DEPT.

OF FAMILY MEDICINE BRAITHE WAITE MEMORIAL SPECIALIST HOSPITAL PORT HARCOURT

CLINICAL TOPIC:PRESENTATION PALLIATIVE CARE BY DR. SORGIA M. C. AND DR. MRS ONUA F.

TABLE OF CONTENT
1. 2. 3. 4. 5. 6. 7. 8.

Introduction Definition and Explanation of palliative care Aim of palliative care Palliative care as different from hospice care Palliative care and end of life care Providers of palliative care Specialist palliative care services

Principles of palliative care management.

b c d e f g

Support for patients and carers Symptom control Control of pain Treatment of other symptom the dying phase Spiritual issues The special role of the family Doctor

9. Nursing aspect of palliative care 10. Conclusion.

PALLIATIVE CARE
INTRODUCTION

Family medicine practice is a medical specialty that provide continuing and comprehensive health care for the individual and the family. Continuing health care is an ongoing responsibility for managing a patient's medical care regardless of the patients state of health or the disease process.

comprehensive medical care spans through the spectrum of medicine. It involves varying depth of knowledge in many disciplines and its application in problem solving in the care of the patient. A family physician is responsible for care of the patient from cradle to grave and takes care of unselected and undifferentiated care.

DEFINITION AND EXPLANATION OF PALLIATIVE CARE Palliative care is an approach that improves the quality of life of patients and their families facing the problem 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, psychosocial and spiritual. Palliative care: Provides relief from pain and other distressing symptoms; Affirms life and regards dying as a normal process; Intends neither to hasten or post phone death. Integrates the psychological and spiritual aspects of patient care; Offers a support system to help patients live as actively as possible until death.

Offers a support system to help the family cope during the patients illness and in their own bereavement Uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated. Will enhance quality of life and may also positively influence the course of illness. Is applicative early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapies, and includes those investigations needed to better understand and manage distressing clinical complications. WHO defines palliative care for children as the active total care of the childs body, mind, and spirit, and also involves giving support to the family. It begins when illness is diagnosed, and continues regardless of whether or not a child receive treatment directed at the disease. Health providers must evaluate and alleriate a childs physical, psychological and social distress.

AIM OF PALLIATIVE CARE

Palliative care aims to relieve symptoms such as pain, shortness of breath, fatigue constipation, nausea, loss of appetite and difficulty sleeping. It helps patients gain the strength to carry on with daily life. It improves their ability to tolerate medical treatments. And it helps them better understand their choices for care. Overall, palliative care offers patients the best possible quality of life during their illness. Palliative care benefits both patients and their families. Along with symptom management, communication and support for the family are the main goals. The team helps patients and families make decisions and choose treatment that are in line with their goals.

PALLIATIVE CARE AS DIFFERENT FROM HOSPICE CARE Palliative care is not dependent on prognosis and is appropriate at any point in an illness. It can also be provided at the same time as treatment that is meant to cure the patient. Hospice care always provides palliative care and it is focused on terminally ill patients-people who no longer seek treatments to cure them and who are expected to live for about six months or less.

PALLIATIVE CARE AND END OF LIFE CARE

Palliative care, also called comfort care can be primarily directed at providing relief to a terminally ill person through symptom management and pain management. The goal is not to cure, but to provide comfort and maintain the highest possible quality of life for as life remains. Well rounded palliative care programs also address mental and spiritual needs. Palliative care addresses the physical and psychological aspects of end of life. It involves: -

Pain and other symptom management; Social psychological, cultural, emotional and spiritual support Care giver support; and Bereavement support. Whether palliative care is offered through a formal palliative care program or a variety of other avenues, the focus of care is on achieving comfort and respect for the person nearing death and maximizing quality of life for the patient, family and loved ones.

PROVIDERS OF PALLIATIVE CARE

Palliate care requires an interdisciplinary team model (broad multidisciplinary approach that includes the family) that provides support for the whole person and those who are sharing the persons journey in love. Usually a team of experts, including palliative care doctors, nurses social workers, chaplains, massage therapists, pharmacists, nutritionists. Etc palliative care can be delivered in hospitals, hospice and home care settings. Working in partnership with the primary doctor the palliative care team provides:
-

Expert treatment of pain and other symptoms. Close, clear communication. Help navigating the health care system. Guidance with difficult and complex treatment choices. Detailed practical information and assistance. Emotional and spiritual support for you and your family.

