End of life care

end of life care contain both hospice care and palliative care. 10-20% of the ICU.

1. End of life care Presented by Pankaj Nurse Practitioner 2 nd yr Moderator Dr. sushant Khanduri Associate professor

2. END OF LIFE CARE Palliative Care Making life as easy as possible for patients and families living with serious illness Hospice care hospice care is given when there is life expectancy of 6 month or less

3. End of Life in the ICU 10-20% of all ICU patients die Often illnesses are unanticipated – little previous discussion of illness with family Prognostication variable Culture of aggressive treatment Patients not generally able to participate

4. Five Most Common Symptoms Pain Nausea/vomiting Breathlessness Weight loss Weakness / fatigue

5. Basics of Pain Management Use a pain scale WHO pain ladder Use standing doses, not PRN Always have a breakthrough pain plan 10% of daily opioid dose q 1-2 h Reassess dosage needs daily

6. Assessment of Pain PQRST P = Provoking/Palliating factors Q = Quality in patient’s own words R = Radiates S = Severity T = Time Recommended instruments: • McGill Pain Questionnaire (MPQ) and its short form (SF-MPQ)

7. WHO 3-step Ladder 1 mild (1-3) 2 moderate (4-6) 3 severe (7-10) Morphine H y dro m orp h one Methadone Levorphanol Fentanyl Oxycodone ± Adjuvants A/Codeine A/Hydrocodone A/Oxycodone A / D ih y drocodeine Tramadol ± Adjuvants ASA Acetam i nophen NSAIDs ± Adjuvants

8. Neuropathic Pain Tricyclic Antidepressants (1 in 3 pts respond) Desipramine , other TCA’s, venlafaxine Use limited by CV adverse effects Gabapentin / Pregabalin (1 in 4 patients respond) usual effective dose 900–1800 mg / d; max may be > 3600 mg / d minimal adverse effects drowsiness, tolerance develops within days Systemic administration of local anesthetics Lidocaine or mexiletine effective in 30 RCT’s Combination may be the most effective Brunnhuber , K., Nash, S., Meier, D.E., et al (2008

9. Bone pain Metastasis to bone 70% of pt with prostate, breast CA 30% of pt with thyroid, lung, bladder CA Multidisciplinary approach, including: Analgesics: opioids , NSAIDs Disease modifying therapy (chemotherapy, hormone therapy) Corticosteroids Bisphosphonates Radiopharmaceuticals (strontium, samarium) External beam radiation Orthopedic intervention External bracing

10. Depression Loss of social position, job, prestige, income Loss of role in family Insomnia, chronic fatigue Sense of helplessness Disfigurement Anger Bureaucratic bungling Delays in diagnosis unavailable physicians uncommunicative physicians Failure of therapy Friends who do not visit T o t al Pain Anxiety Fear of hospital or nursing home Fear of pain Worry about family and finances Fear of death Spiritual unrest, uncertainty about future Physical pain Other symptoms Adverse effects of treatment O'Neill, B., Fallon, M. BMJ 1997, 315p. 801-80

11. Nausea/ V omiting Patients with cancer 13-17% of terminally ill cancer patients in the last 1-2 weeks of life 6-68% of all patients with cancer Patients with other illnesses: AIDS: 43% to 49% of patients Heart disease: 17% to 48% of patients Renal disease: 30% to 43% of patients Assessment: simple visual analogue scales or numerical rating scales

12. C a use Drug Examples V – Vestibular C h o l i n er g ic Histaminic Anticholinergic Antihistaminic Scopolamine Pr o m e th a zi n e Diphen- hydramine O – Obstructive C h o l i n er g ic Histaminic 5HT3 Drugs stimulating the myenteric plexus Senna products M- Motile (dysmotility of upper gut) C h o l i n er g ic Histaminic 5HT3 Prokinetics (stimulating 5HT4 receptors) Prokinetics, metoclo- pramide I – infectious/inflam- mat o ry C h o l i n er g ic Histaminic 5HT3 Neurokinin 1 Anticholinergic Antihistaminic 5HT3 antagonists Neurokinin 1 ant. Anti-inflammatory Scopolamine Promethazine D i p h e n h y dr a m i ne Odansetron Apprepitant Corticosteroids Brunnhuber, K., Nash, S., Meier, D.E., et al (2008) See handout for doses, cost Treat anxiety if present Management of nausea and vomiting

