PALLIATIVE CARE

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• Palliative care in stroke

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Overview

• Stroke demographics
• Palliative care
• Definition
• Role
• Palliative care in stroke
• Case studies

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FACT

• Stroke Education Ltd (NZ) 2006

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World effects

• Stroke is the 2nd major cause of death worldwide
  and the leading cause of long-term disability in
  adults.
• (Donnan GA 2008)
• According to the WHO, 15 million people worldwide
  have a stroke ever year, 5 million of whom die
  and 5 million are permanently disabled .
• In the US alone, there are about 5.5 million
  stroke survivors and every 45 seconds someone has
  a stroke. Every 3 minutes someone in the USA dies
  from a stroke, and about half of stroke survivors
  are left disabled.
• In Europe, approximately 650,000 people die of
  stroke.

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UK effects

• 150,000 people have a stroke in the UK each
  year.
• There are over 67,000 deaths due to stroke each
  year in the UK.
• Office of National Statistics Health
  Statistics Quarterly

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Men vs Women

• Men are 25 more likely to suffer strokes than
  women.
• 60 of deaths from stroke occur in women.
• Women live longer
• they are older on average when they have strokes
• thus more often killed
• (NIMH 2002)

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Out of 10!

• About 2 out of 10 people who have a stroke die
  within the first month.
• 3 out of 10 die within the first year.
• 5 out of 10 die within the first 5 years.
• The more time that passes after a stroke, the
  less is the risk of dying from it.

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• What is Palliative Care?

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World Health Organisation

• Palliative care is an approach that improves the
  quality of life of patients and their families
  facing the problem associated with
  life-threatening illness, through the prevention
  and relief of suffering by
• early identification.
• impeccable assessment.
• treatment of pain.
• physical, psychosocial and spiritual.

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Palliative Care

• Affirms life and regards dying as a normal
  process
• Uses a team approach to address the needs of
  patients and their families, including
  bereavement counselling.
• World health organisation 2010

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Palliative Care

• Palliative care
• Specialist palliative care
• Terminal Care

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Who is involved in Palliative care?

Multidisciplinary team Doctors through to the
kind word from a domestic
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Goals of palliative Care

• Best quality of life.
• Support system to promote patients families
  self worth.
• Poor care prior to death makes bereavement
  difficult and has long term repercussions on the
  health of family and friends. Parkes CM
  (1998)
• Provide relief from suffering.
• Symptom control.

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What is good palliative care

• Humanity
• Dignity
• Respect
• Good communication
• Clear information
• Best possible symptom control
• Psychological support when needed
• Continuity of care

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Nurses role in palliative care

• All nurses should be able to
• Undertake basic symptom assessment and
  management.
• Understand the experience of the dying patient
  and their families.
• Engage in communication regarding individual
  needs and experiences.
• Consult the specialist palliative care
  practitioners if the needs of patients are out of
  the nurses experience.
• Aranda S (2003)

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Symptoms stroke patients experience

• Pain
• Fatigue
• Weakness
• Lack of energy
• Weight loss
• Difficulty swallowing
• Anorexia
• Early Satiety

• Restlessness agitation
• Dry mouth
• Constipation
• Respiratory secretions
• Dyspnoea
• Anxiety

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Stages in palliative care.Is their a role in
stroke?
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Case 1

• 71, male, independent.
• Found in bed unconscious, doubly incontinent,
  dehydrated.
• Right lateral gaze, L-sided weakness, extensive
  R-sided pneumonia, sore in his L leg, swelling in
  R-side head/face.
• CT head large L-sided intracerebral haemorrhage.
• DNR, decided against feeding, withdraw Abx- died
  24hrs later.

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Terminal care Case 1

• Communication amongst health care professionals.
• Symptom assessment control
• Pain, agitation, restlessness, breathing
• Dignity
• pressure sore management, mouth care
• Liverpool Care Pathway.
• All of the above can be managed by the MDT
• Specialist input can be sought as a one of
  measure if adequate symptom control is not
  achieved.

