1. Palliative Care St William’s Parish Pat Treston Pat Treston 20 th September 2006 20 th September 2006

2. To cure, occasionally To relieve, often To comfort, always.

3. Definition of Palliative Care “Palliative Care provides for all the medical and nursing needs of the patient for whom cure is not possible, and for all the psychological, social and spiritual needs of the patient and the family, for the duration of the patients illness, including bereavement care”“Palliative Care provides for all the medical and nursing needs of the patient for whom cure is not possible, and for all the psychological, social and spiritual needs of the patient and the family, for the duration of the patients illness, including bereavement care”

4. Palliative CarePalliative Care Hospice CareHospice Care Terminal CareTerminal Care

5. Quality of Life Hopes, Dreams, Aspirations Day to day reality

6. The causes of suffering Pain Physical symptoms Psychological Social Cultural Spiritual

7. TOTAL SUFFERING Physical symptoms Psychological Social Cultural Spiritual Pain Total Suffering

8. Pain Physical symptoms Psychological Social Cultural Spiritual Interdependence of various causes of suffering

9. Pain Physical symptoms Psychological Social Cultural Spiritual Interdependence of various causes of suffering

10. Multidisciplinary Team MedicalMedical Nursing – CNC. Registered Nurses, ENs, AINsNursing – CNC. Registered Nurses, ENs, AINs PhysiotherapistPhysiotherapist Occupational therapist/DieticianOccupational therapist/Dietician Counsellors/psychologistsCounsellors/psychologists Bereavement counsellors – adult, childrenBereavement counsellors – adult, children Pastoral care workersPastoral care workers VolunteersVolunteers

12. Goals of Palliative Care To relieve and prevent suffering:To relieve and prevent suffering: by controlling pain and other physical symptoms by controlling pain and other physical symptoms by addressing psycho- spiritual distress by addressing psycho- spiritual distress by recognizing role of cultural factors by recognizing role of cultural factors To involve people important to the patientTo involve people important to the patient To promote a degree of acceptance by the patient and familyTo promote a degree of acceptance by the patient and family To provide a process of care that guides the patient’s understanding and decision makingTo provide a process of care that guides the patient’s understanding and decision making To achieve a peaceful deathTo achieve a peaceful death To provide bereavement support for families/loved ones.To provide bereavement support for families/loved ones.

13. Characteristics of Palliative Care Patient centredPatient centred Family CentredFamily Centred ComprehensiveComprehensive ContinuousContinuous Co-ordinatedCo-ordinated TeamworkTeamwork Regular reviewRegular review

14. Pain Management Relief and prevention: Thorough assessmentThorough assessment Explanation, education Explanation, education Reassurance Reassurance Treatment appropriate to stage of diseaseTreatment appropriate to stage of disease Radiotherapy / ChemotherapyRadiotherapy / Chemotherapy

15. Principles of Using Analgesics Use of appropriate drug for type of painUse of appropriate drug for type of pain Use of appropriate drug for severity of painUse of appropriate drug for severity of pain Combinations of drugsCombinations of drugs Use of adjuvant analgesicsUse of adjuvant analgesics Adequate dosageAdequate dosage Dose titrated for each individual patientDose titrated for each individual patient Time dosage according to duration of action of drugTime dosage according to duration of action of drug

16. Principles of Using Analgesics Strict scheduling to prevent pain, not just when it occursStrict scheduling to prevent pain, not just when it occurs Provision of breakthrough medicationProvision of breakthrough medication Written instructions on medication useWritten instructions on medication use Anticipation and treatment of side effectsAnticipation and treatment of side effects Keep regime as simple as possibleKeep regime as simple as possible Use of oral route where possibleUse of oral route where possible

17. Opioids Morphine – slow release, rapidly acting. p.o/s.cMorphine – slow release, rapidly acting. p.o/s.c Oxycodone – SR, rapidly actingOxycodone – SR, rapidly acting Hydromorphone – injection, liquidHydromorphone – injection, liquid Fentanyl – Patches, injectionFentanyl – Patches, injection Methadone - tabletsMethadone - tablets

19. Facts v. Myths about Morphine It is not addictiveIt is not addictive Does not mean death is closeDoes not mean death is close Will not hasten deathWill not hasten death Individual doses vary widelyIndividual doses vary widely No maximal doseNo maximal dose Not everyone needs to take itNot everyone needs to take it

21. Case Study Jim Smith, 65 years old Jim Smith, 65 years old Married to Mary, 2 sons John & Peter in Brisbane, daughter Susan in Melb. Married to Mary, 2 sons John & Peter in Brisbane, daughter Susan in Melb. (all married with young children) (all married with young children) Persistent cough in January 2005 Persistent cough in January 2005 Dx : Large cancer R lung Dx : Large cancer R lung Treated with radiotherapy to control size of tumour – not curative Treated with radiotherapy to control size of tumour – not curative No spread elsewhere, esp. brain No spread elsewhere, esp. brain

22. Case Study June 2005 – chest wall pain and increasing breathlessness, esp. on exertion.June 2005 – chest wall pain and increasing breathlessness, esp. on exertion. Referred to Mt Olivet Home Care ServiceReferred to Mt Olivet Home Care Service 7/7/2005 Commenced on SR Morphine with extra Morphine mixture, bowel medication, equipment arranged, domiciliary nurses.7/7/2005 Commenced on SR Morphine with extra Morphine mixture, bowel medication, equipment arranged, domiciliary nurses. 3 weeks later, distressing productive cough, fever, increased pain, more breathless.3 weeks later, distressing productive cough, fever, increased pain, more breathless. Probable chest infectionProbable chest infection

23. Case Study 1/8/2005 Admitted to Palliative Care Unit “I don’t want any treatment. I want to die”“I don’t want any treatment. I want to die” Reasons explored –Reasons explored – Tired of feeling unwell, debilitated Tired of feeling unwell, debilitated Demoralised by pain and breathlessness Demoralised by pain and breathlessness Not clinically depressed Not clinically depressed Enjoyed visits from work mates, grandchildren, watching sport on TV. Enjoyed visits from work mates, grandchildren, watching sport on TV.

