HX3.1 Palliative Care in Non-Malignant Disease Flashcards
What are the issues in palliative care in non-malignant disease-problems?
Longer duration
Greater symptom burden
Different disease trajectory- less predictable
Less expectation of death
Traditionally always something else to try
Failure to regard diseases as progressive
Lack of research re symptom control
How is COPD classified?
Stage 0 chronic symptoms/normal spirometry Stage 1( mild) = >80% of FEV1 Stage 2( moderate) = ≤80% of FEV1 Stage 3( severe ) = ≤50% of FEV1 Stage 4 (very severe) = ≤30% of FEV1 (or <50% with respiratory failure/right heart failure)
How does COPD compare to lung cancer?
Symptom burden the same as lung cancer but …..
Suffering is greater
Time longer/uncertainty re dying on each exacerbation/social isolation/alienation from doctors
Stigma of being/having been a smoker-”their own fault”
What are the symptoms of COPD?
Dyspnoea
Cough/sputum
Wheeze
Airway irritability
Fatigue/ reduced appetite /weight loss if severe
Anxiety/panic attacks/depression/poor sleep
Functional limitation
Thirst
What are the characteristics on the last year of life in pt w/COPD
High users of primary care services High burden on carers 80% housebound 30% chair bound Only group that most (52%)prefer to die in hospital ?Most not formally recognised as dying
What is the “Tx” in advanced COPD?
Stop smoking Antibiotics (?maintainance) Inhaled bronchodilators (b2 agonists (LABA) and anti-cholinergics(LAMA)) Flu/strep pneumonia vaccine Trial of oral steroids Treatment of exacerbations (including non invasive ventilation) Mucolytics Small amount of exercise LTOT
What is name of the curve displaying the relationship between the onset of COPD symptoms and ages at smoking cessation?
Fletchers Curve.
What is the efficacy of Long Term Oxygen Therapy in COPD?
Long-term oxygen therapy(LTOT) improves survival in advanced COPD.
What are the indications for LTOT in COPD?
STABLE SEVERE DISEASE
NON SMOKERS
Chronic arterial oxygen saturation <88% with sleep or exercise
GIVEN FOR 15+HRS A DAY
How is LTOT delivered?
Oxygen given via home concentrator or ambulatory O2 via cylinder
Give at 2-3L/min
Short burst O2 used if not on LTOT and may give some relief for exercise related dyspnoea
Target range is 88-92% saturation in acute exacerbations, NOT higher.
What is NIPPV?
Non-Invasive Positive Pressure Ventilation
Ventilatory support triggered by patient’s own breathing
Reduces need to intubate by 58%(NNT 5)
Palliates severe breathlessness
?need for nocturnal NIPPV
What is the TX for breathlessness in COPD?
OPIOIDS –reduce tachypnoeic response to hypercapnia /hypoxia /exercise. Safe
?BENZODIAZEPINES
Fan
Which type of COPDer is worse?
Pink Puffers more breathless than blue bloaters and have less risk of respiratory depression
What discussion need to take place between doctor an pt in advanced stage COPD?
Pulmonary rehabilitation programmes
Discussions re palliative care/end of life care - patients prefer this discussion to be with respiratory physician or GP, and not in the midst of an exacerbaton(Taylor etal)
Discussions re symptom control / recurrent admissions /resuscitation
What is the typical prognosis in COPD?
5YR Survival overall 40-70%
22-43% die within 1 yr of admission for acute exacerbation
36-50% die within 2 yrs
50%(STAGE II)= 90% 3yr survival
>60y.o. and FEV1 < 50% (STAGE III)=75% 3yr survival
Age-weight loss-declining FEV1-cvs problems
What is the trigger for SPC in COPD?
- Severe disease STAGE IV -FEV1 <12months (and 1 of the following:
- Advanced age / multiple co-morbidity / severe systemic manifestations/complications)
Long term O2 therapy (LTOT)?
The housebound?
What is Dementia?
Clinical disorder characterised by impairments in... Memory Intellect Judgement Language Insight Social skills
What are the different types of dementia?
Alzheimer’s Multi-infarct(vascular) Mixed Lewy body dementia Fronto-temporal (esp. Behaviour) Alcohol induced Other e.g. CJD, AIDS
What is the prevalence of dementia in Ireland?