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Case 2

• 84, female, wheelchair-bound, house-bound,
  previous CVA.
• Unconscious, L-sided weakness, pyrexia.
• CT head intracerebral haemorrhage.
• Husband no life-prolonging measures.
• DNR, artificial feeding commenced, Abx given,
  prognosis likely soon death.
• Still alive on day 15 - Abx stopped.
• Still alive on day 25 - NG feed stopped.
• Died on day 31 of admission.

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Palliative careCase 2

• Communication
• Husband-medical team?
• No life prolonging measures - Abx?, Feeding?,
  Hydration?
• Ethical issues? Right / wrong?
• Prolonging suffering?
• Quality of life?
• Would Specialist Palliative Care input help?
• the key to good palliative care is that the
  dying process is actively managed rather than
  drifted into when all else fails
• (Jarrett, 1997)

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Case 3

• 39, female, business owner.
• Decreased conscious level, quadriplegia.
• MRI bilateral ventral pontine infarction with
  patent basilar artery- Locked-in syndrome.
• 5/52 ITU, then ASU-MDT care.
• 7/52 post-CVA reliable voluntary movement in
  upper limb jaw, goal-directed PT possible.
• Depressed, contractures, pain, functional gain.
• 3/12 post-CVA rehab unit.
• D/C 10/12 post-CVA with maximal community
  support.

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Stroke survivorsCase 3

• A case for Specialist Palliative care?
• Chronic disease management
• Continuity of care
• Community support
• Psychological support / counselling
• 1 in 5 stroke pts have suicidal thoughts
• Symptom management
• Lack of palliative specialist / information in
  stroke management partnerships are therefore
  required to ensure a holistic approach to stroke
  management.

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Best Practice Tools

• Liverpool care pathway (LCP)
• (Ellershaw Wilkinson 2003)
• Gold standard framework (GSF)
• (Thomas 2003)
• Preferred Place of care Tool (PPC)
• (Storey et al 2003)

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Points to remember

• Palliative care can be implemented by the generic
  medical team.
• Limitations to practise
• Ethical
• Implementation of specialist palliative care
  early on in acute management of patients.
• More research is required to see if Specialist
  Palliation is require for stroke survivors which
  may in fact improve rehabilitation outcome.

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Communication and compassion
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References / Bibliography

• http//www.stroke-education.com/info/StrokeInfo.do
  
• National Institute of Neurological Disorders and
  Stroke (NINDS) (1999). "Stroke Hope Through
  Research". National Institutes of Health.
  http//www.ninds.nih.gov/disorders/stroke/detail_s
  troke.htm.
• Villarosa, Linda, Ed., Singleton, LaFayette, MD,
  Johnson, Kirk A. (1993). Black Health Library
  Guide to Stroke. Henry Holt and Company, New
  York.
• Murray CJ, Lopez AD (1997). "Mortality by cause
  for eight regions of the world Global Burden of
  Disease Study". Lancet 349 (9061) 126976.
  doi10.1016/S0140-6736(96)07493-4. PMID 9142060.
• Donnan GA, Fisher M, Macleod M, Davis SM (May
  2008). "Stroke". Lancet 371 (9624) 161223.
  doi10.1016/S0140-6736(08)60694-7. PMID 18468545.
  
• The World health report 2004. Annex Table 2
  Deaths by cause, sex and mortality stratum in WHO
  regions, estimates for 2002.. Geneva World
  Health Organization. 2004. http//www.who.int/enti
  ty/whr/2004/en/report04_en.pdf.
• Office of National Statistics Health Statistics
  Quarterly
• 2005 Coronary Heart Disease Statistics. British
  Heart FoundationRoyal College of Physicians,
  (2001),
• http//www.omnimedicalsearch.com/conditions-diseas
  es/stroke-introduction.html

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References / Bibliography

• WHO guidelines cancer pain relief 2nd ed.
  Geneva World health organisation 1996