2. Care for End Stage Cancer Patients
9/27/2014
Care for End Stage Cancer Patients
Dr. Peggy Lu 2

3. Determine the Level of Care
Curative Care
Palliative Care
Comfortable care

4. Health Care Worker Attitudes
We should be able to fix it or cure it
We must make people feels better
If a patient dies we fail
We have technology and drugs and there is always more we can do

5. What we need to learn We will die Life is finite
Not all technology works
How we want to die
We must face our own mortality so we can help others face theirs

6. Nearing the End of Life What’s going to happen to me?
Have I done everything I should have done?
What are my other options?
How much control will I have over my life and my death?
Will my wishes about my care be followed?
How much pain and suffering will I have?
What am I going to do about money?

7. “The Good End of Life” Preparation Clear decision-making
Pain and symptom relief
Contribution to others
Completion
Affirmation

8. Self-Determined Life Goals
-Who I am and what I am leaving behind
-What are my most important needs
-Where do I want to die
Assist the patient in meeting their end of life goals

9. The Elderly
-It is essential to ask elderly patients their wishes directly
-Medical personnel more often discuss these matters with surrogates or family members, neglecting to ascertain elderly patient’s opinions and therefore misunderstand patient's needs and wishes.

10. Why do you need an advance directive?
Your have a right to be informed and decided for yourself
Advance directives are for times you can’t speak for yourself.
Free loved ones from making difficult decisions

11. Choosing DNR/DNI They want quality of the life they have left
They want to avoid risks and harms of CPR
They accept their prognosis and death

12. When is Hospice Care Appropriate?
Life expectancy of 6 months of less
Curative care is no longer effective or desired
Goals are transitioned to comfortable and quality of life.

13. What can Hospice Care Provide?
Minimized suffering
Care is focused on pain and symptom management
Coordination of care: The patient and family are supported by physicians, nurses, hospice aides, social workers, volunteers
Spiritual Care
Respite Care
Bereavement Care

14. Communication, Control, Support
Honest communication
Allow as much control as possible
Maintain patient dignity
Address fear of unknown
Listen, listen, listen
Asses non-verbal cues
Empower love ones to provide support

15. Emotions as Patients Near the End of Life
Fear
Anger
Guilt and regret
Grief
Anxiety and depression
Feeling alone
Seeking meaning

16. Physical symptoms in the last 2-3 months of life
Fatigue/weakness
Pain
Appetite changes
Problems breathing

17. Physical symptoms in the last 2-3 months of life
Nausea/vomiting
Bowel obstruction
Bowel/bladder incontinence
Diarrhea or constipation
Delirium/agitation/confusion
Drowsiness and sleeping

18. Important Pain Management Concepts
Medications are given according to physician’s orders and do not hasten the end of life
Assess/reassess the duration and effectiveness of pain management
Assess non-verbal patients
Correct medications make the dying process more comfortable
Always believe the patient’s report of pain.

19. Types of pain medications
Long-acting time released forms
Short-acting forms
Patch
Lozenges
Liquid
Rectal suppositories
Pain medicine pump

20. Appetite Changes
Happens to more than 8/10 of end stage cancer patients
It is normal in the last months of life for parts of body to start slowing down and eventually shut down.
Avoid family food battles

21. Problem Breathing Even thinking about breathing problem can be scary
Patient may feel SOB or need breathe faster and harder than normal.
Most often, severe symptom happens while the patient is unconscious and not aware.
Things that can be done: Position, Oxygen, Decongestion, Medicines to reduce anxiety, Opioids

22. What Caregivers Can Do? Help patient turn and change position
Try ice chips or sips of liquid if the patient is having trouble swallowing.
Do not push fluids. Near the end of life, some dehydration is normal and also more comfortable for the patient.
Pad the bed beneath the patient with layers of disposable waterproof pads.

23. What Caregivers Can Do?
If patient is very restless, try to find out if they are having pain and give breakthrough pain medications if needed
Gentle touching, caressing holding and rocking are usually helpful and comforting.
Always assume the patient can hear you and continue to speak with and touch the patient to reassure them of your presence.

24. Saying the Four Things Please forgive me I forgive you Thank you
I love you
The 5th: Good bye

25. Signs that death has occurred
Breathing stops
Blood pressure can not be heard
Purse stops
Eyes stop moving and may stay open
Pupils of the eyes stay large even in bright light
Control of bowels or bladder may be lost as the muscles relax.

26. Life is pleasant.
Death is peaceful.
It is the transition that is troublesome.
Isaac Asimov ( )

27. Good Life and Good Death