Presentation on theme: "End of life/Palliative care issues in Internal Medicine"— Presentation transcript:
1End of life/Palliative care issues in Internal Medicine Dr Lynn Alison LambertB.Sc. PhD, MB ChB, FRCP (Lond) DTM&HInternal Medicine, University of CalgaryEnd of life/Palliative care issues in Internal Medicine
2DisclosuresI have a vested interest in good end of life care – one day I will die too.No sponsorship or financial links with any drug companyMost of the information in this workshop is from:The Oxford Textbook of Palliative Medicine, 4th Edition 2010Hanks, G., Cherry, N., Christakis, N., ,Fallon, M., Kaasa, S., Portenoy, R. (Eds)Palliative Medicine, A Case Based Manual , 3rd edition 2012Doreen 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
3As Bob Dylan once said: “He who isn’t busy being born is busy dying”
4What 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, EnglandFrom 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.
5Palliative medicineIs holistic care, taking into account a patients cultural, spiritual and individual needsRespects a patients wishesEven if they are not what we would chooseInforms a patient of what can be doneTreatment options – pros and consCommunicates prognosis accuratelyCommunicates with the family/friends(provided the patient gives permission)
6History Dame Ciceley Saunders Nurse, social worker, doctor Founded St Christopher’s Hospice in London, 1967Wrote reports of a series of cases of terminally ill patients , 1100 by 1967Realised that in terminal care there may bePhysical needs, emotional distress, social issues (housing, finance, family)Championed pain management – regular not prnBattled current ideas/fears re opiate addiction
7History 2 1973- 1st International Symposium on Pain control 1976 1st International Congress on the Care of the Terminally Ill – Montreal1987 Palliative Medicine recognised as a specialty in UK2006 ACGME and ABMS in US approved a new specialty in hospice and palliative medicine.
8Top 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 2020IHD,Cerebrovascular diseaseCOPDRespiratory infectionLung CancerSo palliative medicine in non- malignant disease is important
9Why internists need to be good at palliative care Whole patient management/ whole person medicineCare of Elderly with multiple problemsNot enough hospice placesPalliative medicine in non-malignant diseaseEspecially COPD and heart failureDrug interactionsCare of younger patients with complex diseases
10Is 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.
11Palliative care for the General Medical patient Generally discussion is left too lateOften 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 relativesTo avoid this we need to engage with our patients in advance care planning
12Signposts in Palliative Care How to recognise that the time has come for some end-of-life / goals of care discussionThe 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.
13Communication at the end of life What are the barriers?
14Communication at the end of life What are the barriers?What can we do as clinicians?
15Communication at the end of life What are the barriers?What can we do as clinicians?How can we do better?
16Canadian Pallium project Communication resource with clinical scenariosAllow us to observe examples of good communication skillsAccess via You Tube
17Palliative MedicineShould be what we do every day as part of usual care in Internal MedicineIs it?
18Having 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” initiativeBooklet, videosFamily MeetingUseful to get everyone “on the same page”
19Goals Of Care – Calgary Region R Resuscitative CareM Medical Care (excluding resuscitative care)C Comfort CareMore flexible than DNR versus no DNR
20Rules 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 anxietiesBe realistic (but not dogmatic) about the prognosisWith yourselfWith the patientFind OutWhat the patient wantsAccept that:referral to a palliative care specialist does not mean that you have given up on the patient
21When to involve the palliative care team Sooner rather than laterFor symptom control when you are unsure what to doTo aid access to community services and hospiceWhen you recognise that you don’t have time to do it properly yourselfAs a learning resource(a phone call may be enough)
22End 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)
23Liverpool Care Pathway - used when patient has hours or days left to live Useful in hospital or at homeDocuments discussions with relativesNotes an advance directive (if done)AssessesPain, nausea, vomiting, agitation, breathlessness, skin condition, constipationAnticipates need for drugs for:Pain, agitation, respiratory secretions, nausea vomiting, dyspnoea,
24Liverpool Care Pathway Has a section for discontinuation of routine:blood tests, glucose monitoring, vital signs, oxygen, iv antibioticsDocumentspatients wishes re care after deathE.g. who washes body, need for burial within 24hoursDiscussions with relatives and information givenInformation leaflets, death certificate, post mortem request
25Patients at the end of life- Cases Elderly personCancer patientHeart FailureRenal FailureLiver diseaseComplex case
26Palliative care for the elderly patient Holistic careLooks at social, Personal and spiritual issuesRemoval of unnecessary treatmentsDiscussion of Goals of Care for the futureSometimes operative treatment is the best palliation – e.g. repair of fractured NOF
28Patient with COPDMr Murray is a 74 year old retired oil worker, ex smoker, is on his fourth admission to hospital this year with COPDLast time he went to ICU and was ventilated for 2 weeksHe hasn’t left the house sinceHe has home oxygen and a nebuliserHe is readmitted with breathlessness, wheeze and cachexia
29Mr Murray What is his prognosis? What will you do for him? What are you going to discuss?How will you do it?
