PALLIATIVE CARE AND PRINCIPLES OF MANAGEMENT OF TERMINALLY ILL - ITANKA.pptx

PALLIATIVE CARE Presentation for resdient doctors especially those practising in Nigeria

1. Palliative Care and Principles of Management of Terminally Ill Patients Dr. Itanka U.C. Supervising Senior Registrar: Dr. Shittu

2. Outline Introduction Aims of Palliative Care Domains of Palliative Care Classification Indications Contraindication Principle of Management of the Terminally Ill Ethical Considerations Locoregional Challenges Current Trends Conclusion References

3. Introduction Derived from the Latin word Pallium- To cloak/cover To palliate means to lessen the severity of the symptoms of an illness without curing or removing the underlying cause. An approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness , through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychological and spiritual. Gaining grounds the world over due to increasing advanced cancer burden.

4. Palliative medicine has been recognized as a specialty i n UK since 1987 A ustralia and New Zeland since 1988 more recently in USA 1996. Nigeria- 2003 in UCH. The approach to patients care is “holistic”, hence multidisciplinary.

5. Definition of Terms Terminally Ill Patients One with a confident diagnosis that cure is not possible Prognosis usually in months or less Treatment is aimed at relief of symptoms Most of such patients have an advanced malignancy but non malignant diseases also fall into this like - ESRD, Chronic obstructive Airway Disease, Multiple Sclerosis, Motor neuron disease etc

6. Definition of Terms Critical Illness: A state of ill health with vital organ dysfunction, a high risk of imminent death if care is not provided and the potential for reversibility

7. Definition of Terms Surgical Palliative Care The treatment of suffering and promotion of quality of life for terminally ill patients under surgical care. Palliative Surgery A surgical procedure done with the primary intention of improving Quality of Life and/or relieving symptoms caused by an advanced disease. Effectiveness judged by the presence and durability of patient acknowledged symptom resolution. Hospice is a “type” of palliative care for those who are at the end of their lives.

8. Statement of Surgical Importance With an increasing population of cancer patients and most of them invariably needing palliative care at a point, the practising surgeon must be armed with the principles of caring for the terminally ill.

9. Historical Perspective Cure sometimes, treat often, comfort always – Hippocrates . Dame Cicely Saunders founded Hospice care 1967.

10. Aims of Palliative Care Provide relief from pain and other distressing symptoms. Affirm life and regard dying as a normal process. Neither to hasten or postpone death. Integrate the psychological and spiritual aspects of patient care. Offer a support system to help patients live as actively as possible until death. Offer a support system to help the family cope during the patient's illness and in their own bereavement. U se a team approach to address the needs of patients and their families, including bereavement counseling, if indicated. Enhance the quality of life, and may also positively influence the course of illness.

11. Domains of Palliative Care

12. Classification of Palliative Care Based on Timing of Intervention Downstream : Care assessed at later part Upstream : Patients palliative care needs are assessed early in their trajectory Based on approach Consultative Integrative

13. Indications of Palliative Care

14. Contraindication Patient’s refusal

15. Principle of management Pre-Care Palliative Care Post Palliative Care

16. Evaluation Establish an Indication Assess for common symptoms of the terminally ill Proper counseling Communication Prognosis Goals of Care - Palliative

17. Evaluation Goals of Care – Palliative Not always restricted to medical care Advance Care planning – Clear understanding of the wishes of the patient eg DNR, will. Treatment options, outcomes and likely adverse effects Review

18. Symptoms of the Terminally ill General Pain Numbness CNS Insomnia Dizziness Respiratory System Cough Dyspnoea GIT Anorexia Nausea and Vomiting Dysphagia Constipation Diarrhoea Hiccups Urogenital System Incontinence Loss of libido Integuments/MSS Pruritus

19. Psychological Symptoms Anxiety Depression Irritability Delirium Confusion

20. Principle of Management of Pain Evaluation – History (SOCRATES) Measure the pain – N/B children Cause of pain – concept of TOTAL PAIN

21. Pain Management can be modified in most patients Not all pain require analgesia Limit unnecessarily painful procedures Analgesics should be prescribed regularly to preempt pain Prescribe p.r.n . Doses of analgesics in Breakthrough pain Incident pain

22. Surgical Management of Pain

23. Dyspnoea Suction secretions if present Positioning, loose clothing. Limit volume of IVF; consider diuretics if fluid overload/pulmonary edema . Behavioural strategies like breathing exercises. Look for the cause and manage. Fatique Sleep hygiene Gentle exercise Address potentially contributing factors like anemia , depression, side effects of medications.

