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WRHA Palliative Care Program
Dr. M. Harlos, Medical DirectorL. Embleton, Program Director
April 30, 2014
http://palliative.info
The presenters have no conflicts of interest to disclose
Objectives
• To provide an overview of the services offered by the WRHA Palliative Care program
• To review considerations for Respiratory Therapists in caring for palliative patients
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.
Role of WRHA Palliative Care Program
• WRHA Palliative Care Program is a clinical program that:– Provides and promotes quality palliative care for
patients/families with life limiting/threatening illnesses
– Provides support to health care teams providing care to palliative patients in any care setting
Role of WRHA Palliative Care Program
Two streams of service provided:
• Consultation
• Registration
Consultative Services• available to any patient with a life-limiting/threatening
illness, at any time in the illness trajectory, in any care setting for:
1. Symptom management2. Assistance with planning care3. Clarifying goals of care
• provided by inter-professional team members:– Palliative Care Physician– Palliative Care Clinical Nurse Specialist– Psycho-social Support Specialist
Consultative Services
To access consult service:• During business hours, all consults should be
directed to Palliative Care Program204-237-2400
• After hours – MD to MD consults available 24 hours a day through St. Boniface Paging
204-237-2053
Registration on Program
Patients can be “registered” on the Palliative Care Program if they meet program criteria:
– Prognosis of less than 6 months (approximately)– No longer receiving aggressive treatment which
requires on-going monitoring for and treatment of serious complications
– Have chosen a comfort-focused approach including a decision to decline attempted resuscitation
Registration on ProgramOnce registered with the program, patients are eligible for:
– Case management through Palliative Care Coordinator– Access to Community Palliative Care Nursing 24/7
• Palliative Care Nurses have access to Palliative Care Physician
– Admission to Palliative Care Units (PCU) and Hospice – if bed available
– Enrollment on Provincial Palliative Care Drug Access Program
Inpatient Care settings
Palliative Care units:– St. Boniface Hospital – 15 beds
• Tertiary Care Facility
– Riverview Health Centre – 30 beds
Hospices:– Grace Hospice – 12 beds– Jocelyn House – 4 beds
Community Palliative Care Program
• Approximately 400 patients at any one time• Each community team considers patients in their
area as their “ward”– Inclusive of all care settings – home, acute care and long
term care– Team meetings are held to discuss patient care needs
(rounds)• Focus on meeting needs in a proactive way
– Opportunity to strengthen networks with other care teams to support patients and families including the opportunity to model “palliative care”
PCHs
PCHs
PCHs
NortheastNorthwest
South
Central
Patients at home
Home
PCHs
Patients at home
Patients at home
7 Oaks
HSC
VGH
ConcordiaGrace
CommunityClinics
CommunityClinics
CommunityClinics
Community Teams:• Community
Nurses• CNS• MD• Coordinator• Psychosocial
Pediatric Palliative Care
• Established in 2006– Services provided by physician and CNS
• Consultative service –no dedicated beds
• ~ 80 new patients each year
Diagnosis ofLife-Limiting
Illness
Transitioning to Palliative
Palliative
Consult Service
Community Palliative Nursing
• Case Coordinator• Admission Eligibility• Medication Coverage
• comfort-focused• prognosis “6 mo. or less”• some treatment limitations
(DNAR, no TPN, no chemoTx with high adverse effects
• aggressive, often toxic treatment focused on cure or life-prolonging disease modification
Considerations For The
Respiratory Therapist In Caring
For Palliative Patients
• Initiating and maintaining ventilatory support
• Setting up and supporting O2
• Educate patient, families, involved health care team
• Withdrawing ventilatory support
• Withdrawing O2
• Transport of palliative patients
• Nebulized meds (includinglidocaine)
Resp. Therapy
Palliative Care
SharedCare
1. Role of O2 therapy in palliative patients
2. Noninvasive ventilation in ALS
3. Role of opioids in palliation of dyspnea
4. Transport of dying patients; role of Health Care Directive, ACP
5. Withdrawal of life-sustaining treatments – ventilatory support (invasive and noninvasive), oxygen
Specific Issues
• not a straightforward issue
• “hypoxia kills” – a common mantra in medical care
• should also be mindful that “supplemental O2 prolongs the natural dying process”
• the awake hypoxic patient feels less air hunger and does better physiologically with O2 supplementation
• the unconscious/comatose patient does not likely experience air hunger
• what about the awake, dyspneic, non-hypoxic palliative patient?
• studies of “air vs. O2” used room air by nasal prongs and are therefore not practical – “medical air” not available in clinical practice, and dyspnea is helped by cool air in nasopharynx
Role of O2 In Palliative Patients
• N = 32 non-dyspneic patients with Palliative Performance Scale ≤ 30% (median survival 9 days or less), at risk of developing dyspnea (CA lung, CHF, COPD, pneumonia)
• excluded if: mechanically ventilated, on high-flow O2 by FM; tracheostomy; experiencing respiratory distress at study entry
• SpO2, end-tidal CO2 measured; dyspnea assessed using Respiratory Distress Observation Scale
• patients were rotated blindly from O2, medical air, no-flow cannulae
• no difference in comfort between interventions
• results suggest that O2 need not be prescribed to patients who are near death and not exhibiting respiratory distress regardless of oxygen saturation.
• O2 can often be withdrawn when the patient makes a transition from terminal illness to imminent death, particularly as consciousness decreases.
