End of life/Palliative care issues in Internal Medicine

Dr Lynn Alison LambertB.Sc. PhD, MB ChB, FRCP (Lond) DTM&HInternal Medicine, University of Calgary

Disclosures

I have a vested interest in good end of life care – one day I will die too.

No sponsorship or financial links with any drug company Most of the information in this workshop is from:

The Oxford Textbook of Palliative Medicine, 4th Edition 2010 ▪ Hanks, G., Cherry, N., Christakis, N., ,Fallon, M., Kaasa, S.,

Portenoy, R. (Eds) Palliative Medicine, A Case Based Manual , 3rd edition 2012▪ Doreen Oneschuk, Neil Hagen and Neil MacDonald (Eds)

Discussions with my colleagues in Palliative care in Foothills Medical Centre, Calgary - with special thanks to Dr Jessica Simon.

Personal experience with many patients at the end of their lives

As Bob Dylan once said: “He who isn’t busy being born is busy dying”

What is Palliative Medicine? “Palliative Medicine is no more , no less

than the quality of care we should be offering all our patients every day - care tailored to their needs , skilled, compassionate”

quote from the late Sir Raymond (Bill) Hoffenberg, President of the Royal College of Physicians of London 1983-1989. Former Professor of Internal Medicine, University of Birmingham Medical School, Birmingham, England

From Palliative Medicine, A Case Based Manual, by Doreen Oneschuk

(U of Alberta) Neil Hagen (U of C) and Neil MacDonald (McGill)

So - Palliative Medicine is for everyone.

Palliative medicine

Is holistic care, taking into account a patients cultural, spiritual and individual needs

Respects a patients wishes Even if they are not what we would choose

Informs a patient of what can be done Treatment options – pros and cons

Communicates prognosis accurately Communicates with the family/friends

(provided the patient gives permission)

History

Dame Ciceley Saunders Nurse, social worker, doctor Founded St Christopher’s Hospice in London,

1967 Wrote reports of a series of cases of terminally

ill patients -340 1960, 1100 by 1967 Realised that in terminal care there may be▪ Physical needs, emotional distress, social issues

(housing, finance, family)▪ Championed pain management – regular not prn▪ Battled current ideas/fears re opiate addiction

History 2

1973- 1st International Symposium on Pain control

1976 1st International Congress on the Care of the Terminally Ill – Montreal

1987 Palliative Medicine recognised as a specialty in UK

2006 ACGME and ABMS in US approved a new specialty in hospice and palliative medicine.

Is there a need for internal medicine physicians to know about palliative care if we have all these specialists? Top 5 predicted causes of death in

2020 IHD, Cerebrovascular disease COPD Respiratory infection Lung Cancer

So palliative medicine in non- malignant disease is important

Why internists need to be good at palliative care

Whole patient management/ whole person medicine

Care of Elderly with multiple problems

Not enough hospice places Palliative medicine in non-malignant

disease Especially COPD and heart failure

Drug interactions Care of younger patients with

complex diseases

Is Palliative Medicine “Terminal Care” only?

Good Palliative care practice is the ability to recognise when the aim of a patient’s treatment is mainly that of symptom control rather than life prolongation.

This can be months or even years before the patients terminal phase.

Allows a patient to live with their disease and not just be dying from it.

Palliative care for the General Medical patient

Generally discussion is left too late Often goals of care are discussed

when the patient arrives in the Emergency Department with an acute complication of a terminal illness.

This is stressful for doctors , patients and relatives

To avoid this we need to engage with our patients in advance care planning

Signposts in Palliative Care

How to recognise that the time has come for some end-of-life / goals of care discussion

The Surprise Question: “Would I be surprised if this patient

were to die in the next 6 months?” If the answer is “No” then you should

look for cues from the patient that they wish to discuss this. Try some exploratory questions.

Communication at the end of life

What are the barriers?

Communication at the end of life

What are the barriers? What can we do as clinicians?

Communication at the end of life

What are the barriers? What can we do as clinicians? How can we do better?

Canadian Pallium project

Communication resource with clinical scenarios

Allow us to observe examples of good communication skills

Access via You Tube

Palliative Medicine

Should be what we do every day as part of usual care in Internal Medicine

Is it?

Having a Goals of Care discussion-what you can do

Initiate the discussion of advance care planning “are there any limitations on your treatment I

should know about” “do you have any specific wishes about your

treatment?” “Do you have a personal directive?”

Alberta “Conversations Matter” initiative Booklet, videos

Family Meeting Useful to get everyone “on the same page”

Goals Of Care – Calgary Region

R Resuscitative Care

M Medical Care (excluding resuscitative care)

C Comfort Care

More flexible than DNR versus no DNR

Rules for internal medicine

Ask yourself “what am I trying to achieve here?” Don’t be caught up in a curative mode and fail to

pick up on the patient’s anxieties Be realistic (but not dogmatic) about the

prognosis With yourself With the patient

Find Out What the patient wants

Accept that: referral to a palliative care specialist does not mean

that you have given up on the patient

When to involve the palliative care team

Sooner rather than later For symptom control when you are

unsure what to do To aid access to community services

and hospice When you recognise that you don’t

have time to do it properly yourself As a learning resource

(a phone call may be enough)

End of life care

The last days How to die with dignity in hospital

Is this difficult? How can we make it better?

