End of Life and Palliative Care - PowerPoint Presentation

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End of Life and Palliative Care - PPT Presentation

How Americans died in the past Early 1900s Average life expectancy 50 years Childhood mortality high Adults lived into 60s How Americans died in the past Prior to antibiotics people died quickly ID: 930492

life care hospice palliative care life palliative hospice pain death die patients treatment cancer family patient 2012 illness therapy

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Slide1

End of Life and Palliative Care

Slide2

How Americans died in the past

Early 1900s

Average life expectancy 50 years

Childhood mortality high

Adults lived into 60s

Slide3

How Americans died in the past

Prior to antibiotics people died quickly

Infectious disease

Accidents

Medicine focused on caring, comfort

Nursing care in the home

Sick cared for at home

Slide4

Medicine’s shift in focus..

Science, technology, communication

Marked shift in values, focus of North American society

Death denying

Value productivity, youth, independence

Devalue age, family, interdependent caring

Slide5

Medicine’s shift in focus..

Potential of medical therapies

fight aggressively against all illness, death

prolong life at all costs

Improved sanitation, public health, antibiotics, other new therapies

Death now the enemy

Sense of failure if patient not saved

Slide6

End of Life in America today

Modern health care

few cures

longer life with chronic illness

dying process prolonged

Slide7

Protracted life threatening illness

More than 90% will experience:

predictable steady decline with relatively short terminal phase

slow decline punctuated by periods of crisis

Slide8

Sudden death from an unexpected cause

Time

Death

Health Status

Slide9

Steady decline, short terminal phase

Time

Decline

Death

Health Status

Slide10

Slow decline, periodic crisis, sudden death

Time

Crises

Decline

Death

Health Status

Slide11

Cost of Dying (14:20)

http://www.youtube.com/watch?v=

F6xPBmkrn0g

Slide12

Symptoms, suffering

Fears, fantasy, worry

Multiple physical symptoms

9.7 - 13.5 average

Psychological distress

Social isolation

Caregiving

Financial pressures

Slide13

Coping Strategies

Vary among individuals

May become destructive

suicidal ideation

premature death via physician assisted suicide or

euthansia

Slide14

Place of death

Preference: 90% want to die at home

Reality: 20% will die at home

Majority of institutional deaths could occur at home

Societal lack of familiarity with dying process

Slide15

Role of hospice, palliative care

Hospice started in US in 1970s

Percentage of total US deaths in hospice

11% in 1983

17% in 1995

Median length of stay

20 days

Slide16

Bridge the Gap:

Large gap between reality, desire

Fears

Die on machine

Die in discomfort

Be a burden

Die in institution

Desires

Die not on ventilator

Die in comfort

Die with family and friends

Die at home

Slide17

The palliative care approach

Adapted from lecture by

Maxine de la Cruz, MD

Slide18

What is 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.

Slide19

What is Palliative Care?

In patients with

serious

illnesses, irrespective of prognosis (any age/stage)

…

Complex Symptom Management

Emotional and Spiritual Support for Patients And Families

Assistance with Difficult Medical Decision Making

Support for Referring Physicians and Plans of Care

Assistance with Coordination of Care (i.e. home/

outpt

Palliative or transitions to Hospice Care)

Slide20

Not your Momma’s

Palliative

Care: A Conceptual

Shift

Medicare Hospice Benefit

Life Prolonging Care

Old

Palliative Care

Bereavement

Hospice Care

Life Prolonging Care

New

Death

Slide21

Palliative care continuum

Palliative care can be employed from time of diagnosis until death

It has a role in the relief of symptoms and suffering and improving quality of life

Slide22

Reduce physical and emotional symptoms

Improve function and reduce disability

Integrating complimentary therapies into patients’ current treatment

Coordinate with patient’s primary care specialist in order to achieve the best possible care

Assist in making informed decisions throughout their illness

Offer assistance in finding end-of-life resources and coordinating care with community services

Allow simultaneous palliation of suffering along with continued treatment (no requirement to give up curative care)

What are the goals of Palliative Care

Slide23

Patient and family centered approach to care that optimizes quality of life

by anticipating, preventing, and treating suffering

Interdisciplinary team work closely together

A model of shared decision making

Why is Palliative Care Different

Slide24

Pain and symptom control

Avoid inappropriate prolongation of the dying process

Achieve a sense of control

Relieve burdens on family

Strengthen relationships with loved ones

Singer et al.

