terminal illness care
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Ten Leading Causes of Death in
world due to Severe illnesses
HEART DISEASE
MALIGNA NT NEOPLASM
CEREBROVASCULAR DISEASE
CHORIC LOWER RESP. DISEASE
ACCIDENTS
ALZHEIMER’S DISEASE
DIABETES MELLITUS
INFLUENZA AND PNEUMONIA
NEPHRITIS,NEPRITIC SYNDROME,NEPHROSIS
SEPTICEMIA
MALIGNA
NT
NEOPLASM
Cancer Patient according to
geographic
Cancer Patient
Cancer vs heart disease
Risk factor
Smoking Tobacco smoking is a strong, modifiable risk
factor for cardiovascular disease, pulmonary
disease, and cancer. Smokers have an
approximately 1 in 3 lifetime risk of dying
prematurely from a tobacco-related cancer or
cardiovascular or pulmonary disease. Tobacco
use causes more deaths from cardiovascular
disease than from cancer. Lung cancer and
cancers of the larynx, oropharynx, esophagus,
kidney, bladder, pancreas, and stomach are all
tobacco-related.
Diet Modification diets high in fat are associated with increased risk
for cancers of the breast, colon, prostate, and
endometrium. These cancers have their highest
incidence and mortalities in western cultures,
where fat comprises an average of one-third of
the total calories consumed
Suspected
Carcinogens
Screening
Recommendations
for Asymptomatic
Normal-Risk
Subjects
TUMOR MARKERS
TREATMENT
Staging and treatment planning Cancer stage is an assessment of the extent of
tumor spread and treatment is based on staging.
Most malignancies are staged by the tumor, lymph
node, and metastasis (TNM) system from stages I
to IV. The T classification is based on the size and
extent of local invasion. The N classification
describes the extent of lymph node involvement,
and the M classification is based on the presence or
absence of distant metastasis.
Staging and treatment planning Appropriate radiologic staging must be performed
before therapy, usually including computed tomographic(CT) imaging. Fluorodeoxyglucose-positron emission tomography (FDG-PET) adds to CT in select malignancies. Brain imaging with magnetic resonance imaging ([MRI] preferable) or CT with intravenous contrast should be considered in advanced melanoma and lung and kidney cancer. See tumor type discussion for further details.
Complete surgical staging provides more accurate extent of the disease than clinical staging and is possible only in patients with resectable disease when surgery is performed with an intent to cure.
Tumor grade is an assessment by the pathologist of the tumor's similarity to the cell of origin and the proliferation rate, usually low, moderate, or high grade.
Principles of radiation
Curative intent radiotherapy is used in several settings. Neoadjuvant: Preoperative therapy intended to reduce
both the extent of surgery and the risk of local relapse.
Adjuvant: Postoperative intended to reduce the risk of local relapse.
Definitive: High dose with curative intent, usually not followed by surgery.
Concurrent chemo radiation: Chemotherapy with definitive radiation significantly increases toxicity but increases efficacy in some settings.
Palliative radiotherapy
is used in lower dosing to
reduce symptoms, including
bony pain, obstruction
(esophageal, bronchial),
bleeding (GI, gynecologic,
bronchial, cutaneous), and
neurologic symptoms (brain
metastasis)
Principles of chemotherapy Traditional, cytotoxic chemotherapy targets all dividing
cells and has broad toxicities.
Chemotherapy is typically given in 2-, 3-, or 4-week “cycles.” In most regimens, intravenous treatment is given on the first day of the cycle, with no further treatment until the next cycle. In other regimens, treatments are weekly for 2 or 3 weeks, with 1 week off prior to the next cycle.
Curative intent chemotherapy includes neoadjuvant, adjuvant, and chemoradiation protocols in solid tumors. Chemotherapy alone is curative in many lymphomas, leukemias, and germ cell tumors (GST).
Palliative chemotherapy is used in advanced solid tumors and hematologic malignancies, with a focus on prolonging survival without overly affecting quality of life. Should only be used in patients with a good performance status.
Chemotherapy on various disease
Surgical Management Goals of therapy, cure versus palliation, must guide
any surgical intervention.
Surgical resection is often performed only when there
is a possibility of cure, though palliative surgery is
performed to relieve discomfort (mastectomy for local
control in a patient with metastatic disease) in some
malignancies.
Complete lymph node staging provides useful
information for postoperative treatment planning
(adjuvant therapy).
Surgical resection of isolated metastatic sites in
select patients can improve survival. Examples
include solitary brain metastases, pulmonary
metastases from colorectal cancer or sarcomas, and
liver metastases from colorectal cancer
Hormonal Therapy
Endocrine or hormonal therapy for cancer, the
earliest form of systemic therapy, is almost
entirely limited to breast cancer and prostate
cancer . Many premenopausal breast cancers
are thought to be under the influence of
estrogens, and hormonal deprivation
(ablation) may produce long-term responses
in properly selected patients (those with
estrogen and/or progesterone receptor
positivity who have predominantly soft tissue
or bone disease).
Aromatase Inhibitors
Patients who have experienced a prolonged
objective response or stable disease with
hormonal therapy may be candidates for
second, third-, or fourth-line hormonal
therapy.
