care for end stage cancer patients dr. peggy lu. determine the level of care curative care...
TRANSCRIPT
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Care for End Stage Cancer Patients
Dr. Peggy Lu
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Determine the Level of Care
• Curative Care
• Palliative Care
• Comfortable care
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Health Care Worker Attitudes
• We should be able to fix it or cure it
• We must make people feels better
• If a patient dies we fail
• We have technology and drugs and there is always more we can do
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What we need to learn
• We will die
• Life is finite
• Not all technology works
• How we want to die
• We must face our own mortality so we can help others face theirs
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Nearing the End of Life
• What’s going to happen to me?• Have I done everything I should have done?• What are my other options?• How much control will I have over my life and my
death?• Will my wishes about my care be followed?• How much pain and suffering will I have?• What am I going to do about money?
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“The Good End of Life”
• Preparation
• Clear decision-making
• Pain and symptom relief
• Contribution to others
• Completion
• Affirmation
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Self-Determined Life Goals
-Who I am and what I am leaving behind
-What are my most important needs
-Where do I want to die
Assist the patient in meeting their end of life goals
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The Elderly
-It is essential to ask elderly patients their wishes directly
-Medical personnel more often discuss these matters with surrogates or family members, neglecting to ascertain elderly patient’s opinions and therefore misunderstand patient's needs and wishes.
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Why do you need an advance directive?
• Your have a right to be informed and decided for yourself
• Advance directives are for times you can’t speak for yourself.
• Free loved ones from making difficult decisions
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Choosing DNR/DNI
• They want quality of the life they have left
• They want to avoid risks and harms of CPR
• They accept their prognosis and death
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When is Hospice Care Appropriate?
• Life expectancy of 6 months of less
• Curative care is no longer effective or desired
• Goals are transitioned to comfortable and quality of life.
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What can Hospice Care Provide?
• Minimized suffering
• Care is focused on pain and symptom management
• Coordination of care: The patient and family are supported by physicians, nurses, hospice aides, social workers, volunteers
• Spiritual Care
• Respite Care
• Bereavement Care
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Communication, Control, Support
• Honest communication
• Allow as much control as possible
• Maintain patient dignity
• Address fear of unknown
• Listen, listen, listen
• Asses non-verbal cues
• Empower love ones to provide support
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Emotions as Patients Near the End of Life
• Fear
• Anger
• Guilt and regret
• Grief
• Anxiety and depression
• Feeling alone
• Seeking meaning
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Physical symptoms in the last 2-3 months of life
• Fatigue/weakness
• Pain
• Appetite changes
• Problems breathing
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Physical symptoms in the last 2-3 months of life
• Nausea/vomiting
• Bowel obstruction
• Bowel/bladder incontinence
• Diarrhea or constipation
• Delirium/agitation/confusion
• Drowsiness and sleeping
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Important Pain Management Concepts
• Medications are given according to physician’s orders and do not hasten the end of life
• Assess/reassess the duration and effectiveness of pain management
• Assess non-verbal patients
• Correct medications make the dying process more comfortable
• Always believe the patient’s report of pain.
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Types of pain medications
• Long-acting time released forms
• Short-acting forms
• Patch
• Lozenges
• Liquid
• Rectal suppositories
• Pain medicine pump
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Appetite Changes
• Happens to more than 8/10 of end stage cancer patients
• It is normal in the last months of life for parts of body to start slowing down and eventually shut down.
• Avoid family food battles
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Problem Breathing
• Even thinking about breathing problem can be scary
• Patient may feel SOB or need breathe faster and harder than normal.
• Most often, severe symptom happens while the patient is unconscious and not aware.
• Things that can be done: Position, Oxygen, Decongestion, Medicines to reduce anxiety, Opioids
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What Caregivers Can Do?
• Help patient turn and change position
• Try ice chips or sips of liquid if the patient is having trouble swallowing.
• Do not push fluids. Near the end of life, some dehydration is normal and also more comfortable for the patient.
• Pad the bed beneath the patient with layers of disposable waterproof pads.
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What Caregivers Can Do?
• If patient is very restless, try to find out if they are having pain and give breakthrough pain medications if needed
• Gentle touching, caressing holding and rocking are usually helpful and comforting.
• Always assume the patient can hear you and continue to speak with and touch the patient to reassure them of your presence.
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Saying the Four Things
• Please forgive me
• I forgive you
• Thank you
• I love you
• The 5th: Good bye
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Signs that death has occurred
• Breathing stops
• Blood pressure can not be heard
• Purse stops
• Eyes stop moving and may stay open
• Pupils of the eyes stay large even in bright light
• Control of bowels or bladder may be lost as the muscles relax.
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Life is pleasant.
Death is peaceful.
It is the transition that is troublesome.
Isaac Asimov (1920-1992)
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Good Life and Good Death