortality conference
  and peer review.
• Crit Care Med.2006 34S399-S403.

18
Triggers for Requesting Palliative Care Consults

• Family Request
• Futility considered by medical team
• Family disagreement with team, advance directive,
  or each other gt 7days
• Death expected during this ICU stay
• Length of stay in ICU gt 1 month
• gt 3 ICU admissions in one month
• GCS lt 8 for gt 1 week in a patient gt75 years of
  age
• Bradley CT, Crit Care Med, 2009 37 946-950

19
Possible Triggers for Requesting Palliative Care
Consults in the Elderly

• Days on ventilator
• Multiorgan failure gt 3 organ systems
• Acute renal failure requiring dialysis

20
The Consulting Physician

• Emphasize that this is a good team to have on
  board if/as the disease progresses and goals of
  care change
• Emphasize the positive aspects of what palliative
  care can dorather than how the palliative care
  team will help them accept death and dying
• The palliative care team is comfortable with both
  aggressive and expedient care and the issues of
  life closure and completion.
• Weissman DE. Consultation in Palliative
  Medicine. Arch Intern Med. 1997 157 733-737.

21
Palliative Care - Teamwork

• Multidisciplinary - helps with disease
  progression and change in goals of care
• Palliative care can be aggressive and expedient
• Reduce symptoms and suffering
• Meet patient-family preferences
• Reach patient-family-professional consensus on
  goals of medical care
• Improve patient and family satisfaction
• Improve utilization outcomes (length of stay, ICU
  days, readmission rate, rate of hospice referral,
  ER use)

22

• Hospitals are a place of miracles and cures, but
• when that cannot be the outcome, we must
• palliate often and comfort always.
• AN Galanos. NC Med J. July/August 2004, vol
  65,4. pg 218

23
Acknowledgements

• Anthony Galanos, MD
• Jennifer Gentry, RN
• SICU Staff

24
Thank you
25
Development of Palliative Care

• 1975 Karen Ann Quinlan
• Persistent vegetative state
• Family requested removal of ventilator to allow
  patient to die denied by hospital supported by
  NJ Supreme Court who suggested development of
  hospital ethics committees
• ICU care in such instances supported an
  oppressive medical technology, unnaturally
  prolonging dying Gregory Pence

26
Development of Palliative Care

• 1990s Increased debate over medical futility
• 1993 JCAHO required mechanism for ethical
  consultations
• Also in 1990s Physician assisted suicide
  movement
• Many saw this movement as driven by failure of
  medicine to provide adequate care for the dying
  patient

27
Development of Palliative Care
JAMA 2741591, 1995.
28
Development of Palliative CareSUPPORT Study

• Phase I observational study of 4301 seriously ill
  hospitalized patients
• Phase II study a 2 year controlled study with
  4804 patients and physicians randomized to
  intervention group or control
• Physicians received estimates of the likelihood
  of 6 month survival, outcomes of CPR, and
  functional disability at 2 months

JAMA 2901166, 2003.
29
Development of Palliative CareSUPPORT Study

• Showed inadequacies to discuss end of life issues
• Misunderstanding about the goals of care
• Poor communication
• Inattention to pain management and comfort care
• Patients have right to relief from suffering

JAMA 2901166, 2003.