Liverpool Care pathway (or similar)

Liverpool Care Pathway - used when patient has hours or days left to live Useful in hospital or at home Documents discussions with relatives Notes an advance directive (if done) Assesses

Pain, nausea, vomiting, agitation, breathlessness, skin condition, constipation

Anticipates need for drugs for: Pain, agitation, respiratory secretions,

nausea vomiting, dyspnoea,

Liverpool Care Pathway

Has a section for discontinuation of routine: blood tests, glucose monitoring, vital

signs, oxygen, iv antibiotics Documents

patients wishes re care after death▪ E.g. who washes body, need for burial within

24hours Discussions with relatives and

information given▪ Information leaflets, death certificate, post

mortem request

Patients at the end of life- Cases

Elderly person Cancer patient Heart Failure Renal Failure Liver disease Complex case

Palliative care for the elderly patient

Holistic care Looks at social, Personal and

spiritual issues Removal of unnecessary treatments Discussion of Goals of Care for the

future Sometimes operative treatment is

the best palliation – e.g. repair of fractured NOF

How to assess patients prognosis?

Patient with COPD

Mr Murray is a 74 year old retired oil worker, ex smoker, is on his fourth admission to hospital this year with COPD Last time he went to ICU and was ventilated

for 2 weeks He hasn’t left the house since He has home oxygen and a nebuliser

He is readmitted with breathlessness, wheeze and cachexia

Mr Murray

What is his prognosis? What will you do for him? What are you going to discuss? How will you do it?

Prognosis

Gold classification of COPD O normal spirometry, I Mild COPD II Moderate III Severe IV Very Severe

ADO Index BODE index

Prognosis- BODE Index

BMI, Airflow Obstruction, Dyspnoea, Exercise Capacity

BMI 19FEV1 38% predicted MMRC dyspnea scale

Too breathless to leave house

6 min walk < 149 mScore 9 25% 4 year

survival

Prognosis

GOLD III –Severe ADO (age, dyspnea, FEV1)

3 year mortality 47.2% BODE

4 year mortality 75%

What will you do?

What are his goals of care?

Points to consider

Discuss goals when patient is well if possible Pre-discharge In clinic

And document it Discuss interventions which will be

accepted and those which he does not want

Involve family Advance directive

Complex Case

“Please see this 76 year old Eastern European in ED lady whose potassium is high (5.9)” Gynae oncology consult

3 months ago- rectal cancer Biopsied - adenocarcinoma Declined operation

1 month ago vaginal bleeding New gynae cancer (ovarian)

2 weeks ago DVT – is on warfarin

Complex Case Continued

Having radiotherapy to perineum to control bleeding Felt “unwell” sent to ED

Had a brief cyanotic /apnoeic attack (bagged and recovered)

Is tachycardic, breathless and in pain She has vomited and it is blood streaked Hb is 72 g/L ECG new –RBBB Abdo looks distended

What do you do next?

She is “R1 goals of care” (for everything)

How far do you go?

Discuss

Issues

Potassium Pain Abdomen Vomiting (hematemesis?) Anemia Breathlessness Goals of care Patients values Family

Liver Case

53 year old night club manager Admitted to medical team yesterday

Jaundice, ascites and dehydration Seen in liver clinic 6 months ago

told to stop drinking Wife left 3 months ago

Hit the bottle even harder Sister brought him to ED when he

went yellow

Liver case continued

His bilirubin is 220, INR 1.8, WCC 12 albumin 28His urine output is poor (Urea 10, Creat 140)He has tense ascites and is uncomfortableHis creatinine is rising and he keeps trying to pull

out his ivHe is mildly encephalopathicThe nurses have tied his hands to the bedHis mother is on her way to the hospitalHis daughter, inVancouver, is 8 months pregnantHepatology say he is not a candidate for

transplantation

What are you going to do?

What is his prognosis? What do you need to do now?

Discuss

Prognosis

Severe alcoholic hepatitis can have a mortality of 50% at 30 days

1 year after an admission for alc. Hep 40% of patients are dead

Patients over 50 do worse than younger ones

Glasgow Alcoholic hepatitis score

Glasgow Alcohol Hepatitis score Age over or under 50 White count < 15, >=15 Urea <5mmol/L> INR <1.5, 1.5-2, >2 Bilirubin <125, 125-250, >250umol/L Day 1 Score is 9

predicts Day 28 outcome as 46% survival and Day 84 as 40% survival

Day 7 score was 12 37% chance of survival at Day 84

Liver case – 4 weeks later

Bilirubin continues to rise (480 umol/L)

Creatinine is 420 umol/L INR is 2.1 He is only intermittently lucid and

often in pain

What can you do for him?

What to do?

Prognosis MELD Score is 41; 3 month mortality is

90% (MELD – Model for End Stage Liver

disease) If already dialysed (& even if creatinine

lower) mortality is 100% Glasgow score also poor

Now what do you do?

Palliative Care Team

Can be involved even if you are still hoping for recovery

Can help with symptoms, support family

Can educate us May have more time to talk

Take home message

Think about goals of care in both acute and chronic diseases

Try to get a prognostic indicator Give the patient a chance to have a

conversation about the future Involve the palliative care team

sooner rather than later

And if you have been..

....thanks for listening.