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Palliative Care Overview And Concepts Mike Harlos MD, CCFP, FCFP Professor and Section Head, Palliative Medicine, University of Manitoba Medical Director,

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Presentation on theme: "Palliative Care Overview And Concepts Mike Harlos MD, CCFP, FCFP Professor and Section Head, Palliative Medicine, University of Manitoba Medical Director,"— Presentation transcript:

1 Palliative Care Overview And Concepts Mike Harlos MD, CCFP, FCFP Professor and Section Head, Palliative Medicine, University of Manitoba Medical Director, WRHA Palliative Care Medical Director, Pediatric Symptom Management Service

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3 What Is Palliative Care? Surprisingly difficult to define Not defined by: –Body system (compare with dermatology, cardiology) –What is done (compare with anesthesiology, surgery) –Age (compare with pediatrics, geriatrics) –Location of Care (compare with ER, critical care) Any illness, any age, any location…

4 What Is Palliative Care? Palliative Care is an approach to care which focuses on comfort and quality of life for those affected by life-limiting/life-threatening illness. Its goal is much more than comfort in dying; palliative care is about living, through meticulous attention to control of pain and other symptoms, supporting emotional, spiritual, and cultural needs, and maximizing functional status. The spectrum of investigations and interventions consistent with a palliative approach is guided by the goals of patient and family, and by accepted standards of health care. (a personal definition)

5 Thank you for giving me aliveness Jonathan – 6 yr old boy terminally ill boy Ref: Armfuls of Time; Barbara Sourkes

6 What if…? What would things look like? Time frame? Where care might take place What should the patient/family expect (perhaps demand?) regarding care? How might the palliative care team help patient, family, health care team? What would things look like? Time frame? Where care might take place What should the patient/family expect (perhaps demand?) regarding care? How might the palliative care team help patient, family, health care team? Palliative Care… The What If…? Tour Guides Can Help Inform The Choice Of Not Intervening Disease-focused Care (Aggressive Care) Disease-focused Care (Aggressive Care)

7 Today Dawn of Time Lifetime Risk of Dying (%) A SOBERING TRENDLINE Timeline

8 Heart disease:1:2 men; 1:3 women (age 40+) Cancer: > 1:3 Alzheimer's:1:2.5 – 1:5 by age 85 Diabetes:1:5 Parkinsons1:40 Lifetime Risk of: Death: 1:1 Palliative Care – Relevance In Context

9 Dont confuse Palliative Care – the philosophy of approach to care in the context of life-limiting illness with Palliative Care service delivery…. the latter is the application of the broad philosophy within the constraints of existing (limited) resources Services are focused on the most needy, which tends to be in the final months of life

10 Program Criteria Available Services

11 Cure/Life-prolonging Intent Palliative/ Comfort Intent Bereavement DEATHDEATH Active Treatment Palliative Care DEATHDEATH EVOLVING MODEL OF PALLIATIVE CARE

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13 Societal acknowledgement of CA as a terminal illness More definable palliative phase in CA than non- malignant illness Maximizing quality of life in non-cancer illnesses often requires expertise in that specific disease, with aggressive disease-focused interventions (CHF, COPD) Budget constraints on may preclude aggressive disease-focused management of illness. Over-representation of cancer diagnosis, due to:

14 Withdrawal of life-sustaining therapy Inoperable surgical conditions Ischemic gut Gangrenous limbs Dissecting aortic aneurysm Massive stroke Trauma Palliative Care services should be challenged to broaden their involvement to address the needs of those affected by sudden, unanticipated end- of-life circumstances:

15 How To Raise The Bar Of Expectations On Such a Fundamentally Sad Issue?

16 Low Expectations… how can you have high expectations for death?Expect – if not demand… High level of skill and knowledge in pain and symptom control Consultations if necessary Communication with patient and/or family Clear, honest, respectful Proactive/preemptive when issues predictable Availability and Accessibility Dignity – connection to the who involved; the person

17 Compare With Other Interfaces With Health Care Surgery –Informed consent –Teaching videos –Booklets Obstetrics –Prenatal classes –Birth Plan What About A Death Plan… with broader expectations than the usual clinical issues in a Health Care Directive?

18 SYMPTOMS IN ADVANCED CANCER Ref: Bruera 1992 Why Do We Care? Conference; Memorial Sloan-Kettering

19 Symptoms At The End of Life in Children With Cancer Wolfe J. et al, NEJM 2000; 342(5) p % Pain Dyspnea Nausea And Vomiting Successfully Treated (% Of Affected Children) 27 % 16 % 10 %

20 SUFFERING EMOTIONAL PSYCHOSOCIAL PHYSICAL SPIRITUAL

21 CHALLENGE- Alleviate Suffering for a Condition Which: Ultimately will affect every one of us: - Large numbers - We have our own death issues as care providers Only approximately 10% of Canadians have access to specialty care Few physicians or nurses have even basic training Clinicians dont intuitively know when they need advice… They dont know what they dont know The process & outcome are expected to be terrible… after all, it is death How can you tell when something inherently horrible goes badly? Has a tremendous impact on those close to the individual… collateral suffering No chance of feedback from patient after the fact

22 1.Adequate knowledge base 2.Attitude / Behaviour / Philosophy Active, aggressive management of suffering Team approach Recognizing death as a natural closure of life Broadening your concept of successful care Effective care of the dying involves:

23 Potential Palliative Conditions The Usual Suspects – progressive life-limiting illness –Incurable cancer –Progressive, advanced organ failure (heart, lung, kidney, liver) –Advanced neurodegenerative illness (ALS, Alzheimers Disease) Sudden fatal medical condition –Acute stroke –Withholding or withdrawing life-sustaining interventions (ventilation, dialysis, pressors, food/fluids…) –Trauma – eg. head injury –Ischemic limbs, gut –Post-cardiac arrest ischemic encephalopathy –etc…

24 Potential Palliative Care Interventions Control of Pain Dyspnea Nausea Vomiting Support Emotional Spiritual Psychosocial CPR Ventilation Highly burdensome Interventions Infections Transfusions Hypercalcemia Dialysis Tube Feeding Palliative Generally Not Palliative Variable

25 Potential Palliative Care Settings Anywhere

26 Improving Palliative Care Core competencies Curriculum in undergrad and post- grad in all involved disciplines Continuing education Education Professional Practice Stds of practice for symptom management, availability, responsiveness, communication Certain palliative interventions held to higher scrutiny and rigour – eg. palliative sedation Specialty area for nursing Public Awareness Raise awareness and expectations Improve death culture Empower in decision-making Service Availability Core requirements for facility and program accreditation (CCHSA) Risk management people need to see poor palliative care as a risk Re-frame good palliative care as prevention/promotion


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