end-of-life care heart failure and copd dr sally reeder specialty doctor in palliative medicine
TRANSCRIPT
END-OF-LIFE CARE
HEART FAILURE and COPD
Dr Sally ReederSpecialty Doctor in Palliative Medicine
LIFE-LIMITING ILLNESS
• Symptoms• Patient and carer needs• Psychological support• Spiritual needs• Social isolation• Carer support• Quality of Life
PARALLEL SYMPTOMS
• Lethargy• Decreased mobility• Pain• Dyspnoea• Anorexia• Nausea• Depression• Anxiety• Decreased QOL
DIFFERENCES
• Predicting mortality• Terminal phase• Understanding of diagnosis and prognosis• Discussions about prognosis• End-of-Life discussions• Contact with health and social services• Financial support• Availability of specialist services in community
NON-CANCER PATIENTS
• Unpredictable illness trajectory• Acute events – hospital admissions• Patient attitude to diagnosis• Timing of death uncertain
• ?opportunities for End-of-Life discussions• Patient choice
• Palliative specialist involvement limited
ILLNESS TRAJECTORIES
• 3 typical illness trajectories
-Steady progression eg: cancer
-Gradual decline eg: HF / COPD
-Prolonged gradual decline eg: dementia / old age
WHO DEFINITIONof
PALLIATIVE CARE
• An approach that improves quality of life.
• Life-threatening illness
• Prevention and relief of suffering
• Early identification
• Impeccable assessment
• Treatment – physical, psychological, spiritual.
LIFE-LIMITING ILLNESSES
PALLIATIVE MEDICINE
• WHO SHOULD DELIVER THIS PALLIATIVE CARE?General Practitioners?Cardiologists?Specialist clinic staff?
• WHEN AND WHERE SHOULD IT BE DELIVERED?At diagnosis?Clinic appointments?Hospital admissions?GP appointments?
SHOULD THE PALLIATIVE CARE TEAM BECOME INVOLVED,
AND WHEN?
• Hospital-based Palliative Specialists• Hospice out-patient clinics• Day Hospice attendance• Hospice admission
BARRIERS to ACCESSINGSPECIALIST PALLIATIVE CARE
SERVICES
From Cardiology
• Palliative care only for dying patients
• Need to continue active intervention
• Concerns medications will be stopped
• Lack of understanding what SPC can offer
From Specialist Palliative care
• Floodgates will open / patient load
• Stretch charitable funding
• ? Skills to manage these patients
• Chronically ill - ? Exacerbation
? Block beds
From Patients
• I don’t have cancer
• I’m not dying
• Distressing
• Lack of understanding – their disease
palliative care
COST
HEART FAILURE / COPD
?
AN EQUITABLE SERVICE
• All life-limiting illnesses under SPC umbrella• Early introduction to the service• Patient and carer education• End-of-Life discussions• PPC documents• Day hospice
END-STAGE HEART FAILURE
• Optimal treatment but still symptomatic
• Principles of Symptom control
Assessment and investigation
Intervention to reversible factors
Palliation of irreversible factors
• Rationalisation of medication• Renal dysfunction / Hypotension
MEDICATIONS
• Statins – stop• Aspirin / Clopidogrel – stop
• ACE Inhibitors – reduce if renal dysfunction
• Loop diuretics• Spironolactone
• B Blockers• Digoxin – stop, unless in AF
BREATHLESSNESS
• Common• Assess for treatable causes
Infection ; Effusion: PE; underlying Ca; pulmonary oedema
asthma; COPD; anxiety
• Oxygen - ?benefit• Opioids – careful monitoring
• Anxiolytics• Non –pharmacological measures
breathing techniques; fan:pacing;
PAIN in HEART FAILURE
• Angina; - ct anti-anginal medication as long as possible
• musculoskeletal;• arthritis; • Gout
• WHO analgesic ladder
• Avoid NSAIDs
Amitriptyline
NAUSEA
• Consider causeMedication – opioids; digoxin toxicity; spironolactoneconstipation;renal failureanxiety
• Avoid Cyclizine – strong anticholinergic effects
• MetoclopramideLevomepromazineHaloperidol
• Syringe driver
OTHER SYMPTOMS
• FatigueOver-diuresis; hypokalaemia; poor sleep; anaemia; depression;PND; periodic respiration; sleep apnoea
• DepressionAvoid tricyclics
• ItchGood skin care of oedematous legs; SSRI
• ConstipationAvoid bulking agents eg: fybogel
TERMINAL STAGE
• Not tolerating oral medication
• Syringe driver
Analgesics
Antiemetics
Anxiolytics
Diuretic
• Liverpool Care Pathway LCP
End-Stage COPD
• Difficult to diagnose
• Persistent breathlessness despite optimum treatment
• Severe airflow obstruction FEV1 <30%• Housebound• An increased frequency of hospital admissions
• Fear / anxiety
STUDY of COPD PATIENTSNEEDS
• Diagnosis and disease process• Treatment options• Prognosis• What dying might be like• Advance care planning
ie: identical to needs of cancer patients!
End – Stage COPD
• Respiratory and non-respiratory symptoms
BREATHLESSNESS Decreased mobility
Wheeze Depression
Cough Social isolation
Fatigue
Pain
Poor sleep
• Worse standard of daily life than Lung Ca
MANAGEMENT• Bronchodilators• Anticholinergics
• Oxygen• Anxiolytics• Opioids
• Coping strategiespurse-lip breathing; slow expiration; lean forward
• Pyschological support – end-of–life planning
GOING FOR GOLD
• Equitable end-of-life care
• ALL appropriate patients on palliative register
• Avoid un-necessary hospital admissions
• Advanced care planning
• Patient choice
Domiciliary Visits
• Primary care team + Hospice Dr
• Aim - to recognise end-stage
- respect patients choices
- control symptoms
- prevent hospital admissions
- strive for a “good death”
COPD PILOT
• Looking at providing an equitable service• Recognising the different illness trajectories• Meeting patients needs• Introduction to the Hospice• Acknowledging what's already available
COPD PILOT
• Joint clinic at St Johns Hospice
RLI Respiratory team
SJH Doctor / Day hospice nurse
Physio / OT / CT• COPD patients chosen by respiratory team
FEV1 < 30
> 3 admissions• 6 week programme