Recently, aromatase inhibitors (e.g.,
anastrazole, letrozole, exemestane), which
decrease the conversion of metabolites in fat
and muscle into estrogen, have been found to
be more effective than tamoxifen as first-line
therapy in both the adjuvant and metastatic
settings
Corticosteroids
The corticosteroids, typically
prednisone or dexamethasone,
are widely used in the treatment
of hematologic and oncologic
cancers. In Hodgkin's disease ,
the non-Hodgkin's lymphomas ,
and multiple myeloma
,corticosteroids have antitumor
activity.
Immunotherapy
Two cancers that are
characterized by often
unpredictable clinical behavior,
melanoma and renal cell
carcinoma , are treated with
interferon or interleukin-2 or both
, Dramatic responses are
uncommon, and immunotherapy
is only a minor component of
cancer therapy.
Molecularly Targeted Agents
Targeted agents are drugs directed at a
specific molecular point, such as a protein
tyrosine kinase, or at the presence of a
specific antigen on a tumor cell. Tyrosine
kinase inhibitors include imatinib and
erlotinib. The current best example of the
success of tyrosine kinase inhibitor
therapy is the dramatic response of
chronic myelogenous leukemia (CML ) to
imatinib (Gleevec). Imatinib also has
activity against gastrointestinal stromal
cell tumors.
Bone Marrow/Stem Cell
Transplantation Because the major dose-limiting
toxicity of most chemotherapeutic
agents is myelosuppression,
approaches have been developed to
harvest the pluripotent stem cells
found in bone marrow, peripheral
blood, or, less often, cord blood before
marrow-damaging chemotherapy, so
that the stem cells can be reinfused
later . This technique is most effective
for acute leukemias , relapsed
lymphomas, and germ cell tumors.
CANCER OF UNKNOWN
PRIMARY ORIGIN
The first signs or symptoms of cancer are frequently the result of metastases to visceral or nodal sites. In most such patients, routine clinical evaluation with a comprehensive history, physical examination, complete blood cell count, screening chemistries, and directed radiologic evaluation of specific symptoms or signs identifies the primary tumor. Patients who have no primary tumor located after this routine clinical evaluation are defined as having cancer of unknown primary site. Further clinical and pathologic evaluation will identify the primary site in only a few patients, and approximately 80% will never have a primary site identified during their subsequent clinical course.
The initial clinical and pathologic evaluation
should focus on identifying a primary site
when possible and on identifying patients for
whom specific treatment is indicated. In most
patients with cancer of unknown primary site,
the diagnosis of advanced cancer is strongly
suspected after the initial history and physical
examination.
Biopsy
The diagnosis of metastatic cancer should be
confirmed by biopsy of the most accessible
metastatic lesion. Fine-needle aspiration may
or may not provide sufficient material for
optimal histologic examination and special
pathologic procedures. If tissue is inadequate,
a larger biopsy sample should be obtained so
all necessary stains and procedures can be
performed.
RECOMMENDED EVALUATION FOLLOWING INITIAL LIGHT MICROSCOPIC DIAGNOSIS
SPECIFIC
PATIENT
SUBSETS AND
RECOMMENDED
TREATMENT
Curability of Cancers with
Chemotherapy
A. Advanced Cancers With Possible
Cure
Acute lymphoid and acute myeloid
leukemia (pediatric/adult)
Hodgkin's disease (pediatric/adult)
Lymphomas—certain types
(pediatric/adult)
Germ cell neoplasms
Embryonal carcinoma
Teratocarcinoma
Seminoma or
. Advanced Cancers With Possible
Cure
Choriocarcinoma
Gestational trophoblastic neoplasia
Pediatric neoplasms
Wilms' tumor
Embryonal rhabdomyosarcoma
Ewing's sarcoma
Peripheral neuroepithelioma
Neuroblastoma
Small cell lung carcinoma
Ovarian carcinoma
Advanced Cancers Possibly Cured by Chemotherapy and Radiation Squamous carcinoma (head and neck)
Squamous carcinoma (anus)
Breast carcinoma
Carcinoma of the uterine cervix
Non-small cell lung carcinoma (stage III)
Small cell lung carcinoma
Cancers Possibly Cured With
Chemotherapy as Adjuvant to
Surgery
Breast carcinoma
Colorectal carcinomaa
Osteogenic sarcoma
Soft tissue sarcoma
Cancers Possibly Cured with
"High-Dose" Chemotherapy With
Stem Cell Support
Relapsed leukemias, lymphoid and myeloid
Relapsed lymphomas, Hodgkin's and non-
Hodgkin's
Chronic myeloid leukemia
Multiple myeloma
Cancers Responsive With Useful Palliation, But Not Cure, by
Chemotherapy
Bladder carcinoma
Chronic myeloid
leukemia
Hairy cell leukemia
Chronic lymphocytic
leukemia
Lymphoma—certain
types
Multiple myeloma
Gastric carcinoma
Cervix carcinoma
Endometrial
carcinoma
Soft tissue sarcoma
•Head and neck
cancer
•Adrenocortical
carcinoma
•Islet-cell
neoplasms
•Breast
carcinoma
•Colorectal
carcinoma
•Renal
carcinoma
Tumor Poorly Responsive in
Advanced Stages to
Chemotherapy
Pancreatic carcinoma
Biliary-tract neoplasms
Thyroid carcinoma
Carcinoma of the vulva
Non-small cell lung carcinoma
Prostate carcinoma
Melanoma
Hepatocellular carcinoma
Salivary gland cancer
SEPTICEMIA
Septic shock
OVERVIEW
• Septic shock is the most common cause of mortality
in the intensive care unit. It is the 10th leading cause
of death overall.