24. Weakness and Immobility Patient who is immobile and confined to bed loses muscle strength A normal person loses 10-15% muscle bulk when completely rested and takes up to 60 days to regain this. Management Good nursing care and regular physiotherapy Special mattresses Wheelchair

25. Nausea and vomiting

26. Anorexia

27. Dysphagia

28. Symptoms Pruritus Moisturize skin
Try specialized anti-itch lotions
Apply cold packs
Counter stimulation, distraction, and relaxation. Evaluate for cause and palliate eg Obstructive jaundice

29. Constipation Inactivity, anorexia, low-residue diet and analgesic drugs - - (occupying opioid gut receptors) can all give rise to constipation. Treated by combined faecal softener and peristalsis- inducing (stimulant) laxative,
Suppositories, enemas or manual disimpaction may also be required. ( Senokot or Dulcolax are also useful stimulant laxatives. Lactulose 15 ml twice daily is an osmotic stimulant – an alternative.)

30. Diarrhoea Diarrhoea has many causes. It may be due to constipation with overflow (spurious diarrhoea) and treated . Treat the cause Convulsion Primary or secondary brain deposits may produce fits and convulsions. Treat with diazepam l0mg three times a day, phenytoin l00mg three times a day or sodium valproate ( Epilim ) 200mg three times a day. However. Dexamethasone may reduce or eliminate the need for anticonvulsants.

31. Anxiety Psychotherapy Depression Tender loving care is required, along with mood-elevating prednisolone 5 mg twice daily. Amitriptyline 25-75 mg daily is a useful antidepressant. It potentiates the analgesic effects of opiates in addition to its inherent analgesic activity. When giving amitriptyline, oral hygiene is important as it causes a dry mouth Agitation/Terminal Restlessness Evaluate for organic or drug cause Educate family. Provide calm

32. Palliative surgeries General Surgery Toilet mastectomy Drainage procedures for ascites E ndoscopic interventions for stenting an obstructed lumen, ablation of tumor, hemostasis Peritonectomy Laparotomy/laparoscopy and bypass or resection for relief of biliary or bowel obstruction. Colostomy Biliary stenting Cardiothoracic Closed-Tube Thoracostomy Drainage for malignant pleural effusion. Palliative thoracocentesis O esophagus stenting

33. Palliative surgeries Urology Palliative cystectomy for recalcitrant hematuria Urinary diversion Internal iliac artery embolization Cytoreductive Nephrectomy Orthopaedics Endoprosthesis Internal fixation Debulking surgeries Neurosurgery stereotactic radiosurgery (SRS) hypophysectomy External ventricular drainage Intracranial metastasectomy

34. Other forms of Surgical Palliation Palliative Radiotherapy Palliative Chemotherapy IV Oral routes HIPEC

35. Post-Care/Bereavement Grief and mourning are natural responses to loss; most people will go through that without clinical intervention Breaking Bad news Stages of grief Autopsy

36. Ethics of Palliative Care Patients diagnosed with terminal illness are vulnerable in their emotional state and depend on their health care professionals (and non-professionals) for compassionate empathetic care, sensitive sharing of information to promote participation in decision-making and effective symptom management. Their vulnerability should not be exploited

37. Foundations of the Ethical Care Respect for life Acceptance of the ultimate inevitability of death Relationship of honesty & trust between HCP & patient Beneficence and Non Maleficence Respect for Autonomy Justice

38. Ethical Challenges Euthanasia Consent for surgery Curative surgeries in metastatic disease – hepatic metastectomy . Voluntary Organ donation of healthy organs of the dead terminally ill patient. Futility of care

39. Locoregional Perspective and Challenges 2003, first Palliative care inclusion in Nigeria. Limited Pain and Palliative care policy Poor health workers to patient ratio Members of MDT not knowing about the aim of care. Unavailability of palliative medicines like opioids

40. Current Trends Out-patient palliative Care

41. Conclusion Palliative care is care offered to the Terminally ill. Good communication and patient’s wishes should be respected. Multidisciplinary. Should be part of care of all terminally ill.

42. References National Policy and Strategic Plan for Hospice and Palliative Care, 2021. Past Update presentations https://www.slideshare.net/ooooottam/palliative-care-and-end-of-life-care Postgraduate Surgery; The Candidate’s Guide, AlFallouji