Palliative Care

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Palliative Care

• St Williams Parish
• Pat
  Treston
• 
  20th September 2006

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To cure, occasionally To relieve, often
To comfort, always.
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Definition of Palliative Care

• Palliative Care provides for all the medical and
  nursing needs of the patient for whom cure is not
  possible, and for all the psychological, social
  and spiritual needs of the patient and the
  family, for the duration of the patients illness,
  including bereavement care

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• Palliative Care
• Hospice Care
• Terminal Care

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Quality of Life

Hopes, Dreams, Aspirations
Day to day reality
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The causes of suffering
Pain
Physical symptoms
Spiritual
Psychological
Cultural
Social
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Total Suffering
Pain
Physical symptoms
Spiritual
TOTAL SUFFERING
Cultural
Psychological
Social
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Interdependence of various causes of suffering
Pain
Physical symptoms
Spiritual
Psychological
Cultural
Social
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Interdependence of various causes of suffering
Pain
Physical symptoms
Spiritual
Psychological
Cultural
Social
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Multidisciplinary Team

• Medical
• Nursing CNC. Registered Nurses, ENs, AINs
• Physiotherapist
• Occupational therapist/Dietician
• Counsellors/psychologists
• Bereavement counsellors adult, children
• Pastoral care workers
• Volunteers

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Goals of Palliative Care

• To relieve and prevent suffering
• by controlling pain and other physical
  symptoms
• by addressing psycho- spiritual distress
• by recognizing role of cultural factors
• To involve people important to the patient
• To promote a degree of acceptance by the patient
  and family
• To provide a process of care that guides the
  patients understanding and decision making
• To achieve a peaceful death
• To provide bereavement support for families/loved
  ones.

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Characteristics of Palliative Care

• Patient centred
• Family Centred
• Comprehensive
• Continuous
• Co-ordinated
• Teamwork
• Regular review

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Pain Management

• Relief and prevention
• Thorough assessment
• Explanation, education
• Reassurance
• Treatment appropriate to stage of disease
• Radiotherapy / Chemotherapy

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Principles of Using Analgesics

• Use of appropriate drug for type of pain
• Use of appropriate drug for severity of pain
• Combinations of drugs
• Use of adjuvant analgesics
• Adequate dosage
• Dose titrated for each individual patient
• Time dosage according to duration of action of
  drug

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Principles of Using Analgesics

• Strict scheduling to prevent pain, not just when
  it occurs
• Provision of breakthrough medication
• Written instructions on medication use
• Anticipation and treatment of side effects
• Keep regime as simple as possible
• Use of oral route where possible

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Opioids

• Morphine slow release, rapidly acting. p.o/s.c
• Oxycodone SR, rapidly acting
• Hydromorphone injection, liquid
• Fentanyl Patches, injection
• Methadone - tablets

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Facts v. Myths about Morphine

• It is not addictive
• Does not mean death is close
• Will not hasten death
• Individual doses vary widely
• No maximal dose
• Not everyone needs to take it

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Case Study

• Jim Smith, 65 years old
• Married to Mary, 2 sons John Peter in
  Brisbane, daughter Susan in Melb.
• (all married with young children)
• Persistent cough in January 2005
• Dx Large cancer R lung
• Treated with radiotherapy to control size of
  tumour not curative
• No spread elsewhere, esp. brain

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Case Study

• June 2005 chest wall pain and increasing
  breathlessness, esp. on exertion.
• Referred to Mt Olivet Home Care Service
• 7/7/2005 Commenced on SR Morphine with extra
  Morphine mixture, bowel medication, equipment
  arranged, domiciliary nurses.
• 3 weeks later, distressing productive cough,
  fever, increased pain, more breathless.
• Probable chest infection

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Case Study

• 1/8/2005 Admitted to Palliative Care Unit
• I dont want any treatment. I want to die
• Reasons explored
• Tired of feeling unwell, debilitated
• Demoralised by pain and breathlessness
• Not clinically depressed
• Enjoyed visits from work mates,
  grandchildren, watching sport on TV.

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Case Study

• Informed of pros and cons of antibiotics
• Goals of treatment
• Commenced on antibiotics
• Morphine dose increased
• Oxygen
• Nebulised saline
• Physiotherapy
• ? good symptomatic improvement.

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Case Study

• Family meeting decision ? home with extra
  supports, home oxygen.
• Pain well controlled, mobilising short distances,
  using extra morphine for breathlessness on
  exertion.
• Mood reactive, accepting, dealing with
  practicalities will, EPOA, Advanced Health
  Directive.
• 12/8/2005 Discharged home

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Case Study

• Condition reasonably stable for next 2 weeks
• Relatively sudden onset of confusional state
• no sleep for 2 nights, restless,
  disorientated, refusing oxygen, not eating.
• 26/8/2005 Readmitted PCU - delirium
• Many potential causes medication, infection,
  spread to brain, low oxygen levels
• Investigations ?reversible cause

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Case Study

• Found to have high calcium level
• ? Competent to make decision about treatment
• Discussed with family
• Best symptomatic treatment if effective,
  potentially life prolonging (AHD)
• Treatment not administered
• Managed with haloperidol (anti psychotic) and
  other medications as required

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Case Study

• 28/8/2005 Condition deteriorating , physically
  weaker, pain apparently controlled, breathless at
  rest, still refusing to keep oxygen on, sleep
  disturbance, increasing confusion/disorientation,
  suspicious, irritable, unable to have lucid
  conversation with family.
• Family distressed
• 2 days later, found wandering in the corridor,
  breathless and unsteady, abusive, angry,
  physically aggressive, lashing out at staff,
  overtly paranoid and fearful telling visitors
  he was going to be killed.
• Danger to himself and others

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Case Study

• Discussion with family - probable terminal
  restlessness, irreversible, portent of
  approaching death.
• Joint decision made to sedate patient
• Commenced on larger doses of antipsychotic
  medication, sedative agents and analgesics in
  syringe driver.
• Remained drowsy with some periods of awareness, ?
  recognised family members.

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Case Study

• Over next few days appeared to be pain free,
  oxygen continued
• Minimal oral intake, sips of water when awake.
• Daughter arrived from Melbourne very distraught
  at deterioration in fathers condition.
• Accused staff of allowing him to die of
  starvation and dehydration.
• Explanation / reassurance.
• Mouth Care

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Case Study

• Medications continued, given extra analgesia
  prior to bathing/ moving as appeared to grimace
  and moan.
• Medication for terminal secretions
• 5 days after commencing sedation died peacefully
  with family at the bedside.

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Death should simply become a discrete, but
dignified exit of a peaceful person from a
helpful society without pain or suffering and
ultimately without fear
Phillipe Aires
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You matter because you are you. You matter to
the last moment of your life and we will
do all we can to help you- Not only to die
peacefully, But to live until you die
Cecily Saunders
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