1. End of life/Palliative care issues in Internal Medicine
Dr Lynn Alison Lambert
B.Sc. PhD, MB ChB, FRCP (Lond) DTM&H
Internal Medicine, University of Calgary
End of life/Palliative care issues in Internal Medicine

2. Disclosures
I have a vested interest in good end of life care – one day I will die too.
No sponsorship or financial links with any drug company
Most of the information in this workshop is from:
The Oxford Textbook of Palliative Medicine, 4th Edition 2010
Hanks, G., Cherry, N., Christakis, N., ,Fallon, M., Kaasa, S., Portenoy, R. (Eds)
Palliative Medicine, A Case Based Manual , 3rd edition 2012
Doreen Oneschuk, Neil Hagen and Neil MacDonald (Eds)
Discussions with my colleagues in Palliative care in Foothills Medical Centre, Calgary - with special thanks to Dr Jessica Simon.
Personal experience with many patients at the end of their lives

3. As Bob Dylan once said: “He who isn’t busy being born is busy dying”

4. What is Palliative Medicine?
“Palliative Medicine is no more , no less than the quality of care we should be offering all our patients every day - care tailored to their needs , skilled, compassionate”
quote from the late Sir Raymond (Bill) Hoffenberg, President of the Royal College of Physicians of London Former Professor of Internal Medicine, University of Birmingham Medical School, Birmingham, England
From Palliative Medicine, A Case Based Manual, by Doreen Oneschuk
(U of Alberta) Neil Hagen (U of C) and Neil MacDonald (McGill)
So - Palliative Medicine is for everyone.

5. Palliative medicine
Is holistic care, taking into account a patients cultural, spiritual and individual needs
Respects a patients wishes
Even if they are not what we would choose
Informs a patient of what can be done
Treatment options – pros and cons
Communicates prognosis accurately
Communicates with the family/friends
(provided the patient gives permission)

6. History Dame Ciceley Saunders Nurse, social worker, doctor
Founded St Christopher’s Hospice in London, 1967
Wrote reports of a series of cases of terminally ill patients , 1100 by 1967
Realised that in terminal care there may be
Physical needs, emotional distress, social issues (housing, finance, family)
Championed pain management – regular not prn
Battled current ideas/fears re opiate addiction

7. History 2 1973- 1st International Symposium on Pain control
1976 1st International Congress on the Care of the Terminally Ill – Montreal
1987 Palliative Medicine recognised as a specialty in UK
2006 ACGME and ABMS in US approved a new specialty in hospice and palliative medicine.

8. Top 5 predicted causes of death in 2020
Is there a need for internal medicine physicians to know about palliative care if we have all these specialists?
Top 5 predicted causes of death in 2020
IHD,
Cerebrovascular disease
COPD
Respiratory infection
Lung Cancer
So palliative medicine in non- malignant disease is important

9. Why internists need to be good at palliative care
Whole patient management/ whole person medicine
Care of Elderly with multiple problems
Not enough hospice places
Palliative medicine in non-malignant disease
Especially COPD and heart failure
Drug interactions
Care of younger patients with complex diseases

10. Is Palliative Medicine “Terminal Care” only?
Good Palliative care practice is the ability to recognise when the aim of a patient’s treatment is mainly that of symptom control rather than life prolongation.
This can be months or even years before the patients terminal phase.
Allows a patient to live with their disease and not just be dying from it.

11. Palliative care for the General Medical patient
Generally discussion is left too late
Often goals of care are discussed when the patient arrives in the Emergency Department with an acute complication of a terminal illness.
This is stressful for doctors , patients and relatives
To avoid this we need to engage with our patients in advance care planning

12. Signposts in Palliative Care
How to recognise that the time has come for some end-of-life / goals of care discussion
The Surprise Question:
“Would I be surprised if this patient were to die in the next 6 months?”
If the answer is “No” then you should look for cues from the patient that they wish to discuss this. Try some exploratory questions.

13. Communication at the end of life
What are the barriers?

14. Communication at the end of life
What are the barriers?
What can we do as clinicians?

15. Communication at the end of life
What are the barriers?
What can we do as clinicians?
How can we do better?

16. Canadian Pallium project
Communication resource with clinical scenarios
Allow us to observe examples of good communication skills
Access via You Tube

17. Palliative Medicine
Should be what we do every day as part of usual care in Internal Medicine
Is it?

18. Having a Goals of Care discussion-what you can do
Initiate the discussion of advance care planning
“are there any limitations on your treatment I should know about”
“do you have any specific wishes about your treatment?”
“Do you have a personal directive?”
Alberta “Conversations Matter” initiative
Booklet, videos
Family Meeting
Useful to get everyone “on the same page”

19. Goals Of Care – Calgary Region
R Resuscitative Care
M Medical Care (excluding resuscitative care)
C Comfort Care
More flexible than DNR versus no DNR

20. Rules for internal medicine
Ask yourself “what am I trying to achieve here?”
Don’t be caught up in a curative mode and fail to pick up on the patient’s anxieties
Be realistic (but not dogmatic) about the prognosis
With yourself
With the patient
Find Out
What the patient wants
Accept that:
referral to a palliative care specialist does not mean that you have given up on the patient

21. When to involve the palliative care team
Sooner rather than later
For symptom control when you are unsure what to do
To aid access to community services and hospice
When you recognise that you don’t have time to do it properly yourself
As a learning resource
(a phone call may be enough)

22. End of life care The last days How to die with dignity in hospital
Is this difficult?
How can we make it better?
Liverpool Care pathway (or similar)