30Prognosis Gold classification of COPD ADO Index BODE index O normal spirometry,I Mild COPDII ModerateIII SevereIV Very SevereADO IndexBODE index
31Prognosis- BODE IndexBMI, Airflow Obstruction, Dyspnoea, Exercise CapacityBMI 19FEV1 38% predictedMMRC dyspnea scaleToo breathless to leave house6 min walk < 149 mScore % 4 year survival
32Prognosis GOLD III –Severe ADO (age, dyspnea, FEV1) BODE 3 year mortality 47.2%BODE4 year mortality 75%
35Points to consider Discuss goals when patient is well if possible Pre-dischargeIn clinicAnd document itDiscuss interventions which will be accepted and those which he does not wantInvolve familyAdvance directive
36Complex Case“Please see this 76 year old Eastern European in ED lady whose potassium is high (5.9)”Gynae oncology consult3 months ago- rectal cancerBiopsied - adenocarcinomaDeclined operation1 month ago vaginal bleedingNew gynae cancer (ovarian)2 weeks ago DVT – is on warfarin
37Complex Case Continued Having radiotherapy to perineum to control bleedingFelt “unwell” sent to EDHad a brief cyanotic /apnoeic attack(bagged and recovered)Is tachycardic, breathless and in painShe has vomited and it is blood streakedHb is 72 g/LECG new –RBBBAbdo looks distended
38What do you do next? She is “R1 goals of care” (for everything) How far do you go?Discuss
40Liver Case 53 year old night club manager Admitted to medical team yesterdayJaundice, ascites and dehydrationSeen in liver clinic 6 months agotold to stop drinkingWife left 3 months agoHit the bottle even harderSister brought him to ED when he went yellow
41Liver case continuedHis 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
43What are you going to do? What is his prognosis? What do you need to do now?Discuss
44PrognosisSevere alcoholic hepatitis can have a mortality of 50% at 30 days1 year after an admission for alc. Hep40% of patients are deadPatients over 50 do worse than younger onesGlasgow Alcoholic hepatitis score
45Glasgow Alcohol Hepatitis score Age over or under 50White count < 15, >=15Urea <5mmol/L>INR <1.5, 1.5-2, >2Bilirubin <125, , >250umol/LDay 1 Score is 9predicts Day 28 outcome as 46% survival and Day 84 as 40% survivalDay 7 score was 1237% chance of survival at Day 84
46Liver case – 4 weeks later Bilirubin continues to rise (480 umol/L)Creatinine is 420 umol/LINR is 2.1He is only intermittently lucid and often in painWhat can you do for him?
47What 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 poorNow what do you do?
48Palliative Care TeamCan be involved even if you are still hoping for recoveryCan help with symptoms, support familyCan educate usMay have more time to talk
49Take home messageThink about goals of care in both acute and chronic diseasesTry to get a prognostic indicatorGive the patient a chance to have a conversation about the futureInvolve the palliative care team sooner rather than later