Palliative Care and the Operating Department

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Palliative Care and the Operating Department

• Phil Warren
• Head of Education
• Earl Mountbatten Hospice
• Isle of Wight

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Perioperative Care

• Embedded within evidence-based practice, the
  Perioperative care framework embodies theoretical
  knowledge, organisational skills, cognitive
  judgement and interpersonal integrity which is
  applied to the holistic care of the surgical
  patient. This must encompass the physiological
  and psychological support to patients who require
  care at all levels of dependency within all
  aspects of Pre Operative, Intra Operative and the
  Post Operative phases of patient care".

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Perioperative Care

• Some would argue that the Perioperative process
  encompasses all care from Pre-hospital,
  Diagnosis, Preoperative, Intraoperative,
  Postoperative, Discharge and follow-up. This is
  the true Perioperative picture!

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Definition

• Palliative care is the active holistic care of
  patients with advanced progressive illness.
  Management of pain and other symptoms and
  provision of psychological, social and spiritual
  support is paramount. The goal of palliative care
  is achievement of the best quality of life for
  patients and their families. Many aspects of
  palliative care are also applicable earlier in
  the course of the illness in conjunction with
  other treatments". (NICE)

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Supportive Care

• Supportive care helps the patient and their
  family to cope with their condition and
  treatment, to cure, to continuing illness or
  death and into bereavement. It helps the patient
  to maximise the benefits of treatment and to live
  as well as possible with the effects of the
  disease. It is given equal priority alongside
  diagnosis and treatment. (NCPC, NICE)

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Who has palliative care needs?

• The dying?
• Those with incurable illness?
• Those with life-threatening illness?
• Those with chronic illness?
• Those with any illness??

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Causes of Death
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Illness Trajectories
Organ failure
Cancer
Dementia and decline
Sudden death
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Choice Access

• Perioperative care- surgeon, place, timing etc.
  accessed by all?
• Palliative care place of care, place of death.
  accessed by some?
• Differing criteria affect admission and
  acceptance of dying status

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Place of Death

• Place home hospital hospice care
  home
• Preference 56 11 24
  4
• Actual 18.3 56.9 4.3
  20.5
• Higginson I (2003) Priority for end of life care
  in England, Wales and Scotland, NCPC

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Place of occurrence of death by underlying cause
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In context

• An example
• Upper GI surgery 5 year survival
• Oesophagus 5 male, 8 female
• Stomach 9 male, 11 female
• Pancreas 2 male, 2 female

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Palliative Care for All

• Seeing similarities between cancer, heart failure
  and others
• Shift to longer term palliative care requirements
  as cancer becomes more chronic and other chronic
  conditions adopt palliative needs
• Palliative care becoming more complex as
  co-morbidity increases
• Palliative care needs of older people differ from
  those of younger people

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Palliative Care for All

• NCPC needs assessment shows geographical
  distribution of need in other conditions differs
  from cancer
• Future in educating and empowering other
  specialists and usual carers not large scale
  expansion of specialist palliative care delivery.

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End of Life Care programme (EoLC)

• Aims
• To extend the boundaries of palliative care
  provision..for all patients regardless of
  diagnosis
• By enabling more patients to live and die in the
  place of their choice
• Gold Standards Framework
• Liverpool Care Pathway

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Gold Standards Framework

• A programme for community palliative care
• Aim - for the best for all
• Processes Identify, Assess, Plan
• Goals symptom free, place of care, security
  support, carers, staff
• Key tasks the 7 Cs , communication,
  co-ordination, control of symptoms, continuity
  including out of hours, continued learning, carer
  support, care in the dying phase

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Liverpool Care Pathway

• Devised for use in hospitals, but can be used in
  primary/community/care home settings.
• Empowers generalists to care for the dying, not
  just for cancer patients
• IOW ICP Last Days of Life

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Last Days of Life ICP (IOW)

• Criteria for use decreased level of
  consciousness shortened life prognosis, valid
  not for CPR, MDT agree that the patient is dying
• Patient assessment and care record, nursing,
  comfort, religious needs, psychological insight
  etc
• Pain and symptom control algorithms

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Issues to consider

• Professionals not eliciting their problems and
  concerns
• Service not available
• Patients and carers being unaware of the services
  available that might help them
• Professionals unaware of benefits of existing
  services and not offering access or referral
• Poor communication and co-ordination amongst
  professionals

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Palliative Care Provision IOW
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The patient journey

• From diagnosis to surgery and beyond
• At any point palliative care needs may be
  required
• In theatre? Patient needs our needs

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What can we do?

• Broader understanding, long term implications of
  our care
• Communication!
• Education, access local provision
• Do not work in isolation
• Share experiences
• User involvement

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References

• Isle of Wight Healthcare NHS Trust (2005)
  Integrated Care Pathway Last Days of Life
• NHS (2005) End of Life Care Programme
• NHS (2005) The Gold Standards Framework
• Tebbit. P. (2005) Where the results of Needs
  Assessment are taking us. NCPC
• Young. E. (2005) National Council for Palliative
  Care

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Useful Links

• www.ncpc.org.uk
• www.endoflifecare.nhs.uk
• www.helpthehospices.org.uk
• phil.warren_at_iwhospice.org