23. Liverpool Care Pathway - used when patient has hours or days left to live
Useful in hospital or at home
Documents discussions with relatives
Notes an advance directive (if done)
Assesses
Pain, nausea, vomiting, agitation, breathlessness, skin condition, constipation
Anticipates need for drugs for:
Pain, agitation, respiratory secretions, nausea vomiting, dyspnoea,

24. Liverpool Care Pathway
Has a section for discontinuation of routine:
blood tests, glucose monitoring, vital signs, oxygen, iv antibiotics
Documents
patients wishes re care after death
E.g. who washes body, need for burial within 24hours
Discussions with relatives and information given
Information leaflets, death certificate, post mortem request

25. Patients at the end of life- Cases
Elderly person
Cancer patient
Heart Failure
Renal Failure
Liver disease
Complex case

26. Palliative care for the elderly patient
Holistic care
Looks at social, Personal and spiritual issues
Removal of unnecessary treatments
Discussion of Goals of Care for the future
Sometimes operative treatment is the best palliation – e.g. repair of fractured NOF

27. How to assess patients prognosis?

28. Patient with COPD
Mr Murray is a 74 year old retired oil worker, ex smoker, is on his fourth admission to hospital this year with COPD
Last time he went to ICU and was ventilated for 2 weeks
He hasn’t left the house since
He has home oxygen and a nebuliser
He is readmitted with breathlessness, wheeze and cachexia

29. Mr Murray What is his prognosis? What will you do for him?
What are you going to discuss?
How will you do it?

30. Prognosis Gold classification of COPD ADO Index BODE index
O normal spirometry,
I Mild COPD
II Moderate
III Severe
IV Very Severe
ADO Index
BODE index

31. Prognosis- BODE Index
BMI, Airflow Obstruction, Dyspnoea, Exercise Capacity
BMI 19
FEV1 38% predicted
MMRC dyspnea scale
Too breathless to leave house
6 min walk < 149 m
Score % 4 year survival

32. Prognosis GOLD III –Severe ADO (age, dyspnea, FEV1) BODE
3 year mortality 47.2%
BODE
4 year mortality 75%

33. What will you do?

34. What are his goals of care?

35. Points to consider Discuss goals when patient is well if possible
Pre-discharge
In clinic
And document it
Discuss interventions which will be accepted and those which he does not want
Involve family
Advance directive

36. Complex Case
“Please see this 76 year old Eastern European in ED lady whose potassium is high (5.9)”
Gynae oncology consult
3 months ago- rectal cancer
Biopsied - adenocarcinoma
Declined operation
1 month ago vaginal bleeding
New gynae cancer (ovarian)
2 weeks ago DVT – is on warfarin

37. Complex Case Continued
Having radiotherapy to perineum to control bleeding
Felt “unwell” sent to ED
Had a brief cyanotic /apnoeic attack
(bagged and recovered)
Is tachycardic, breathless and in pain
She has vomited and it is blood streaked
Hb is 72 g/L
ECG new –RBBB
Abdo looks distended

38. What do you do next? She is “R1 goals of care” (for everything)
How far do you go?
Discuss

39. Issues Potassium Pain Abdomen Vomiting (hematemesis?) Anemia
Breathlessness
Goals of care
Patients values
Family

40. Liver Case 53 year old night club manager
Admitted to medical team yesterday
Jaundice, ascites and dehydration
Seen in liver clinic 6 months ago
told to stop drinking
Wife left 3 months ago
Hit the bottle even harder
Sister brought him to ED when he went yellow

41. Liver case continued
His bilirubin is 220, INR 1.8, WCC 12 albumin 28 His urine output is poor (Urea 10, Creat 140) He has tense ascites and is uncomfortable His creatinine is rising and he keeps trying to pull out his iv He is mildly encephalopathic The nurses have tied his hands to the bed His mother is on her way to the hospital His daughter, inVancouver, is 8 months pregnant Hepatology say he is not a candidate for transplantation

43. What are you going to do? What is his prognosis?
What do you need to do now?
Discuss

44. Prognosis
Severe alcoholic hepatitis can have a mortality of 50% at 30 days
1 year after an admission for alc. Hep
40% of patients are dead
Patients over 50 do worse than younger ones
Glasgow Alcoholic hepatitis score

45. Glasgow Alcohol Hepatitis score
Age over or under 50
White count < 15, >=15
Urea <5mmol/L>
INR <1.5, 1.5-2, >2
Bilirubin <125, , >250umol/L
Day 1 Score is 9
predicts Day 28 outcome as 46% survival and Day 84 as 40% survival
Day 7 score was 12
37% chance of survival at Day 84

46. Liver case – 4 weeks later
Bilirubin continues to rise (480 umol/L)
Creatinine is 420 umol/L
INR is 2.1
He is only intermittently lucid and often in pain
What can you do for him?

47. What to do? Prognosis Now what do you do?
MELD Score is 41; 3 month mortality is 90%
(MELD – Model for End Stage Liver disease)
If already dialysed (& even if creatinine lower) mortality is 100%
Glasgow score also poor
Now what do you do?

48. Palliative Care Team
Can be involved even if you are still hoping for recovery
Can help with symptoms, support family
Can educate us
May have more time to talk

49. Take home message
Think about goals of care in both acute and chronic diseases
Try to get a prognostic indicator
Give the patient a chance to have a conversation about the future
Involve the palliative care team sooner rather than later

50. And if you have been..
....thanks for listening.