• most patients tolerated a crossover from oxygen to air or no flow, however 3 patients experienced distress that was relieved by a return to oxygen. An inability to reliably predict which patient will
experience distress requires close clinical observation when withdrawing O2
Campbell et al continued…
• generally our practice is to focus on comfort, not oximetry
- good O2 sats, patient uncomfortable: intervention needed
- poor O2 sats, patient comfortable: no change needed
• often nasal prongs are better tolerated than mask, regardless of oximetry
• if a patient feels benefit with O2 even though room air oximetry is normal, we would use O2 if feasible
• in the unresponsive patient, consider tapering over a few hours as tolerated
• improved quality of life and survival, though this has not been demonstrated in bulbar onset ALS
• bulbar patients less tolerant of NIV (mouth leaks, sialorrhea)
Noninvasive Ventilation in ALS
• tendency to gradually increase its use – eventually to 24/7; the implications of this does not seem to be commonly discussed
• patient may be completely dependent on NIV, and unable to remove mask in event of machine or power failure
• the very patients who selected NIV rather than tracheostomy often find themselves on “life-support” with NIV, having to decide about withdrawal of ventilatory support
• conversations around end-of-life issues should be included when discussing any ventilatory support
• care setting for patients dependent on NIV need to address:- risk management around power / machine failure- ability to address symptoms in context of acute distress- ability to ensure comfort in context of withdrawal
Palliative Considerations Regarding NIV
Johnson MJ, Abernethy AP, and Currow DC. Gaps in the evidence base of opioids for refractory breathlessness. A future work plan? J Pain Symptom Manage. United States; 2012;43(3):614-24.
Opioids And Dyspnea
• Regarding fear of respiratory depression –
• higher doses of opioids and benzodiazepines used in the withdrawal of life-sustaining treatment were not associated with a decreased time from withdrawal of life support to death
• Of 11 studies providing information on ABGs or O2 sat, only one study reported any significant changes in oxygenation after opioid administration
• Recommend that:
• Oral and/or parenteral opioids can provide relief of dyspnea.
• Opioids should be dosed and titrated for the individual patient with consideration of multiple factors (e.g., renal, hepatic, pulmonary function, and current and past opioid use) for relief of dyspnea.
American College Of Chest Physicians Consensus Statement On The Management Of Dyspnea In Patients
With Advanced Lung Or Heart Disease - 2010
• Official American Thoracic Society Statement: Update on the Mechanisms, Assessment, and Management of Dyspnea – 2012- Opioids have been the most widely studied agent in the
treatment of dyspnea. Short-term administration reduces breathlessness in patients with a variety of conditions, including advanced COPD, interstitial lung disease, cancer, and chronic heart failure
• Canadian Thoracic Society Clinical Practice Guideline 2011: Managing Dyspnea In Patients With Advanced Chronic Obstructive Pulmonary Disease- “We recommend that oral (but not nebulized) opioids be
used for the treatment of refractory dyspnea in the individual patient with advanced COPD”
Thorax. England; 2014;69(4):393-4.
• “Failure to properly treat chronic refractory breathlessness with opioids as outlined in specialist clinical guidelines is now substandard medical care and is also a breach of clinicians' ethical and legal duties to the patient” … “considered negligent”
• In addition to being a breach of professional, ethical and legal duties, failure to treat chronic refractory breathlessness adequately should be viewed as a breach of human rights.
Common Concerns About Aggressive Use of Opioids at End-Of-Life
• How do you know that the aggressive use of opioids for dyspnea doesn't actually bring about or speed up the patient's death?
• “I gave the last dose of morphine and he died a few minutes later… did the medication cause the death?”
1. Literature: the literature supports that opioids administered in doses proportionate to the degree of distress do not hasten death and may in fact delay death
2. Clinical context: breathing patterns usually seen in progression towards dying (clusters with apnea, irreg. pattern) vs. opioid effects (progressive slowing, regular breathing; pinpoint pupils)
3. Medication history: usually “the last dose” is the same as those given throughout recent hours/days, and was well tolerated
• may reduce overall oxygen demand
• “The administration of sedatives (midazolam and morphine) has been associated with decreases in oxygen demand and the attenuation of the cardiopulmonary response associated with increased work of breathing”
• see also: Endoh H et al; Effects of naloxone and morphine on acute hypoxic survival in mice. Crit Care Med; 1999;27(9):1929-33
- significantly lower oxygen consumption and improved survival in morphine treated rats subjected to acute hypoxic hypoxia
• risk of patient death during transport
• a Health Care Directive or Advance Care Plan is an important tool in preventing unwanted/inappropriate resuscitation attempts
• clear “what-if” plans need to be prepared, with involvement of patient and/or family
- e.g. limited bagging but no chest compressions, or allow natural death
• medications on hand for symptom management
Transporting Palliative Patients
“Planning for Care In Advance”
2 Formal Processes
Health Care Directive• document outlining care
expectations• supported by legislation• 16+ yrs, competent• can name proxy• can be made on any
piece of paper• helps inform the ACP
process
Advance Care Planning
• Consensus-based process
• Patient/family/SDM* and Health Care Team
• Can be done if patient not able to participate
−cognitive impairment−children
* SDM = Substitute Decision Maker
• allowing the natural course of illness to unfold, in contrast to euthanasia
• RT not always included in the decision-making process, yet may still be involved – can be a difficult role to serve
• in a palliative care setting, we may need RT to help with the machine settings, extubation, perhaps suctioning
• comfort is paramount – biggest threat to comfort is air hunger
• preemptive & reactive opioids and sedatives are main pharmacologic interventions
• no specific predetermined dose – essentially only 3 possible doses: not enough; perfect; too much
- the correct dose is the one that is effective, avoids harm if possible, and is proportionate to the need
Withdrawal Of Ventilatory Support
• “…respect and protect the legal rights of the patient, including the right to informed consent and refusal or withdrawal of treatment.”