• Despite aggressive treatment mortality ranges from
15% in patients with sepsis to 40-60% in patients
with septic shock.
Reference Diseases
Incidence in US (cases per 100,000)
AIDS1 17
Colon and rectal cancer2 48
Breast cancer2 112
Congestive heart failure3 ~196
Severe sepsis4 ~300
Number of deaths in US each year
Acute myocardial infarction5 218,000
Severe sepsis4 215,000
1Centers for Disease Control and Prevention. 2000. Incidence rate for 1999. 2American Cancer Society. 2001. Incidence rate for 1993-1997.4Angus DC et al. 2001. Crit Care Med 29:1303-1310. 5National Center for Health Statistics. 2001.
SIRS
Sepis
Severe sepsis-SIRS
Septic shock
MODS
(Systemic Inflammatory Response Syndrome) is a systemic
inflammatory response to non specific insults
SIRS
SIRS is either due to Infection or others (major
burn-major traume-pancreatitis –hypovolemic shock)
Clinically?!
1. hyperthermia >38°C or hypothermia <36°C
2. • tachycardia >90 bpm
3. • tachypnoea >20 r.p.m. or PaCO2 <4.3 kPa
4. • neutrophilia >12 × 10–9 l–1 or neutropenia <4
000
Clinically?!
• Known or suspected infection,
plus
• >2 SIRS Criteria.
Sepis
•The systemic inflammatory response to infection.
Severe sepsis-SIRS
•Severe sepsis resulting in at least one organ
failure
Clinically?!
•Sepsis plus >1 organ dysfunction.
Septic shock
•Sepsis induced shock with hypotension
despite adequate resuscitation along with the
presence of perfusion abnormalities which may
include, but are not limited to lactic acidosis,
oliguria, or an acute alteration in mental status.
MODS
(multiple organ dysfunction syndrome) The presence of
altered organ function in an acutely ill patient such that
homeostasis cannot be maintained without intervention.
SIRSsystemic
inflammatory
response
syndrome
SEPSISSIRS with a presumed or confirmed
infectious process
•Severe sepsisSepsis with ≥1 sign of organ failure
Septic shockSIRS + Infection + Organ
Failure + Refractory
Hypotension
Caustive organisms
• Gram –ve the commonest
• Staphylococcus
• Candida
Sources of infection
• Endogenus source
1. Causes ofPeritonitis
2. Perforated viscous
3. Gangrenous bowel
4. Genitourinary infection
• Exogenus source
Infected CVP
Predisposing factors
• Old age
• DM
• Corticosteroid therpy
• Malignancy
• Major operation
It is not precisely understood, but it involves a complex interaction
between the pathogen and the host's immune system.
Physiological response to localized infection:o Influx of activated PMN leukocytes & monocytes release of inflammatory
mediators
o Local vasodilatation & increased endothelial permeability
o Activation of the coagulation cascade.
The same occurs in septic shock but at a systemic level. Diffuse endothelial disruption
Increased vascular permeability
Vasodilatation
Thrombosis of end organ capillaries
Infection
Inflammatory
Mediators
Endothelial
DysfunctionVasodilation
Hypotension Vasoconstriction Edema
Maldistribution of Microvascular Blood Flow
Organ Dysfunction
Microvascular Plugging
Ischemia
Cell Death
Inadequate
Resuscitation
Preoperative Illness
Trauma or
Operation
Tissue Injury
optimal oxygen
delivery and
support
Recovery
Excessive
Inflammatory
Response
SIRS/MODS
Pathogenesis of SIRS/MODS in
surgical patients
Lungs
Kidneys
CVS
CNS
PNS
Coagulation
GI
Liver
Endocrine
Skeletal Muscle
Adult Respiratory Distress Syndrome18%
Acute Tubular Necrosis 50%
Shock
Metabolic encephalopathy
Critical Illness Polyneuropathy
Disseminated Intravascular Coagulopathy
38%
Gastroparesis and ileus
Cholestasis
Adrenal insufficiency
Rhabdomyolysis
Acute Organ Dysfunction
Identifying Acute Organ Dysfunction
as a Marker of Severe Sepsis
Tachycardia
Hypotensio
n
CVP
PAOP
Jaundice
Enzymes
Albumin
PT
Altered
Consciousness
Confusion
Psychosis
Tachypnea
PaO2 <70 mm
Hg
SaO2 <90%
PaO2/FiO2 300
Oliguria
Anuria
Creatinine
Platelets
PT/APTT
Protein C
D-dimer
• You must suspect sepsis in patient with predisposing
factors,dont wait for septic shock
• The diagnosis of sepsis requires the taking of an
EXCELLENT history, physical examination,
appropriate laboratory tests, and a close follow-up
of hemodynamic status
• Early recognition is live saving in such rapid
overwhelming situation
Hyperdynamic- Warm- Early
Septic Shock
Restlness & confusion
Vitals
1. Temperature fever
more than 38 chills
2. Mild decrease ABP
3. Tachycardia
4. Tachypnea
Skin warm ,dry ,flushed
High cardiac output
Hypodynamic- Cold- Late Septic Shock
Semicomatosed
Vitals
1. Temperature
decreased
2. Tachycardia
3. Tachypnea
4. SBP<90mmHg
Oliguria & low COP
Multiorgan failure start at
this stage
Work-up… Laboratory studies
o CBC
o Coagulation studies
o Blood & urine cultures
Imaging studies
o Chest radiography
o Abdominal radiography
o Others according to the suspected cause.