13. DYSPNEA Prevalence 17-30% of patients living with cancer 90-95% of end-stage COPD patients 60-88% of end-stage heart disease patients Increasingly common as the end of life approaches Best assessment is patient report

14. Recent ACP guidelines show evidence supports treatment with: Oxygen for hypoxemia Strong evidence for COPD & exercise Opioids Theoretical effect of respiratory depression not supported by the literature Beta-agonists for dyspnea from COPD Qaseem, A, Snow, V., Shekelle, P, et al. Ann Intern Med. 2008;148:141-146

15. Fatigue Approximately 40% of cancer patients experience fatigue at the time of diagnosis Worse during or after chemotherapy Higher than 75% in patients with advanced cancer Common with COPD, heart failure Multifactorial Best evaluated by self-assessment measures No gold standard measurement available

16. Management of Fatigue Evidence supports use of: Psychological, psychoeducational interventions (small) Methylphenidate – small, significant improvement Exercise - small improvement Energy conservation, activity management - small but significant effect No effect: progestational steroids, paroxetine , or multivitamins. Insufficient data to recommend any specific complementary therapies Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)

17. Promote energy conservation Evaluate medications Optimize fluid, electrolyte intake Permission to rest Clarify role of underlying illness Educate, support patient, family Include other disciplines

18. Dexamethasone 4mg PO once daily feeling of well-being, increased energy effect may wane after 4-6 weeks continue until death Methylphenidate 5mg PO q 8AM and q noon May increase up to 20mg daily Do not give after 2pm to avoid interfering with sleep

19. Anorexia/ Cachexia Prevalence: 70% of patients with advanced cancer Best assessment is patient report Treatments: Corticosteroids Orally consumed supplements Parenteral nutrition Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)

20. NUTRITION High calorie diet High protein diet If patient cannot take orally. Try enteral feeding( BEST FEEDING ) And lastly parenteral nutrition

21. Management Family education is key Tailor diet to patient preferences Fresh fruit Melon, grapes Things that are cold and sweet Ice cream Lemon drops, zinc lozenges for bad taste in mouth Most patients do not want dairy, fried foods Manage grief, disappointment about change in diet Encourage socializing at meal times even if patient does not want to eat

22. Depression Recent ACP Guidelines: Physicians should screen for and treat depression in patients facing end-of-life Evidence supports use of TCA’s and SSRI’s Psychosocial interventions also effective Some providers will use methylphenidate in patients with very short life expectancy Qaseem, A, Snow, V., Shekelle, P, et al. Ann Intern Med. 2008;148:141-146

23. Delirium Prevalence: 20% to 30% of people with cancer, COPD and end-stage liver disease in SUPPORT 26% to 44% in terminal cancer 83% in people during their final days. Assessment: Confusion Assessment Method (CAM) Memorial Delirium Assessment Scale (MDAS) Treatment in the terminally ill is difficult Prevention is key

24. Drugs are the most common cause of delirium reduction and possibly withdrawal of anticholinergic and psychoactive drugs opioid dose reduction and/or rotation (usually at an equi analgesic dose with a reduction of 20% to 30%) Newer antipsychotics no better than haloperidol

25. Pain Ratings For 16 Common Hospital Procedures For 165 Subjects Urethral catheter Mechanical restraints Movement from bed to chair IM/SC injection None IV catheter Chest x-ray Vitals signs Transfer to a procedure Waiting for a test or procedure PO medications s evere Arterial blood gas Moderate Central line placement Nasogastric tube Peripheral IV insertion Phlebotomy Mild Morrison et al, JPSM 1998

26. EUTHANASIA Euthanasia is described as the deliberate and intentional killing of a person for the benefit of that person in order to relieve him from pain and suffering The term ‘Euthanasia’ is derived from the Greek words which literally means “good death” ( Eu = Good; Thanatos =Death).