SPECIALIST PALLIATIVE CARE SERVICES

These services are provided by specialist multidisciplinary palliative care team and include:
-

Assessment, advice and care for patients and families in all care settings, including hospitals and care homes.

Specialist in patient facilities (in hospices or hospitals) for patients who benefit from continuous support and care of specialist palliative care teams. Intensive co-ordinated home support for patients with complex needs who wish to stay at home:(a) This may involve the specialist care service providing specialist advice alongside the patient's own doctor and district nurse to enable someone to stay in their own home (b) Many teams also now provide extended specialist palliative nursing, medical, social and emotional support and care in the patients home, often known as hospice at home.
-

Day care facilities that offer a range of opportunities for assessment and review of patients needs and enable the provision of physical, psychological and social interventions within a context of social interaction, support and friendship. Many also offer creative and complementary therapies.

Advice and support to all the people involved in a patients care Bereavement support for the people involved in a , patient's care following the patients death Education and training in palliative care. The specialist teams should include palliative medicine consultants and palliative care nurse specialists together with a range of expertise provided by physiotherapists, occupational therapists, dieticians, pharmacist, social workers, and those able to give spiritual and psychological support.

PRINCIPLES OF PALLIATIVE CARE MANAGEMENT

The fundamental principles of palliative care are:Good communication Management planning Symptom control Emotional, social and spiritual support Medical counselling and education Patient involvement in decision making Support for carers. These principles applies not only to incurable malignant disease and HIV/AIDS but also other disease in their chromic stage or terminal stage such as end stage organ failure (heart failure, renal failure, respiratory failure, hepatic failure)

A.
1.

SUPPORT FOR PATIENTS AND CARERS

Patient must be informed of the diagnosis and stage and prognosis for the disease. Patients must be allowed to make a choice of treatment option. The initial consultation must be unhurried and com pathetic. This will achieve the followings Detailed history which can assist in the management Allay patient fears. Give honest answers without labouring the point or giving false hope. Establish good communication and a rapport with the patient The variability in outcome and response to treatment must be discussed. Adopt a whole person approach; attend to physical; psychosocial and spiritual needs.

2. 3.
-

4.

Be prepared to take the initiative and call in other who could help e.g clergy; cancer support group, massage therapists.
5. Give the patient a feeling of security but not false hope. The worst feeling a dying patient can sense is one of rejection and discomforts on the part of the doctor

B.

SYMPTOM CONTROL

Principles of symptom 1. Determine the cause 2. Treat simply 3. Provide appropriate explanation of symptoms and treatment 4. Provide regular review 5. Give medications regularly around the clock, not ad hoc. 6. Plan breakthrough pain relieving doses 7. Provide physical treatment as necessary e.g paracentesis; 8. Pleural tap, nerve block. 9. Provide complementary conservative therapy e.g massage, physiotherapy, occupational therapy dietary advice, relaxation therapy 10. Provide close supervision.

CONTROL OF PAIN Achieving relief of pain is one of the most important functions of palliative care and patients need reassurance that they can expect such relief. BY DEFINITION Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. Pain perception does not therefore correlate with the degree of tissue damage and each patients experience and expression of pain are different.

PAIN CLASSES:1.

2.

3.

NORCICEPTIVE PAIN:- Due to direct stimulation of the peripheral nerve endings (e.g wounds, fracture burns) NEUROPATHIC PAIN:- Due to dysfunction of the pain perception system within the peripheral or central nervous system as a result of injury; disease or surgical damage e.g Diabetic neuropathy; Amputated limb (phantom limp pain) FEATURES OF NUROPATHIC PAIN:Unpleasant persistent burning sensation sometimes stabbing or burning & pain Pain is spontaneous without ongoing tissue damage Pain is located in an area of sensory loss Presence of a major neurological deficit e.g spinal cord trauma Pain in response to non painful stimuli- Allodynia Increased pain in response to painful stimuli _ Hyperalgesia. Unpleasant adnominal sensations - dysaeshesia Poor relief with opioids alone. Visceral pain.