• Glucose control is important in the management of sepsis,
with hyperglycemia associated with higher mortality
• LFTs and bilirubin, alkaline phosphatase, and lipase
levels are important in evaluating multiorgan
dysfunction or a potential source (eg, biliary disease, pancreatitis, hepatitis).
• Serum lactate …It is the best serum marker for tissue perfusion.
Lactate levels >2.5 mmol/L are associated with an increase in mortality.
Septic Shock &
MODSSeptic
• Control Infection Source
Shock
• Optimize Organ Perfusion
(Resuscitation)
MODS
• Support Dysfunctional Systems & Monitoring
Shock
• Optimize Organ Perfusion
(Resuscitation)
1)Circulatory supportI. Fluid replacment to achieve cvp 10-12
cm H2oII. Packed RBCS if low HCTIII. Drugs Inotropes & vassopressor
2)Respiratory support3)Renal support haemodyalisis in ARF
4)TTT of DIC fresh frozen plazma
EGDT is a 3-step protocol
aimed at optimizing tissue
perfusion
Septic• Control Infection Source
Eliminate surgical causes?!
Huge abscess
Peritonitis
gangernous bowel
Antibiotic therapyParentral ,compined ,broad spetrum.
• Antibiotics should be administered within the first hour of
recognition of septic shock, and delays in antibiotic
administration have been associated with increased
mortality.
• Selection of particular antibiotic agents is empirically based
on an assessment of the patient's underlying host defenses,
the potential source of infection, and
the most likely responsible organisms.
• One regimen for septic shock of unknown cause is
ogentamicin or tobramycin 5.1 mg/kg IV
once/day
o3rd generation cephalosporin “cefotaxime 2 g q
6 to 8 h or ceftriaxone 2 g once/day”oor if pseudomonas is suspected ceftazidime 2
g IV q 8 h”
•Renal replacement therapies (dialysis).
•Cardiovascular support (pressors, inotropes).
•Mechanical ventilation.
•Blood Transfusion for hematologic dysfunction.
MODS
• Support Dysfunctional Systems & Monitoring
Recent guidline is that steroids should be administered only in
patients with septic shock whose hypotension is poorly
responsive to fluid resuscitation and vasopressor therapy.
NEVER resuscitate with glucose 5%
Sudden Cardiac
DeathRisk factors & Managements
Risk Factors for SCD Old aged
Male
Has PMHx of Coronory Artery Diseases
High total cholesterol level
Arterial hypertonia (Hypertrophy of Left Ventricle)
Diet factors
Has active physical lifestyle
Smoking
Tachycardia / Variable heart rhythm
Prolonged Q-T segment
Stages of SCD
Prodromal
Period
Acute Cardiac
Symptoms
Disturbances in
blood circulation
Biological
Death
Evidence of clinical death
Main Features
• Asystolic
• Absent of pulsation at major vessels
(Carotid artery)
Additional Features
• Dilated pupils
• Areflexia ( Absent Corneal Reflex and
Pupil reflex towards light )
• Skin paleness (pallor)
SCD Management1. Primary evaluation of patient’s condition
2. Basic Life Support (CPR)
3. Advanced measures to maintain life
support &
full resuscitation of patient
4. Treatment during post- resuscitation
period
5. Long- term treatment
Criteria of adequate
CPR 1. Returning of pulse on major
vessels, synchronous with
compression
on chest.
2. Present of pupil reflex
3. Pink condition of patient
Algorithm of management of
ventricular tachycardia
1. 3 - multiple defibrillator (200 J, 300 J, 360 J)
(if not effective)
2. Continue resuscitation method, tracheal
intubation, prepare lines for IV
(If not effective)
3. Introduce Adrenaline IV 1 mg bolus
(if not effective)
4. Second defibrillator (360 J)
(if not effective)
5. Antiarrhythmic Drugs
Amiodarone ( 300mg IV)
Lidocaine (2.0 -1.5 mg/kg IV)
Magnesium Sulfate (1.0-2.0 g IV)
Antiarrhythmic Drugs
1. It is to stabilize patient’s condition
2. If patient’s condition is still unstable,
continue with defibrillator
3. All Anti-arrhythmic drugs have pro-
arrhythmic effects.
