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

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?
(a personal definition)
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.

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

6. Palliative Care… The “What If…?” Tour Guides
Can Help Inform The Choice Of Not Intervening
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 if…?
Disease-focused Care
(“Aggressive Care”)

7. Lifetime Risk of Dying (%)
A SOBERING TRENDLINE
100 50
Lifetime Risk of Dying (%)
Dawn of Time
Timeline
Today

8. Palliative Care – Relevance In Context
Lifetime Risk of:
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
Parkinson’s 1:40
1:1
Death:

9. Don’t 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. Palliative Care As A Philosophy Of Care
Program
Available
Services
Criteria

11. “Active Treatment” Palliative Care Palliative/ Comfort Intent
EVOLVING MODEL OF PALLIATIVE CARE D E A T H
“Active
Treatment”
Palliative
Care
Cure/Life-prolonging
Intent D E A T H
Palliative/
Comfort Intent
Bereavement

13. Over-representation of cancer diagnosis, due to:
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.

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

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

16. 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
Low Expectations… how can you
have high expectations for death?

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 80 70 % 60 50 40 30 20
Successfully
Treated
(% Of Affected
Children) 10
27 %
16 %
10 %
Pain
Dyspnea
Nausea And Vomiting

20. PHYSICAL
PSYCHOSOCIAL
SUFFERING
EMOTIONAL
SPIRITUAL

21. Alleviate Suffering for a Condition Which:
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 don’t intuitively know when they need advice… They don’t know what they don’t 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. Effective care of the dying involves:
Adequate knowledge base
Attitude / Behaviour / Philosophy
Active, aggressive management of suffering
Team approach
Recognizing death as a natural closure of life
Broadening your concept of “successful” care

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, Alzheimer’s 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
Generally
Not Palliative
Palliative
Variable
Support
CPR
Emotional
Spiritual
Psychosocial
Ventilation
Transfusions
Infections
Highly
burdensome
Interventions
Control of
Hypercalcemia
Pain
Dyspnea
Nausea
Vomiting
Tube Feeding
Dialysis

25. Potential Palliative Care Settings
Anywhere

26. Improving Palliative Care
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
Core competencies
Curriculum in undergrad and post-grad in all involved disciplines
Continuing education
Education
Improving Palliative Care
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