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

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

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

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 LIFE-LIMITING ILLNESSES

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

COST

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

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;

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

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

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

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

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

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!

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

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

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

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”

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

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