4. Do not use more than 1 anti-
arrhythmic drug
Atropine in Sudden Cardiac
Death
Indications
1. Asystolic
2. Heart arrest or bradyarrythmia
1st bolus dose 0.6 - 1.0 mg
If atropine is not effective, change to
adrenaline or euphiline.
Alzheimer’s Disease
What is Alzheimer’s Disease
(AD)?
Of all the diseases to be diagnosed with, Alzheimer’s strikes the most fear into people’s hearts.
It is progressive and debilitating.
It will rob you of: The ability to communicate
Think clearly
Function
Awareness of yourself and environment
All controls including the ability to dress yourself, eat or keep up on personal hygiene.
Memories of your family and loved ones.
Will eventually lead to death.
60-80% cases of dementia fall under
Alzheimer’s Disease In AD Patients:
The areas that control memory &
thinking are affected first.
Plaques form when protein pieces
called beta-amyloid clump together.
These are dense and mostly insoluble.
Neurofibrillary tangles are aggregates
of the protein tau which has
accumulated inside the cells.
Where tangles form the transport
system falls apart and disintegrates.
Nutrients and essential supplies
can’t move through cells and they
die.
This process spreads throughout the
brain.
Deficient in an important
neurotransmitter, acetylcholine, which
is involved in memory function and
may help to preserve nerve cell
Clusters of plaques and dying
nerve cells in a person with AD
Healthy Brain (L) AD Brain (R)
The bottom image shows the two brains together to see the difference in size.
Diagnosing AD
Diagnosis is not a simple process and includes:
Brain Scans
Cognitive Assessments
Laboratory Tests
On average, patients with AD live 7-10 years after
initial diagnosis.
The disease can last as long as 20 years.
4.5 million Americans have
AD.
Affects women more than
men:
2/3 of those diagnosed are women.
Signs & Symptoms
Depression can be a symptom and may begin
occurring up to 3 years prior to diagnosis of AD.
Most people put this off as not a big deal when it
could mean a great difference in outcome if
examined.
Memory Loss
Behavioral Issues not normal to the patient.
Confusion about time and place.
Trouble finding appropriate words or loss of
speech.
Poor judgment.
Changes in mood and personality, such as
suspicion.
Types of Alzheimer’s
Early Onset Alzheimer’s
Diagnosed before the age of 65.
Rare
Late Onset Alzheimer’s
Occurs after the age of 65.
Most common
Familial Alzheimer’s
Entirely inherited
Extremely rare
Cures There are no known cures for Alzheimer’s.
There are many studies underway with some promising results in slowing the disease down. Memantine has shown encouraging results among
those in advanced stages of AD.
Melatonin has also shown some promise but needs further study.
Antioxidants are extremely important.
Exercise for the body & brain at any stage.
A blue dye, methylene blue (MTC), slowed progression by 81%. It causes tau filaments to dissolve.
Prevention The general consensus is that prevention is the
key in dealing with AD. Exercise regularly both body and mind.
Maintain a normal healthy body weight.
Enjoy leisure activities.
Stay connected and social.
Practice stress reduction techniques.
Consume a diet rich in antioxidants.
Avoid trans fat and saturated fat.
Eat a diet that is 75% raw.
Avoid toxins as much as possible in your food and environment.
CEREBROVASCULAR
DISORDERS
CEREBROVASCULAR
DISORDERS
refers to any functional
abnormality of the central
nervous system that occurs
when the normal blood supply
to the brain is disrupted.
STROKE
a sudden neurological
event which results in
the new onset of
neurological
symptoms.
TYPES
ofSTRO
KE
ISCHE
MIC
STROK
E
“BRAIN
MOTOR LOSS-disturbance of voluntary
motor control on the side of
the body opposite the location
of the stroke lesion
•Hemiplegia
•Hemiparesis
COMMUNICATION LOSS
•Dysarthria
•Apraxia
•Agnosia
•Dysphasia or Aphasia
PERCEPTUAL DISTURBANCES
•Homonymous Hemianopsia
•Disturbance in Visual-Spatial Relations
- Unilateral Neglect
•Loss of Peripheral Vision
•Night Blindness
•Diplopia
•Horner’s Syndrome
SENSORY LOSS
•Slight Impairment of Touch
•Loss of Proprioception
•Difficulty in interpreting visual,
tactile, and auditory stimuli
COGNITIVE IMPAIRMENT &
PSYCHOLOGICAL EFFECTS
Memory Loss
Poor Comprehension
Limited Attention Span
Forgetfulness
Lack of Motivation
Depression
Emotional Lability
Hostility
Frustration
Resentment
Lack of Cooperation
ASSESSMENT &
DIAGNOSTICS
•Patient History
•Complete Physical and Neurologic Examination
•Initial Assessment: Airway Patency,
Cardiovascular Status, Gross Neurologic Losses
•Stroke Time Course Classification
STROKE TIME COURSE
CLASSIFICATION
Stage 1: Transient Ischemic Attack
Stage 2: Reversible Ischemic Neurologic Deficits
Stage 3: Stroke in Evolution
Stage 4: Completed Stroke
DIAGNOSTIC TESTS•CT Scan
•12-Lead ECG
•Carotid ultrasound
•Cerebral Angiography
•Transcranial Doppler Flow Studies
•Transthoracic or Transesophageal Echocardiography
•MRI of the brain and/or neck
•Xenon CT
•Single Photon Emission CT
MEDICAL MANAGEMENT
1. Treatment of TIA from atrial fibrillation or
suspected embolic or thrombotic causes
2. Thrombolytic Therapy for Ischemic Stroke
3. Therapy for Patients with Ischemic Stroke
NOT Receiving Thrombolytic Therapy
4. Managing Potential Complications
NURSING MANAGEMENT
•Improving Mobility and Preventing Joint Deformities
•Managing Sensory-Perceptual Difficulties
•Attaining Bowel and Bladder Control
•Improving Thought Processes
•Improving Communication
•Maintaining Skin Integrity
•Improving Family Coping
•Helping the Patient Cope with Sexual Dysfunction
SURGICAL MANAGEMENT
CAROTID ENDARTERECTOMY
- Main surgical procedure for the management of
TIAs and small stroke
- Indicated for patients with symptoms of TIA or
mild stroke found to be due to carotid stenosis
- Complications: stroke, cranial nerve injuries,
infection, hematoma at the incision site, carotid
artery disruption
HEMMORH
AGIC
STROKE
CEREBRAL
ANEURYSM
SUBARACHNOID
HEMORRHAGE
Elements of
Communicating
Bad News the P-
SPIKES
Approach
Acronym Steps Aim of the Interaction
PPreparation Mentally prepare for the interaction with the
patient and/or family.