27. Types Euthanasia can be categorized into two types- active and passive (a)Active Euthanasia- When a person directly and deliberately does something which results in the death of patient. It is considered crime in many country and in India but Netherlands, Belgium, Switzerland is sanctioned by the passage of “Termination of Life on Request and Assisted Suicide (Review Procedures) Act”

28. Euthanasia can be further classified as ‘voluntary’ where euthanasia is carried out at the request of the patient and ‘non-voluntary’ where the person is unable to ask for euthanasia (perhaps because he is unconscious or otherwise unable to communicate), or to make a meaningful choice between living and dying and a surrogate person takes the decision on his behalf.

29. Cases Now we shall discuss two important judgments: Airedale case from the House of Lords, UK and Aruna Shanbaug case from Supreme Court of India giving us a fair idea regarding the evolution of the laws pertaining to Passive Euthanasia in India and the world. irreversible coma or Permanent Vegetative State are indication of ethunasia

30. Aruna Shanbaug

31. Tony bland

32. DNR (Do Not Resuscitate) DNR (Do Not Resuscitate) is a clear concept in most developed countries. It involves not initiating resuscitation in the event of a cardiac or respiratory arrest.

33. CANDIDATES FOR DNR Where life sustaining treatment is likely to be ineffective or futile. -Where patient has prolonged unconsciousness which is unlikely to recover. -Where patient has a terminal condition for which there is no definitive therapy. -Where patient has a chronic debilitating disorder where burden of resuscitation far outweighs the benefits.

34. NOT THE CANDIDATES FOR DNR Patient is unable to pay for advanced care. Where the outcome is doubtful (may or may not improve situation). Where there is conflicting opinion among the family members. Where responsible next of kin is not available for discussion. Where written consent is not available.

35. DNR procedure Clear airway Inotropic support Provide Oxygen Position for comfort Splint Control bleeding Provide pain medication Provide emotional support nutrition

36. Not done in DNR Perform chest compressions Insert advanced airway Administer Cardiac resuscitation drugs Provide ventilator assistance including non invasive ventilation Defibrillate

37. CARE OF DEAD BODY DEAD BODY CARE After death the body undergoes many physical changes. So care must be provided as early to prevent tissue damage /disfigurement of body parts.

38. Purpose of dead body care To prepare the body for the morgue. To prevent discoloration or deformity of the body. To protect the body from post mortem discharge.

39. Check orders for any specimens Ask for special requests to family ( eg : shaving , a special gown , Bible in hand ) Remove all equipments , tubes , supplies and dirty linens. Cleanse the body thoroughly , apply clean sheets Brush and comb the hairs The eyelids are closed and held in place for a few seconds , so they remain closed. Dentures should be in the mouth to maintain facial alignment.

40. 8. Mouth should be closed. 9. Remove all the ornaments. 10. Absorbent pads are placed under the buttocks to take up any feaces and urine released because of muscle sphincter relaxation 11. All the orifices should be closed. 12. Cover with a clean sheet up to the chin. 13. Spray a deodorizer to remove unpleasant odor . 14. Apply name tag ( wrist , right big toe) 15. Allow the family members to view the dead body 16. The body is wrapped in a large piece or plastic or cotton material used to enclose a body after death. Identification is then applied outside of the wrapper.

41. 17. Hand over all the belongings to the relatives. 18. Do complete documentation in the nursing notes. Time of death and actions taken to prevent the death. Who pronounced the death. Any organ donation Personal articles left on the body Personal items given to family Time of discharge and destination of the body Location of name tags on the body Special request by family 19. Hand over the dead body to the relatives / sent to the mortuary.

42. Thank you