end of life/palliative care issues in internal medicine
DESCRIPTION
Dr Lynn Alison Lambert B.Sc. PhD, MB ChB, FRCP (Lond) DTM&H Internal Medicine, University of Calgary . End of life/Palliative care issues in Internal Medicine. Disclosures. I have a vested interest in good end of life care – one day I will die too. - PowerPoint PPT PresentationTRANSCRIPT
End of life/Palliative care issues in Internal Medicine
Dr Lynn Alison LambertB.Sc. PhD, MB ChB, FRCP (Lond) DTM&HInternal Medicine, University of Calgary
Disclosures
I have a vested interest in good end of life care – one day I will die too. No sponsorship or financial links with any drug company Most of the information in this workshop is from:
The Oxford Textbook of Palliative Medicine, 4th Edition 2010 ▪ Hanks, G., Cherry, N., Christakis, N., ,Fallon, M., Kaasa, S.,
Portenoy, R. (Eds) Palliative Medicine, A Case Based Manual , 3rd edition 2012▪ Doreen Oneschuk, Neil Hagen and Neil MacDonald (Eds)
Discussions with my colleagues in Palliative care in Foothills Medical Centre, Calgary - with special thanks to Dr Jessica Simon.
Personal experience with many patients at the end of their lives
As Bob Dylan once said: “He who isn’t busy being born is busy dying”
What is Palliative Medicine? “Palliative Medicine is no more , no less
than the quality of care we should be offering all our patients every day - care tailored to their needs , skilled, compassionate”
quote from the late Sir Raymond (Bill) Hoffenberg, President of the Royal College of Physicians of London 1983-1989. Former Professor of Internal Medicine, University of Birmingham Medical School, Birmingham, England
From Palliative Medicine, A Case Based Manual, by Doreen Oneschuk
(U of Alberta) Neil Hagen (U of C) and Neil MacDonald (McGill)So - Palliative Medicine is for everyone.
Palliative medicine
Is holistic care, taking into account a patients cultural, spiritual and individual needs
Respects a patients wishes Even if they are not what we would choose
Informs a patient of what can be done Treatment options – pros and cons
Communicates prognosis accurately Communicates with the family/friends
(provided the patient gives permission)
History
Dame Ciceley Saunders Nurse, social worker, doctor Founded St Christopher’s Hospice in London,
1967 Wrote reports of a series of cases of terminally
ill patients -340 1960, 1100 by 1967 Realised that in terminal care there may be▪ Physical needs, emotional distress, social issues
(housing, finance, family)▪ Championed pain management – regular not prn▪ Battled current ideas/fears re opiate addiction
History 2
1973- 1st International Symposium on Pain control
1976 1st International Congress on the Care of the Terminally Ill – Montreal
1987 Palliative Medicine recognised as a specialty in UK
2006 ACGME and ABMS in US approved a new specialty in hospice and palliative medicine.
Is there a need for internal medicine physicians to know about palliative care if we have all these specialists? Top 5 predicted causes of death in 2020
IHD, Cerebrovascular disease COPD Respiratory infection Lung Cancer
So palliative medicine in non- malignant disease is important
Why internists need to be good at palliative care Whole patient management/ whole
person medicine Care of Elderly with multiple
problems Not enough hospice places Palliative medicine in non-malignant
disease Especially COPD and heart failure
Drug interactions Care of younger patients with
complex diseases
Is Palliative Medicine “Terminal Care” only?
Good Palliative care practice is the ability to recognise when the aim of a patient’s treatment is mainly that of symptom control rather than life prolongation.
This can be months or even years before the patients terminal phase.
Allows a patient to live with their disease and not just be dying from it.
Palliative care for the General Medical patient Generally discussion is left too late Often goals of care are discussed
when the patient arrives in the Emergency Department with an acute complication of a terminal illness.
This is stressful for doctors , patients and relatives
To avoid this we need to engage with our patients in advance care planning
Signposts in Palliative Care How to recognise that the time has
come for some end-of-life / goals of care discussion
The Surprise Question: “Would I be surprised if this patient
were to die in the next 6 months?” If the answer is “No” then you should
look for cues from the patient that they wish to discuss this. Try some exploratory questions.
Communication at the end of life What are the barriers?
Communication at the end of life What are the barriers? What can we do as clinicians?
Communication at the end of life What are the barriers? What can we do as clinicians? How can we do better?
Canadian Pallium project
Communication resource with clinical scenarios
Allow us to observe examples of good communication skills
Access via You Tube
Palliative Medicine
Should be what we do every day as part of usual care in Internal Medicine
Is it?
Having a Goals of Care discussion-what you can do Initiate the discussion of advance care
planning “are there any limitations on your treatment I
should know about” “do you have any specific wishes about your
treatment?” “Do you have a personal directive?”
Alberta “Conversations Matter” initiative Booklet, videos
Family Meeting Useful to get everyone “on the same page”
Goals Of Care – Calgary Region R Resuscitative Care
M Medical Care (excluding resuscitative care)
C Comfort Care
More flexible than DNR versus no DNR
Rules for internal medicine
Ask yourself “what am I trying to achieve here?” Don’t be caught up in a curative mode and fail to pick
up on the patient’s anxieties Be realistic (but not dogmatic) about the
prognosis With yourself With the patient
Find Out What the patient wants
Accept that: referral to a palliative care specialist does not mean
that you have given up on the patient
When to involve the palliative care team Sooner rather than later For symptom control when you are
unsure what to do To aid access to community services
and hospice When you recognise that you don’t
have time to do it properly yourself As a learning resource
(a phone call may be enough)
End of life care
The last days How to die with dignity in hospital
Is this difficult? How can we make it better?