S Setting of the interaction Ensure the appropriate setting for a serious
and potentially emotionally charged discussion.
P Patient's perception and
preparation
Begin the discussion by establishing the
baseline and whether the patient and family
can grasp the information.
Ease tension by having the patient and family
contribute.
I Invitation and information
needs
Discover what information needs the patient
and/or family have and what limits they want
regarding the bad information.
K Knowledge of the condition Provide the bad news or other information to
the patient and/or family sensitively.
E Empathy and exploration Identify the cause of the emotions—e.g., poor
prognosis.
Empathize with the patient and/or family's
feelings.
Explore by asking open-ended questions.
S Summary and planning Delineate for the patient and the family the next
steps, including additional tests or
Common Physical and
Psychological Symptoms of
Terminally Ill Patients
Palliative Care
What is Palliative Care?
Medical care that focuses on alleviating the
intensity of symptoms of disease.
Palliative care focuses on reducing the
prominence and severity of symptoms.
What is Palliative Care?
The World Health Organization describes
palliative care as "an approach that improves the
quality of life of patients and their families facing
the problems 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."
WHO Definition of Palliative Care
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;
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 counseling, 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.
WHO Definition of Palliative Care
(cont.)
What is the goal of Palliative
Care?
The goal is to improve the quality of life for
individuals who are suffering from severe
diseases.
Palliative care offers a diverse array of assistance
and care to the patient.
The History of Palliative Care
Started as a hospice movement in the 19th
century, religious orders created hospices that
provided care for the sick and dying in London
and Ireland.
In recent years, Palliative care has become a
large movement, affecting much of the
population.
Began as a volunteer-led movement in the United
states and has developed into a vital part of the
health care system.
Palliative vs. Hospice Care
Division made between these two terms in the
United States
Hospice is a “type” of palliative care for those who
are at the end of their lives.
Palliative vs. Hospice Care
Palliative care can be provided from the time of
diagnosis.
Palliative care can be given simultaneously with
curative treatment.
Both services have foundations in the same
philosophy of reducing the severity of the
symptoms of a sickness or old age.
Other countries do not make such a distinction
Who receives Palliative Care?
Individuals struggling with various diseases
Individuals with chronic diseases such as cancer,
cardiac disease, kidney failure, Alzheimer's,
HIV/AIDS,etc
Cancer and Palliative Care
It is generally estimated that roughly 7.2 to 7.5 million people worldwide die from cancer each year.
More than 70% of all cancer deaths occur in developing countries, where resources available for prevention, diagnosis and treatment of cancer are limited or nonexistent.
More than 40% of all cancers can be prevented. Others can be detected early, treated and cured. Even with late-stage cancer, the suffering of patients can be relieved with good palliative care.
Palliative Care and Cancer Care
Palliative care is given throughout a patient’s
experience with cancer.
Care can begin at diagnosis and continue through
treatment, follow-up care, and the end of life.
Palliative Care and Cancer
"Everyone has a right to be treated, and die, with
dignity. The relief of pain - physical, emotional,
spiritual and social - is a human right," said Dr
Catherine Camus, WHO Assistant Director-
General for Noncommunicable Diseases and
Mental Health. "Palliative care is an urgent need
worldwide for people living with advanced stages
of cancer, particularly in developing countries,
where a high proportion of people with cancer are
diagnosed when treatment is no longer effective."
“Cancer Control: Knowledge Into
Action”
Excerpts from the WHO guide for Palliative Care:
“Palliative care is an urgent humanitarian need
worldwide
for people with cancer and other chronic fatal
diseases.
Palliative care is particularly needed in places where
a high proportion of patients present in advanced
stages
and there is little chance of cure.”
