1. END-OF-LIFE CARE HEART FAILURE and COPD Dr Sally Reeder Specialty Doctor in Palliative Medicine

2. LIFE-LIMITING ILLNESS
Symptoms
Patient and carer needs
Psychological support
Spiritual needs
Social isolation
Carer support
Quality of Life

3. PARALLEL SYMPTOMS Lethargy Decreased mobility Pain Dyspnoea Anorexia
Nausea
Depression
Anxiety
Decreased QOL

4. 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

5. 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

6. ILLNESS TRAJECTORIES 3 typical illness trajectories
-Steady progression eg: cancer
-Gradual decline eg: HF / COPD
-Prolonged gradual decline eg: dementia / old age

9. WHO DEFINITION of 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.

10. LIFE-LIMITING ILLNESSES
PALLIATIVE MEDICINE
LIFE-LIMITING ILLNESSES

11. 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?

12. SHOULD THE PALLIATIVE CARE TEAM BECOME INVOLVED,
AND WHEN?
Hospital-based Palliative Specialists
Hospice out-patient clinics
Day Hospice attendance
Hospice admission

13. BARRIERS to ACCESSING SPECIALIST PALLIATIVE CARE SERVICES

14. 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

15. From Specialist Palliative care
Floodgates will open / patient load
Stretch charitable funding
? Skills to manage these patients
Chronically ill - ? Exacerbation
? Block beds

16. From Patients I don’t have cancer I’m not dying Distressing
Lack of understanding – their disease
palliative care

17. COST

18. HEART FAILURE / COPD ?

19. 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

20. 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

21. MEDICATIONS Statins – stop Aspirin / Clopidogrel – stop
ACE Inhibitors – reduce if renal dysfunction
Loop diuretics
Spironolactone
B Blockers
Digoxin – stop, unless in AF

22. 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;

23. PAIN in HEART FAILURE
Angina; - ct anti-anginal medication as long as possible
musculoskeletal;
arthritis;
Gout
WHO analgesic ladder
Avoid NSAIDs
Amitriptyline

24. NAUSEA
Consider cause
Medication – opioids; digoxin toxicity; spironolactone
constipation;
renal failure
anxiety
Avoid Cyclizine – strong anticholinergic effects
Metoclopramide
Levomepromazine
Haloperidol
Syringe driver

25. OTHER SYMPTOMS Fatigue
Over-diuresis; hypokalaemia; poor sleep; anaemia; depression;
PND; periodic respiration; sleep apnoea
Depression
Avoid tricyclics
Itch
Good skin care of oedematous legs; SSRI
Constipation
Avoid bulking agents eg: fybogel

26. TERMINAL STAGE Not tolerating oral medication Syringe driver
Analgesics
Antiemetics
Anxiolytics
Diuretic
Liverpool Care Pathway LCP

27. 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

28. STUDY of COPD PATIENTS NEEDS
Diagnosis and disease process
Treatment options
Prognosis
What dying might be like
Advance care planning
ie: identical to needs of cancer patients!

29. 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

30. MANAGEMENT Bronchodilators Anticholinergics Oxygen Anxiolytics Opioids
Coping strategies
purse-lip breathing; slow expiration; lean forward
Pyschological support – end-of–life planning

31. GOING FOR GOLD Equitable end-of-life care
ALL appropriate patients on palliative register
Avoid un-necessary hospital admissions
Advanced care planning
Patient choice

32. 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”

33. 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

34. 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