1% < 65y.o.
20% > 80y.o.
What is the mean survival for those with dementia?
Mean survival 4.2 yrs for men and 5.7 yrs for women (overall highly variable and up to 20yrs)
What is the leading cause of death in dementia patients?
Intercurrent infection commonest cause of death
What are the common medical complications in the last year of a dementia patients life?
Confusion 86% Urinary incontinence 72% Swallowing problems 72% Decubitus ulcers 70% Aspiration pneumonia 55% Pain 64% Low mood 61% Constipation /Loss of appetite 57% Malnutrition /dehydration 57%
What are common behavioral problems in dementia?
Apathy Disinhibition Wandering Agitation Aggression Binge eating Delusions 73% Depression 40%
What are poor prognostic indicators in dementia?
No consistently meaningful verbal response Uses less than 6 intelligible words Unable to bathe without assistance Unable to dress without assistance Unable to walk without assistance Urinary and faecal incontinence Falls?
BARTHEL SCORE <25g/dl
Reduced oral intake
10% weightloss in last 6/12
What should trigger SPC in dementia? Why needed?
Increase in symptom intensity
Need to manage symptoms from a palliative perspective
Assistance with advanced care directives
Clarification regarding treatment decisions
End of life (Terminal) care
What is the recommended Palliative approach in Dementia?
Symptoms/comfort
Care environment/PLACE OF CARE
Spiritual care/Cultural issues
Death
Family carers and decision making
Bereavement support
What is POLST?
PHYSICIAN’S ORDERS
on LIFE SUSTAINING
TREATMENT
What are advanced care directives? Example?
These directives greatly help relieve guilt and distress for relatives discussing options and decisions re care.
Enduring power of attorney Artificial feeding/fluids Antibiotics PO/iv Hospital referral Resuscitation/DNR
What are the difficulties in introducing SPC in dementia?
Variable presentation
Identifying the end stage PROGNOSTIC PARALYSIS
Place of care
What are the consequences of not introducing appropriate SPC?
Inappropriate use of antibiotics
Pain control inadequate
Advance planning not done
Family not prepared for dying/missing out on bereavement
Dying phase is missed/terminal care not given
What is the prevalence of CCF?
10% of elderly
Mean age = 75
What are the issues surrounding CCF and palliative care?
Most patients unaware of the progressive nature of their disease
There is little acknowledgement that this is a fatal disease
Little discussion re end of life issues takes place
What is heart failure?
Despite a normal or increased filling pressure, the heart is not able to maintain sufficient output to meet the demands of the metabolising tissues
What are the signs of CCF?
SOB/fatigue at rest
Ankle swelling
Objective evidence of dysfunction
Weakness Pain Dyspnoea Depression Poor sleep Insomnia Anorexia Anxiety Constipation Nausea/ vomiting
What is the NYHA Classification for Heart Failure?
Class 1 = no limitation of physical activity
Class 2 = slight limitation
Class 3 = marked limitation
Class 4 = unable to carry out any physical activity without discomfort.
In what stage will most ccf pts die?
MOST DIE IN NYHA III
2 IN 3 WILL DIE SUDDENLY
What is the prognosis in CCF?
Overall 5 yr survival is 25% (worse than for any common cancer except lung ca).
50% will die in 4 yrs
Following first admission, median survival is 16 months,
Refractory symptoms at rest definitely less than 1 year
severe heart failure (III and IV) patients have 50% chance of death in one year
Surprise question.
What are the triggers for SPC in CCF?
>1 episode of decompensation / 6 months NYHA III/IV despite optimal treatment DEATH LIKELY WITHIN 12 MONTHS (“surprise question”) POOR QUALITY OF LIFE NOT SUITABLE FOR SURGERY (TRANSPLANT)
What are the possible Txs for CCF?
Implantable cardiac defibrillators
Decisions re deactivation
Issues in SPC care for CCF’s
10% SPC workload is with patients with non malignant disease(2008)
25% is the estimated demand
What constitutes a good death?
Freedom from distressing symptoms Participation in treatment decisions Planning and preparation for death Completion of life with faith and spiritual experiences Resolution of conflicts Affirmation of wholeness by care givers Trust in physician Continuity of care Avoiding unwanted life support