Who Provides Palliative Care? Usually provided by a team of individuals
Interdisciplinary group of professionals
Team includes experts in multiple fields: Doctors
Nurses
social workers
massage therapists
Pharmacists
Nutritionists
Patient
and
Family
VolunteersPhysicians
Spiritual
Counselors
Social Workers
Pharmacists
Home Health
Aides
Therapists
Nurses
Kübler-Ross model
The Kübler-Ross model,
or the five stages of grief,
is a series of emotional
stages experienced when
faced with impending
death or death of
someone.
KUBLER ROSS - REACTION TO
TERMINAL ILLNESS
KUBLER ROSS - REACTION TO
TERMINAL ILLNESS
Denial
KUBLER ROSS - REACTION TO
TERMINAL ILLNESS
No I am not
KUBLER ROSS - REACTION TO
TERMINAL ILLNESS
Denial
Anger
KUBLER ROSS - REACTION TO
TERMINAL ILLNESS
Denial
Why me?
KUBLER ROSS - REACTION TO
TERMINAL ILLNESS
Denial
Anger
Bargaining
KUBLER ROSS - REACTION TO
TERMINAL ILLNESS
Denial
Anger
Make deals
KUBLER ROSS - REACTION TO
TERMINAL ILLNESS
Denial
Anger
Bargaining
Depression
KUBLER ROSS - REACTION TO
TERMINAL ILLNESS
Denial
Anger
Bargaining
Sense of lose
KUBLER ROSS - REACTION TO
TERMINAL ILLNESS
Denial
Anger
Bargaining
Depression
Acceptance
KUBLER ROSS - REACTION TO
TERMINAL ILLNESS
Denial
Anger
Bargaining
Depression
Make peace with death
KUBLER ROSS - REACTION TO
TERMINAL ILLNESS
Denial
Anger
Bargaining
Depression
Acceptance
Children grieving in divorce
Denial Children feel the need to believe that their
parents will get back together, or will change their
mind about the divorce. Example: “Mom and Dad
will stay together.”
AngerChildren feel the need to blame someone for
their sadness and loss. Example: “I hate Mom for
leaving us.”
Children grieving in divorce
Bargaining In this stage, children feel as if they have some
say in the situation if they bring a bargain to the
table. This helps them keep focused on the
positive that the situation might change, and less
focused on the negative, the sadness they’ll
experience after the divorce. Example: “If I do all
of my chores maybe Mom won’t leave Dad.”
Children grieving in divorce
DepressionThis involves the child experiencing sadness
when they know there is nothing else to be done,
and they realize they cannot stop the divorce.
The parents need to let the child experience this
process of grieving because if they do not, it only
shows their inability to cope with the situation.
Example: “I’m sorry that I cannot fix this situation
for you.” Acceptance
Children grieving in divorce
Acceptance This does not necessarily mean that the child will
be completely happy again. The acceptance is
just moving past the depression and starting to
accept the divorce. The sooner the parents start
to move on from the situation, the sooner the
children can begin to accept the reality of it
Approaches to Palliative Care
Not a “one size fits all approach”
Care is tailored to help the specific needs of the
patient
Since palliative care is utilized to help with various
diseases, the care provided must fit the
symptoms.
SUGGESTED QUESTIONS FOR THE CLINICAL
INTERVIEW WITH PATIENTS FACING THE END OF
LIFE
Tell me the story of your illness. [the
patient's perspective]
Tell me how you first found out about your
illness. [hearing bad news]
What is your understanding now about the
illness? [patient's understanding or
explanatory model]
What do you want to be told about your
illness? [shared decision making and
information preferences]
How has the illness affected you?
[patient's coping]
SUGGESTED QUESTIONS FOR THE
CLINICAL INTERVIEW WITH PATIENTS
FACING THE END OF LIFE
How has your family (or close friends) been affected? [family's coping] What have you discussed with them?
How have you been helped? [supports]
Have there been other tough times you have had to face? [previous coping]
Do you have a religious or spiritual practice or set of beliefs?
Have you been thinking about dying?[addressing death and dying] What kinds of thoughts have you had? What worries?
FEW NURSING
INTERVENTIONS Pain –
limit unnecessary painful procedures
sedation and giving pre-emptive analgesia prior to a
procedure (e.g., including sucrose for procedures in
neonates)
Address coincident depression, anxiety, sense of fear or
lack of control.
Consider guided imagery, relaxation, hypnosis,
art/pet/play therapy, acupuncture/acupressure,
biofeedback, massage, heat/cold, yoga, transcutaneous
electric nerve stimulation, distraction.
Dyspnoea or air hunger-
Suction secretions if present
positioning, comfortable loose clothing, fan to
provide cool, blowing air.
Limit volume of IV fluids, consider diuretics if fluid
overload/ pulmonary oedema present.