JAMA

1999

;281(2):163-168.

The Patient’s Perspective

What Do Palliative Care patients want?

Slide25

Components of Palliative Care

Slide26

Who Can use palliative care

People of all ages

with life threatening illness and their families benefit from palliative care

at various stages of their disease

with congenital injuries or dependent on life-sustaining treatment

with acute, serious, life-threatening illness

living with progressive Chronic conditions

with Chronic and limiting injuries from accidents or other forms of trauma

Slide27

Members of the

Palliative Care Team

Clinical Team

Physician

Nurse Practitioner

Nurse

Dietician

PT/OT

Pharmacist

Psychosocial Team

Social Worker

Case Manager

Psychologist

Chaplain

Slide28

PAIN

FATIGUE

NAUSEA

CACHEXIA

ANOREXIA

INSOMNIA

DEPRESSION

ANXIETY

DROWSINESS

SHORTNESS OF BREATH

CONSTIPATION

SPIRITUAL DISTRESS

CONFUSION/DELIRIUM

What are the common symptoms experienced by patients

Slide29

Symptoms at the End of Life: Cancer vs. Other

Cancer Other

Pain 84% 67%

Trouble breathing 47% 49%

Nausea and vomiting

51% 27%

Sleeplessness 51% 36%

Confusion 33% 38%

Depression 38% 36%

Loss of appetite 71% 38%

Constipation 47% 32%

Bedsores 28% 14%

Incontinence 37

33%

Seale and Cartwright, 1994

Slide30

Pain is an unpleasant sensation happening in varying degrees of severity.

Caused by direct effect of the tumor or from treatment such as radiation therapy or chemotherapy.

Untreated pain may interfere with:

Daily activities and function Appetite

Sleep Joy with family and friends

When pain is well controlled you can:

Be active Interact with family and friends

Sleep better Improved quality of life

Opioids

such as morphine are needed to control pain in most patients

Other non pharmacologic therapies that may be used include:

Breathing and relaxation exercises Guided imagery

Massage, pressure and vibration Music therapy

Distraction Heating pads and cold packs

Patient with Pain

Slide31

“I can only take medicine or other treatments when

I actually have pain.”

“I will become ‘hooked on’ or ‘addicted to’ pain medicine.”

“If I take too much medicine now, it will stop working,

and I may need it later.”

“If I complain too much, I am not being a good patient.”

Patients’ concern with pain medications

Slide32

Approach to a Patient with Multiple Symptoms

55 y/o male with prostate Ca, metastatic to bone

complains of fatigue, drowsiness and back pain – x 2 weeks, partial relief with

hydrocodone

also noted to have swelling of the legs, anxiety, emotional distress

Cancer treatment cancer included surgery, androgen blockade with

Casodex

, and

Taxotere

Had a very supportive family

Wife also recently diagnosed with Liver cancer and receiving therapy

Slide33

Interdisciplinary approach to treatment

Address pain control via

opioids

and behavioral therapies

Physical therapy for mobilization and strengthening

Other

therapeuitic

modalities like art therapy, music therapy

Psychosocial team members for emotional and spiritual support

Use of

psychostimulants

for fatigue and drowsiness

Slide34

Fatigue is excessive feelings of tiredness that may not be relieved by extra amounts

of sleep or rest. Fatigue is controllable.

Causes

• Pain

• Emotional stress/ lack of sleep

• Infection

• Low red blood cell counts

• Inactivity/

deconditioning

• Advanced cancer or cancer treatment

• Difficulty breathing

Patients

with Fatigue

Slide35

What can we do?

Treat possible reversible causes.

Phamacologic

management

Non-pharmacologic therapies

What can the family do?

Encourage physical activity

Continue to engage patients in meaningful interactions

Lifestyle and environmental modifications

What awaits us in the future?

Studies focused on treatment: thalidomide,

dexamethasone

donepezil

, methylphenidate

Patients with Fatigue

Slide36