SLH 25/5/2012

Palliative Care Approach in Wound

management

Content

What is palliative care?

When is palliative care appropriate?

Who do we look after?

How do we look after (Approach)?

Where do we look after them?

There are only 2 things certain in

life: death & taxes

Benjamin Franklin

What is palliative care?

WHO Definition of Palliative Care

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 means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.

http://www.who.int/cancer/palliative/definition/en/

WHO Definition of Palliative Care

provides relief from pain and other distressing symptoms;

affirms life and regards dying as a normal process;

intends neither to hasten or postpone death;

integrates the psychological and spiritual aspects of patient care;

offers a support system to help patients live as actively as possible until death;

http://www.who.int/cancer/palliative/definition/en/

WHO Definition of Palliative Care

offers a support system to help the family cope during the patients illness and in their own bereavement;

uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated;

will enhance quality of life, and may also positively influence the course of illness;

is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications.

http://www.who.int/cancer/palliative/definition/en/

Who are we?

Who are we?

Patient &

family

Doctors

Nurses

Allied Health

Pharmacists

Social worker

Psychologists

Chaplains

Dietitian

When is palliative care suitable?

EVOLUTION OF PALLIATIVE CARE

1960s – 1970s

Early

detection Diagnosis/treatment

Palliative

Care Death

1980s -- present

Preventio

n

Early

detection

Diagnosis/treatment

Palliative care

Death

EVOLUTION OF PALLIATIVE CARE

The Future

Diagnosis Death

Disease-modifying

therapies

Symptom control

Death preparation

Family support

Mr Gan told The Straits Times that he has appointed Prof Pang to head a task force to study the recommendations and how to implement them.

The task force will look into integrating palliative care with curative medical treatment.

This means patients with terminal illnesses will get palliative care while being treated for their conditions, instead of having it kick in only when nothing more can be done to prevent the illness from getting worse.

The report noted that patients identified for palliative care at a late stage usually do not fare well, and often endure unnecessary hospitalisation.

It also pointed to the need to educate people on palliative care, given that many associate it with giving up hope and treatment.

Singapore to promote palliative care

Salma Khalik The Straits Times Publication Date : 06-01-2012

http://www.asianewsnet.net/home/news.php?id=25940&sec=7

& How do we look after them?

(Approach)

Who do we look after?

Causes of mortality in Singapore 2010 http://www.moh.gov.sg/content/moh_web/home/statistics/Health_Facts_Singapore/Principal_Ca

uses_of_Death.html

Total no of death 17610

Cancer 28.5%

Ischaemic Heart Disease 18.7%

Pneumonia 15.7 %

Cerebrovascular Disease (including stroke) 8.4 %

Accidents, Poisoning & Violence 5.5 %

Other Heart Diseases 4.8 %

Chronic Obstructive Lung Disease 2.5 %

Urinary Tract Infection 2.5 %

Nephritis, Nephrotic Syndrome & Nephrosis 2.2 %

Diabetes Mellitus 1.0 %

Palliative care

2020, more than 10,000 people a year would

need palliative care here, up from 8,000 in 2009.

Who do we look after?

Cancer

Organ failures

Frailty

Typical illness trajectories for people with progressive chronic illness.

Murray S A et al. BMJ 2005;330:1007-1011

©2005 by British Medical Journal Publishing Group

Prognosis – identifying the stages

Prognosis of main illness

Prognosis of wound

Prognosis of coormorbidities

If possible, always aim for curative in conjunction

with palliative

Prognostication

“The physician who

can foretell the

course of the illness

is the most highly

esteemed”. Hippocrates

Prognostication

It is about recognising the process ( of transition

from living to dying)

Understanding of the illness

Understanding of the patient ( more difficult)

Ds specific tool

General tool

Prognostication Cancer

Advanced Cancer B12-CRP Index via Pallimed

Breast Adjuvant! Online

Lung Adjuvant! Online

Colon Adjuvant! Online

Paraneoplastic/Complications via EPERC Fast Facts

Congestive Heart Failure Seattle Heart Failure Model via University of Washington

EFFECT (Enhanced Feedback for Effective Cardiac Treatment) via CCORT

Prognostication COPD

BODE Index via EPERC Fast Facts

Dementia Mortality Risk Index or MDS-12 via EPERC Fast Facts

Liver Disease MELD Score (Model for End Stage Liver Disease) via Mayo Clinic

Primary Biliary Cirrhosis via Mayo Clinic

HIV and HAART ART Cohort Collaboration

Prognostication

Intensive Care Unit

APACHE II via SFAR

SAPS via SFAR

ProVent Score

Renal Patients

Modified Charlson Comorbidity Score via EPERC

Fast Facts

Prognostication Hospice/Palliative Care Patients

Palliative Performance Scale v2 (Victoria Hospice) in conjunction with the tables found in these two articles:

Harrold J, Rickerson E, Carroll JT, et al. Is the palliative performance scale a useful predictor of mortality in a heterogeneous hospice population? J Palliat Med. Jun 2005;8(3):503-509.

Lau F, Downing GM, Lesperance M, Shaw J, Kuziemsky C. Use of Palliative Performance Scale in end-of-life prognostication. J Palliat Med. Oct 2006;9(5):1066-1075.