PAIN MANAGEMENT INCLUDE 1. 2. A good detailed history to knows the diagnosis. Necessary investigations are done to help in confirmation of the condition. TREATMENT OF PAIN 1. Pharmacological 2. Non Pharmacological PHARMACOLOGICAL:WHO Analgeisc Ladder Andgesic should be prescribed which is appropriate for the degree of pain and increased until the pain is controlled. If pain remains poorly controlled, strong opiods should be prescribed.

MILD PAIN: Non opioid analgesics e.g paracetanol, Aspirin MODERATE PAIN: Weak opioid e.g codeine 60mg 6hrly STRONG PAIN: Strong opioid e.g morphine, pethidine
Note The side effects of opioids:- constipation, dry month, sedation Note ADJUVANT THERAPY:- there is a place for antidepressant; antiepileptic for neuropathic pain NON PHARMACOLOGICAL 1 Radiotherapy 2. Physiotherapy 3. Psychological techniques simple relaxation 4. Stimulation therapies e.g Acupuncture 5. Herbal medicine and homeopathy.

TREATMENT OF OTHER COMMON SYMPTOMS

CONDITION Anoresia TREATMENT Metoclopramide 10mg tds or Corticosteroid e.g dexamethasone 2-8mg tds, High energy drink supplement SSRI . B Blockers Antidepressant e.g Amitriptylin Oxygen by face mask Breathing technique treat the cause. Change patients posture especially at night opiods e.g morphine Antitussives e.g cocteine linctus

Anxiety Depression Breathlessness Cough (especially intractable)

CONSTIPATION

Give Laxatives Dulcolax liquid paraffin rectal suppositories Treat cause, haloperidol, chlorpromazine Nystatin or miconazole oral gel. Rehydrate with iv fluids; the cause. Loperaminde; treat the cause. ANTACID with anti flatulent e.g Asilone suspension metoclopramide or chlorpromazine benzodiazepine e.g Diazepam anti emetic (e.g metoclopramide, Haloperidol, cyclizine) Anti histamine.

CONFUSION ORAL CANDIDASIS: DEHYDRATION: DIARRHEA: HICCUP: INSOMNIA NAUSEA PRURITUS:-

Sedation:Weakness weight loss:- A patient with cancer loose weight due to an alteration of metabolism by tumour known as cancer cahexia syndrone Rx High calorie, High protein diet.

THE DYING PHASE

Death is an inevitable end not only to the terminal cases but to all mortal being. However discussion with the dying patient is a very difficult task to the physician as it brings with it feelings of failure; loss of hope and fear of causing distress. Apply the principles of care and counseling which include. 1. Be available and be patient 2. Allows them to talk while you listen 3. Reassure them that the felling are normal 4. Accept any show of anger positively 5. Avoid inappropriate reassurance 6. Encourage as much companionship as possible; if desired.

Management Once a patient has entered the dying phase:- bed band, semicomatous, noisy breathing, fever severe fatigue Significant and important change in management - Symptom control - Relief of distress - Care for the family 2. Justifiable medications and investigation e.g opioids 3. Iv Fluid is reduced so that it will not worsen bronchial secretions.

CHECKLIST FOR THE DYING PHASE 1. Stop non essential medication 2. Stop routine observations 3. Ensure availability of parenteral medication for symptom relief. 4. Assess patient and family awareness of condition. 5. Assess religious and spiritual needs 6. Ensure family understands plan of care 7. Ensure continued assessment and management of symptom 8. Arrange appropriate care after death

SPIRITUAL ISSUES
Approaching the end of life, every mortal being wonders what next? where next? and who next? An attempt to answer this questions, the doctor should be sensitive to the needs and that would involve the search for a minister (by the physician or the care giver) who will pray with the patient and give some words of exhortation of life after death.

EUTHANASIA:- (Mercy killing) this should not be practiced.

THE SPECIAL ROLE OF THE FAMILY DOCTOR

The general practitioner is the ideal person to manage palliative care for a variety of reasons:Availability Knowledge of the patient and family Relevant psychosocial influences A key feature is the ability to provide the patient with in dependence and dignity by managing palliative care at home.