Behavioural strategies including breathing
exercises, guided imagery, relaxation, music
Management of Dyspnea
Fatigue –
Sleep hygiene
Gentle exercise
Address potentially contributing factors (e.g.,
anaemia, depression, side effects of medications)
Nausea/vomiting –
Consider dietary modifications (bland, soft, adjust
timing/ volume of foods or
feeds) Aromatherapy: peppermint, lavender;
acupuncture/
Constipation - Increase fibres in diet, encourage
fluids
Oral lesions/dysphagia –
Oral hygiene and appropriate liquid, solid and oral
medication formulation
(texture, taste, fluidity). Treat infections,
complications (mucositis, pharyngitis, dental
abscess, esophagitis).Orophayngeal motility
study and speech (feeding team) consultation
Anorexia–
Manage treatable lesions causing oral pain,
dysphagia, and anorexia.
Support caloric intake during phase of illness
when anorexia is reversible.
Acknowledge that anorexia is intrinsic to the
dying process and may not be reversible.
Prevent/treat coexisting constipation
Pruritus –
Moisturize skin, Try specialized anti-itch lotions,
Apply cold packs, Counter stimulation, distraction,
and relaxation.
Medications for Constipation
Diarrhoea –
Evaluate/treat if obstipation, Assess and treat
infection, Dietary modification.
Depression –
Psychotherapy, behavioural techniques
Anxiety –
Psychotherapy (individual and family),
behavioural techniques
Agitation/terminal restlessness –
Evaluate for organic or drug causes, Educate
family, Orient and reassure child; provide calm.
Medications for the Management of
Delirium
NURSING CARE
Answering the question
Helping the parents
Helping the dying child
Benefit another human being
irreversible cessation of neurologic function of the
brain
discuss the topic with family
Healthy child who dies unexpectedly, children
with cancer, chronic disease etc should be
considered for organ donation
ORGAN DONATION
PATIENTS' PERSPECTIVE ON
A “GOOD DEATH”
Control pain and other
symptoms
Avoid inappropriate
prolongation of dying when life
is no longer enjoyable
Relieve burden on the family
Achieve a sense of control
Strengthen relationships with
loved ones
Common
and
uncommo
n clinical
courses in
the last
days of
terminally
ill patients
GRIEF AND
BEREAVEMENT
Grief is the emotional response to
that loss.
Bereavement is the
acknowledgment of the objective
fact that one has experienced a
death.
BEREAVEMENT
The word 'bereavement' comes from the ancient
German for 'seize by violence'.
Today the word 'bereavement' is used to describe
the period of grief and mourning we go through after
someone close to us dies.
Bereavement is about trying to accept what
happened, learning to adjust to life without that
person
Ways to mournand
express the loss
Accepting the loss
Experiencing pain that comes with grief
Trying to adjustwithout that person
Finding new place to putemotional energy
STAGES OF BEREAVEMENT
The importance of mourning
Mourning allows to say goodbye.
Seeing the body, watching the burial, or scattering
the ashes is a way of affirming what has happened.
Sometimes we need to see evidence that a person
really has died before we can truly enter into the
grieving process.
COUNSELLING
DEFINITION
Counselling is a definitively structured
permissive relationship which allows the client to
gain an understanding of himself to a degree
which enables him to take new positive steps in
the light of his new orientation.
- ROGES
Characteristics
2 individual
Self
realization
Realistic goals
Attitude & action
Bereavement counselling
-to help people cope more effectively with the death of
their patient or a loved one. Specifically,
bereavement counselling can:
offer an understanding of the mourning process
explore areas that could potentially prevent you from
moving on
help resolve areas of conflict still remaining
help you to adjust to a new sense of self
address possible issues of depression or suicidal
thoughts
CONCLUSION
Knowledge about hospitalization,
terminally ill child and the nursing
management help nurses to provide the
adequate and quality care, to support
the family and child and to help her by
self satisfaction. Even though time heals
the wound, an adequate support
accelerates the process.
What does Palliative Care Provide to
the Patient?
Helps patients gain the strength and peace of
mind to carry on with daily life
Aid the ability to tolerate medical treatments
Helps patients to better understand their choices
for care
What Does Palliative Care
Provide for the Patient’s Family?
Helps families understand the choices available
for care
Improves everyday life of patient; reducing the
concern of loved ones
Allows for valuable
support system
Image courtesy of mdanderson.org
Approaches to Palliative Care
A palliative care team delivers many forms of help
to a patient suffering from a severe illness,
including :
Close communication with doctors
Expert management of pain and other symptoms
Help navigating the healthcare system
Guidance with difficult and complex treatment choices
Emotional and spiritual support for the patient and
their family
Palliative Care Is Effective Successful palliative care teams require
nurturing individuals who are willing to
collaborate with one another.
Researchers have studied the positive effects
palliative care has on patients. Recent studies
show that patients who receive palliative care
report improvement in:
Pain and other distressing symptoms, such as
nausea or shortness of breath
Communication with their doctors and family
members
Emotional and psychological state
Where to find Palliative Care?
In most cases, palliative care is provided in the
hospital.
The process begins when doctors refer
individuals to the palliative care team.
In the hospital, palliative care is provided by a
team of experts.
Settings for Palliative Care
Outpatient practice
Hospital Inpatient
Unit based
Consultation Team
Home care
Nursing Home
Hospice
Cost of Palliative Care
Most insurance plans cover all or part of the
palliative care treatment given in hospitals.
Medicare and Medicaid also typically cover
palliative care.
WPRO Palliative Care Systems
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