Or you can use the Victoria Hospice Prognostat, based on their collective knowledge of PPS scores and survival over the last 10+ years.

Victoria Hospice has a number of great prognostic tools on their website as part of the Victoria Palliative Research Network. Palliative Prognostic (PaP) Score requires evaluation of dyspnea, anorexia, KPS, clinical estimate of survival, total WBC, and lymphocyte percentage. Groups into 3 categories of chance at 30d survival. (Via EPERC Fast Facts) Palliative Prognostic Index requires PPS, estimate of oral intake, and evaluation of edema, dyspnea, and delirium. See page 4 of this PDF for the scale.

Prognostication

Declining Palliative Performance Status

Momentum of decline

Are you surprise …..

Prognostication

Take a good history =

communication !

Why is prognostication important?

Establish goal of care

Goal changes as the illness

changes

Prognosis (survival)

Days

- symptoms control alone

Weeks

- mainly focusing on symptoms control

Months

- symptoms control + wound healing if possible

Years

- symptoms control + wound healing if possible

Care of the dying

“We have a large number of [nurses who haven’t trained in the UK] & one of the biggest challenges for them was the idea that you could actually have a planned death. Because in their culture you do everything you can to sustain life…so that was a bit of a challenge there for them to understand that there was a time to die…that we weren’t assisting death but planning for the inevitable.”

[NHB Manager] - St.Christopher’s

o Adapted from slides from Prof Scott Murray

Approach to palliation

Active Palliative Care

Palliative Care with limited

interventions

Full palliative mode

Approach to palliation

Always ask yourself:

What is the goal & extend of care of the patient?

Approach based on the following

principles

Treat the PATIENT, including family and other related persons, not just the disease or the debility.

Patient autonomy

Beneficence

Nonmaleficence

Justice

The above need to be applied against a background of respect for life and acceptance of the ultimate inevitability of death.

Principle of Guidance for

treatment

Medical Indications

Patient’s preference

Quality of life

Contextual

Approach to palliation

Advanced care planning

- BIPAP, antibiotics, NG tubes, extend of invasive

procedures (e.g PCN insertion for

hydronephrosis)

- Hospitalisation, location of care

Medical opinion

- Reversibility of illness

- Stages of patient

Wound care

Cancer Non-cancer

patient

Cancer

Malignant wound (direct invasion vs skin mets)

- eg.fungating breast tumour; SCC; Melanoma

Treatment related wound

- Radiotherapy

- Post-operative

Malignant wound

Disease control if possible

Systemic chemotherapy (+/- hormonal

therapy/targeted therapy etc)

Radiation therapy

Treatment related wound

Aim for healing if possible

Usually reversible (acute wound)

Always ask yourself (or your

colleague)

Can the underlying cause be treated?

Can the wound be treated?

Malignant wound- Common

problems

Pain

Odour/Exudate

Bleed

Self-image/Psychosocial

Pain

Nociceptive v.s neuropathic pain

Pain history (assessment)

Opioids – systemic vs topical

Bleeding

Friable

Slow ooze (microvascular fragmentation) vs

“bleeder”

( vascular disruption)

Avoid surface tear

Alginate dressings, topical adrenaline

compression, silver nitrate, or cautery.

Non-cancer wound care

Can the underlying cause be treated?

Can the wound be treated?

Where do we look after them?

How do we decide?

Advance care planning

Medical condition

Resources/coping of the family

Where?

Community

- Home

- Community hospital

- Inpt hospice

- Nursing home

Institution

- Acute hospital

PALLIATIVE CARE SERVICES In-patient Hospices

• Dover Park Hospice

• Assisi Home and Hospice

• St. Joseph’s Home

• Bright Vision Hospital

Home Care

•Hospice Care Association

•Assisi Home and Hospice

•S’pore Cancer Society

•Methodist Hospice

Fellowship

•Metta Home Care

• DPH (selected cases)

Day Care

• Hospice Care Association

• Assissi Home and Hospice

Home hospice Referral criteria: prognosis less than 1 year

symptomatic patient

Mainly lead by nurses

Role: provide medical input

equipment loan

psychosocial support

Usually visit once weekly or once every 2 weekly

Wound care normally will need to be done by the helper/family/HNF/others

24hour access/support

Inpatient Hospice

Referral criteria: prognosis of less than 3 months

symptomatic

no dedicated caregiver at home

E.g. : Large SCC of the face

Fungating breast lumps with pain

Impending carotid blowout ( impending big

bleed)

St. Joseph’s Home

Run by the Canossian Sisters

located at Jurong Road

22 beds for hospice patients, 108 beds for NH residents

Hospice section started 1985

Only inpatient services

Supported by a GP group; no resident doctors

Assisi Home and Hospice Established 1969

Owned by the Franciscan

Missionaries of the Divine

Motherhood (FMDM)

Sisters

An outreach service of Mt

Alvernia Hospital

40 beds (19 single-bedded

rooms)

Bright Vision Hospice

We’ve discussed

What is palliative care?

When is palliative care appropriate?

Who do we look after?

How do we look after (Approach)?

Where do we look after them?

Palliative Care- In summary

Good clinical care, recognising our advances and

limitation in healthcare

Caring for patient and family

Helping them find meaning in suffering

Listening to them & planning ahead