NURSING ASPECT OF PALLIATIVE CARE During the care of dying patient factors like odors, confusion, disfigurements, combativeness and inconvenience may turn the nurse away from the required care of the dying patient but nurses should be extremely careful that you do not neglect general rules of care of the dying patients as follows: 1. Nurse should provide a calm and peaceful environment. 2. Make the dying patient comfortable in bed with side rides to prevent it patient from falling.

3.
4.

5. 6.

Take a full his of the patient and report where necessary. Half hourly observation of vital signs e.g temperature pulse, respiration and blood pressure and report to the physician any deviation from normal . Maintain patient air way; lying patient on his side and suck with suction machine as directed. Position the patient every 2 hours but note that due to slow metabolic rate and perfusion of distal body parts is also slow as death near, turning patient suddenly to a new position might over tax their circulation.

7.

The nurse should move the patients limbs to prevent circulatory, muscular and joint complication provided the patients general condition permits it. 8 Make sure that the patient chest is not compressed by pillow or light cloths because they optimal lung expansion. If their swallowing reflex is impaired position to allow saliva to drain form the mouth and prevent aspiration. - Give special care to pressure areas as you change the position of the patient. 9. Personal hygiene of the patient - The nurse should maintain a 4 houdy oral hygiene to prevent the tongue and gums becoming coated and to remove saliva that could have forms a good medium for bacteria to multiply.

The nurse should apply a lip balm to prevent it from cracking Maintain daily bathing in bed with application of a lubricating lotion or talcum powder to the entire body. Nurse should cut the patient fingers and toe nails and brush their hairs. Nurse should maintain a sterile condition from urinary catheterization. Observe bladder and bowels for retention of urine and faces Dress any wound present Assist the doctor to set intravenous line and monitor all the intravenous fluids set up and chart. A dry mouth leads to cracking and secondary infection and pain, prevent it by frequent cleaning of mucous membrane with swabs and clean water. If eye conjunctivae appear dry, ask the physician to prescribe moistening eye drop to prevent dryness that might lead to ulceration.

Keep skin surface from rubbing against one another by supporting pillows and good position. Keep skin dry of urine or faces from incontinence. Change the patients cloths and beddings regularly.
DIET:- Give patient adequate nutrients and fluid, by supporting patient to eat or pass an N. G. tube as a recommended and tube feed the patient accord to the condition. PROVISION OF ADEQUATE VENTILATION The nurse should provide good ventilation by opening of windows for fresh air and standing fan at bed side. The screens if any should be position in a way that air can get to the patient.

11.

12.
-

13. Communication with the dying is often one of the most important element of care you can give remembering that hearing is the last sense lost, patient even minutes away from death are capable of hearing every thing you say, continue to explain procedures to a dying patient as if they are conscious. Never make commence in their presence that this patient cannot make it or can he or she make it? 14. Apply communication skills, expressing empathy and compassion. The nurse should accept the help of other professionals including clergy and social workers .

SUPPORTING THE GRIEVING FAMILY

-

The nurse should acknowledge their grief, understand the value of the patient to the family and assist them with the following. Giving information, sharing concern and expressing empathy. Assist in planning a visitation schedule for dying patient and family from becoming fatigued. Allow young children to visit a dying parent when the patient is able to communicate. Continue to use gentile touch as holding a hand or brushing hair from the fore head as if the patient is fully conscious, they may be fully aware of your action even though the patient can give no indication of it.

Urge family members especially the love ones to visit as desired apparently comforting the dying patient 15. MEDICATION - Give prescribed drugs as instructed by the physician. - Remind the physician to prescribe an analgesic to control pain. - Use accurate injection technique and medication dosages. - Nurse should employed a useful means of assessing pain and evaluating the effectiveness of analgesia.
-

CONCLUSION
Palliative care is appropriate for any patient at any stage of a life threatening illness, regardless of age. Palliative and end of life care touches all parts of the health care system, from hospital to hospice to community to home and usually involves an interdisciplinary team of care givers that deal with the medical and psycho-social, spiritual and economic needs of the patient and the family. THANK YOU FOR YOUR AUDIENCE.