Liverpool Care pathway (or similar)
Liverpool Care Pathway - used when patient has hours or days left to live Useful in hospital or at home Documents discussions with relatives Notes an advance directive (if done) Assesses
Pain, nausea, vomiting, agitation, breathlessness, skin condition, constipation
Anticipates need for drugs for: Pain, agitation, respiratory secretions,
nausea vomiting, dyspnoea,
Liverpool Care Pathway
Has a section for discontinuation of routine: blood tests, glucose monitoring, vital
signs, oxygen, iv antibiotics Documents
patients wishes re care after death▪ E.g. who washes body, need for burial within
24hours Discussions with relatives and
information given▪ Information leaflets, death certificate, post
mortem request
Patients at the end of life- Cases Elderly person Cancer patient Heart Failure Renal Failure Liver disease Complex case
Palliative care for the elderly patient Holistic care Looks at social, Personal and
spiritual issues Removal of unnecessary treatments Discussion of Goals of Care for the
future Sometimes operative treatment is
the best palliation – e.g. repair of fractured NOF
How to assess patients prognosis?
Patient with COPD
Mr Murray is a 74 year old retired oil worker, ex smoker, is on his fourth admission to hospital this year with COPD Last time he went to ICU and was ventilated
for 2 weeks He hasn’t left the house since He has home oxygen and a nebuliser
He is readmitted with breathlessness, wheeze and cachexia
Mr Murray
What is his prognosis? What will you do for him? What are you going to discuss? How will you do it?
Prognosis
Gold classification of COPD O normal spirometry, I Mild COPD II Moderate III Severe IV Very Severe
ADO Index BODE index
Prognosis- BODE Index
BMI, Airflow Obstruction, Dyspnoea, Exercise Capacity
BMI 19 FEV1 38% predicted MMRC dyspnea scale
Too breathless to leave house 6 min walk < 149 m Score 9 25% 4 year survival
Prognosis
GOLD III –Severe ADO (age, dyspnea, FEV1)
3 year mortality 47.2% BODE
4 year mortality 75%
What will you do?
What are his goals of care?
Points to consider
Discuss goals when patient is well if possible Pre-discharge In clinic
And document it Discuss interventions which will be
accepted and those which he does not want
Involve family Advance directive
Complex Case
“Please see this 76 year old Eastern European in ED lady whose potassium is high (5.9)” Gynae oncology consult
3 months ago- rectal cancer Biopsied - adenocarcinoma Declined operation
1 month ago vaginal bleeding New gynae cancer (ovarian)
2 weeks ago DVT – is on warfarin
Complex Case Continued
Having radiotherapy to perineum to control bleeding Felt “unwell” sent to ED
Had a brief cyanotic /apnoeic attack (bagged and recovered)
Is tachycardic, breathless and in pain She has vomited and it is blood streaked Hb is 72 g/L ECG new –RBBB Abdo looks distended
What do you do next?
She is “R1 goals of care” (for everything)
How far do you go?
Discuss
Issues
Potassium Pain Abdomen Vomiting (hematemesis?) Anemia Breathlessness Goals of care Patients values Family
Liver Case
53 year old night club manager Admitted to medical team yesterday
Jaundice, ascites and dehydration Seen in liver clinic 6 months ago
told to stop drinking Wife left 3 months ago
Hit the bottle even harder Sister brought him to ED when he
went yellow
Liver case continued
His bilirubin is 220, INR 1.8, WCC 12 albumin 28His urine output is poor (Urea 10, Creat 140)He has tense ascites and is uncomfortableHis creatinine is rising and he keeps trying to pull
out his ivHe is mildly encephalopathicThe nurses have tied his hands to the bedHis mother is on her way to the hospitalHis daughter, inVancouver, is 8 months pregnantHepatology say he is not a candidate for
transplantation
What are you going to do?
What is his prognosis? What do you need to do now?
Discuss
Prognosis
Severe alcoholic hepatitis can have a mortality of 50% at 30 days
1 year after an admission for alc. Hep 40% of patients are dead
Patients over 50 do worse than younger ones
Glasgow Alcoholic hepatitis score
Glasgow Alcohol Hepatitis score Age over or under 50 White count < 15, >=15 Urea <5mmol/L> INR <1.5, 1.5-2, >2 Bilirubin <125, 125-250, >250umol/L Day 1 Score is 9
predicts Day 28 outcome as 46% survival and Day 84 as 40% survival
Day 7 score was 12 37% chance of survival at Day 84
Liver case – 4 weeks later Bilirubin continues to rise (480
umol/L) Creatinine is 420 umol/L INR is 2.1 He is only intermittently lucid and
often in pain
What can you do for him?
What to do?
Prognosis MELD Score is 41; 3 month mortality is
90% (MELD – Model for End Stage Liver
disease) If already dialysed (& even if creatinine
lower) mortality is 100% Glasgow score also poor
Now what do you do?
Palliative Care Team
Can be involved even if you are still hoping for recovery
Can help with symptoms, support family
Can educate us May have more time to talk
Take home message
Think about goals of care in both acute and chronic diseases
Try to get a prognostic indicator Give the patient a chance to have a
conversation about the future Involve the palliative care team
sooner rather than later
And if you have been..
....thanks for listening.