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END-OF-LIFE CARE HEART FAILURE and COPD Dr Sally Reeder Specialty Doctor in Palliative Medicine
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LIFE-LIMITING ILLNESS
Symptoms Patient and carer needs Psychological support Spiritual needs Social isolation Carer support Quality of Life
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PARALLEL SYMPTOMS Lethargy Decreased mobility Pain Dyspnoea Anorexia
Nausea Depression Anxiety Decreased QOL
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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
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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
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ILLNESS TRAJECTORIES 3 typical illness trajectories
-Steady progression eg: cancer -Gradual decline eg: HF / COPD -Prolonged gradual decline eg: dementia / old age
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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.
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LIFE-LIMITING ILLNESSES
PALLIATIVE MEDICINE LIFE-LIMITING ILLNESSES
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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?
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SHOULD THE PALLIATIVE CARE TEAM BECOME INVOLVED,
AND WHEN? Hospital-based Palliative Specialists Hospice out-patient clinics Day Hospice attendance Hospice admission
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BARRIERS to ACCESSING SPECIALIST PALLIATIVE CARE SERVICES
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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
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From Specialist Palliative care
Floodgates will open / patient load Stretch charitable funding ? Skills to manage these patients Chronically ill - ? Exacerbation ? Block beds
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From Patients I don’t have cancer I’m not dying Distressing
Lack of understanding – their disease palliative care
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COST
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HEART FAILURE / COPD ?
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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
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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
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MEDICATIONS Statins – stop Aspirin / Clopidogrel – stop
ACE Inhibitors – reduce if renal dysfunction Loop diuretics Spironolactone B Blockers Digoxin – stop, unless in AF
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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;
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PAIN in HEART FAILURE Angina; - ct anti-anginal medication as long as possible musculoskeletal; arthritis; Gout WHO analgesic ladder Avoid NSAIDs Amitriptyline
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NAUSEA Consider cause Medication – opioids; digoxin toxicity; spironolactone constipation; renal failure anxiety Avoid Cyclizine – strong anticholinergic effects Metoclopramide Levomepromazine Haloperidol Syringe driver
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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
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TERMINAL STAGE Not tolerating oral medication Syringe driver
Analgesics Antiemetics Anxiolytics Diuretic Liverpool Care Pathway LCP
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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
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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!
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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
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MANAGEMENT Bronchodilators Anticholinergics Oxygen Anxiolytics Opioids
Coping strategies purse-lip breathing; slow expiration; lean forward Pyschological support – end-of–life planning
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GOING FOR GOLD Equitable end-of-life care
ALL appropriate patients on palliative register Avoid un-necessary hospital admissions Advanced care planning Patient choice
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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”
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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
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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
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