24. Case Study Informed of pros and cons of antibioticsInformed of pros and cons of antibiotics Goals of treatmentGoals of treatment Commenced on antibioticsCommenced on antibiotics Morphine dose increasedMorphine dose increased OxygenOxygen Nebulised salineNebulised saline PhysiotherapyPhysiotherapy → good symptomatic improvement. → good symptomatic improvement.

25. Case Study Family meeting – decision → home with extra supports, home oxygen.Family meeting – decision → home with extra supports, home oxygen. Pain well controlled, mobilising short distances, using extra morphine for breathlessness on exertion.Pain well controlled, mobilising short distances, using extra morphine for breathlessness on exertion. Mood reactive, accepting, dealing with practicalities – will, EPOA, Advanced Health Directive.Mood reactive, accepting, dealing with practicalities – will, EPOA, Advanced Health Directive. 12/8/2005 Discharged home12/8/2005 Discharged home

26. Case Study Condition reasonably stable for next 2 weeksCondition reasonably stable for next 2 weeks Relatively sudden onset of confusional state :Relatively sudden onset of confusional state : no sleep for 2 nights, restless, disorientated, refusing oxygen, not eating. no sleep for 2 nights, restless, disorientated, refusing oxygen, not eating. 26/8/2005 Readmitted PCU - delirium26/8/2005 Readmitted PCU - delirium Many potential causes – medication, infection, spread to brain, low oxygen levelsMany potential causes – medication, infection, spread to brain, low oxygen levels Investigations – ?reversible causeInvestigations – ?reversible cause

27. Case Study Found to have high calcium levelFound to have high calcium level ? Competent to make decision about treatment? Competent to make decision about treatment Discussed with family :Discussed with family : Best symptomatic treatment if effective, potentially life prolonging (AHD) Best symptomatic treatment if effective, potentially life prolonging (AHD) Treatment not administeredTreatment not administered Managed with haloperidol (anti psychotic) and other medications as requiredManaged with haloperidol (anti psychotic) and other medications as required

28. Case Study 28/8/2005 Condition deteriorating, physically weaker, pain apparently controlled, breathless at rest, still refusing to keep oxygen on, sleep disturbance, increasing confusion/disorientation, suspicious, irritable, unable to have lucid conversation with family.28/8/2005 Condition deteriorating, physically weaker, pain apparently controlled, breathless at rest, still refusing to keep oxygen on, sleep disturbance, increasing confusion/disorientation, suspicious, irritable, unable to have lucid conversation with family. Family distressed +++Family distressed +++ 2 days later, found wandering in the corridor, breathless and unsteady, abusive, angry, physically aggressive, lashing out at staff, overtly paranoid and fearful – telling visitors he was going to be killed.2 days later, found wandering in the corridor, breathless and unsteady, abusive, angry, physically aggressive, lashing out at staff, overtly paranoid and fearful – telling visitors he was going to be killed. Danger to himself and othersDanger to himself and others

29. Case Study Discussion with family - probable terminal restlessness, irreversible, portent of approaching death.Discussion with family - probable terminal restlessness, irreversible, portent of approaching death. Joint decision made to sedate patientJoint decision made to sedate patient Commenced on larger doses of antipsychotic medication, sedative agents and analgesics in syringe driver.Commenced on larger doses of antipsychotic medication, sedative agents and analgesics in syringe driver. Remained drowsy with some periods of awareness, ? recognised family members.Remained drowsy with some periods of awareness, ? recognised family members.

30. Case Study Over next few days appeared to be pain free, oxygen continuedOver next few days appeared to be pain free, oxygen continued Minimal oral intake, sips of water when awake.Minimal oral intake, sips of water when awake. Daughter arrived from Melbourne – very distraught at deterioration in father’s condition.Daughter arrived from Melbourne – very distraught at deterioration in father’s condition. Accused staff of allowing him to die of starvation and dehydration.Accused staff of allowing him to die of starvation and dehydration. Explanation / reassurance.Explanation / reassurance. Mouth CareMouth Care

31. Case Study Medications continued, given extra analgesia prior to bathing/ moving as appeared to grimace and moan.Medications continued, given extra analgesia prior to bathing/ moving as appeared to grimace and moan. Medication for terminal secretionsMedication for terminal secretions 5 days after commencing sedation died peacefully with family at the bedside. 5 days after commencing sedation died peacefully with family at the bedside.

32. “ Death should simply become a discrete, but dignified exit of a peaceful person from a helpful society without pain or suffering and ultimately without fear” Phillipe Aires

33. “ You matter because you are you. You matter to the last moment of your life and we will do all we can to help you- Not only to die peacefully, But to live until you die” Cecily Saunders