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 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.
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 ACCESSING SPECIALIST 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
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