Palliative Care St William’s Parish Pat Treston Pat Treston 20 th September 2006 20 th September...

Palliative CarePalliative CareSt William’s ParishSt William’s Parish

PatPat TrestonTreston

2020thth September 2006September 2006

To cure, occasionally

To relieve, often

To comfort, always.

Definition of Palliative Definition of Palliative CareCare

• ““Palliative Care provides for all the Palliative Care provides for all the medical and nursing needs of the medical and nursing needs of the patient for whom cure is not patient for whom cure is not possible, and for all the possible, and for all the psychological, social and spiritual psychological, social and spiritual needs of the patient and the family, needs of the patient and the family, for the duration of the patients for the duration of the patients illness, including bereavement care”illness, including bereavement care”

•Palliative CarePalliative Care

•Hospice CareHospice Care

•Terminal CareTerminal Care

Quality of LifeQuality of Life

Hopes, Dreams, Aspirations

Day to day reality

The causes of suffering

Pain

Physical symptoms

Psychological

Social

Cultural

Spiritual

TOTAL SUFFERING

Physical symptoms

Psychological

Social

Cultural

Spiritual

Pain

Total Suffering

Pain

Physical symptoms

Psychological

Social

Cultural

Spiritual

Interdependence of various causes of suffering

PainPhysical symptoms

Psychological

Social

Cultural

Spiritual

Interdependence of various causes of suffering

Multidisciplinary TeamMultidisciplinary Team

• Medical Medical • Nursing – CNC. Registered Nurses, ENs, Nursing – CNC. Registered Nurses, ENs,

AINsAINs• PhysiotherapistPhysiotherapist• Occupational therapist/DieticianOccupational therapist/Dietician• Counsellors/psychologists Counsellors/psychologists • Bereavement counsellors – adult, Bereavement counsellors – adult,

childrenchildren• Pastoral care workersPastoral care workers• VolunteersVolunteers

Goals of Palliative CareGoals of Palliative Care• To relieve and prevent suffering:To relieve and prevent suffering: by controlling pain and other physical by controlling pain and other physical

symptomssymptoms by addressing psycho- spiritual distressby addressing psycho- spiritual distress by recognizing role of cultural factorsby recognizing role of cultural factors• To involve people important to the patientTo involve people important to the patient• To promote a degree of acceptance by the To promote a degree of acceptance by the

patient and familypatient and family• To provide a process of care that guides the To provide a process of care that guides the

patient’s understanding and decision makingpatient’s understanding and decision making• To achieve a peaceful deathTo achieve a peaceful death• To provide bereavement support for To provide bereavement support for

families/loved ones.families/loved ones.

Characteristics of Characteristics of Palliative CarePalliative Care

• Patient centredPatient centred• Family CentredFamily Centred• ComprehensiveComprehensive• ContinuousContinuous• Co-ordinatedCo-ordinated• TeamworkTeamwork• Regular reviewRegular review

Pain ManagementPain Management

Relief and prevention:Relief and prevention:• Thorough assessmentThorough assessment• Explanation, educationExplanation, education• ReassuranceReassurance• Treatment appropriate to stage of Treatment appropriate to stage of

diseasedisease• Radiotherapy / ChemotherapyRadiotherapy / Chemotherapy

Principles of Using Principles of Using AnalgesicsAnalgesics

• Use of appropriate drug for type of painUse of appropriate drug for type of pain• Use of appropriate drug for severity of Use of appropriate drug for severity of

painpain• Combinations of drugsCombinations of drugs• Use of adjuvant analgesicsUse of adjuvant analgesics• Adequate dosageAdequate dosage• Dose titrated for each individual patientDose titrated for each individual patient• Time dosage according to duration of Time dosage according to duration of

action of drugaction of drug

Principles of Using Principles of Using AnalgesicsAnalgesics

• Strict scheduling to Strict scheduling to preventprevent pain, not pain, not just when it occursjust when it occurs

• Provision of breakthrough medicationProvision of breakthrough medication• Written instructions on medication useWritten instructions on medication use• Anticipation and treatment of side Anticipation and treatment of side

effectseffects• Keep regime as simple as possibleKeep regime as simple as possible• Use of oral route where possibleUse of oral route where possible

OpioidsOpioids

• Morphine – slow release, rapidly Morphine – slow release, rapidly acting. p.o/s.cacting. p.o/s.c

• Oxycodone – SR, rapidly actingOxycodone – SR, rapidly acting• Hydromorphone – injection, liquidHydromorphone – injection, liquid• Fentanyl – Patches, injectionFentanyl – Patches, injection• Methadone - tabletsMethadone - tablets

Facts v. Myths about Facts v. Myths about MorphineMorphine

• It is not addictiveIt is not addictive• Does not mean death is closeDoes not mean death is close• Will not hasten deathWill not hasten death• Individual doses vary widelyIndividual doses vary widely• No maximal doseNo maximal dose• Not everyone needs to take itNot everyone needs to take it

Case StudyCase Study

• Jim Smith, 65 years old Jim Smith, 65 years old • Married to Mary, 2 sons John & Peter in Married to Mary, 2 sons John & Peter in

Brisbane, daughter Susan in Melb.Brisbane, daughter Susan in Melb. (all married with young children)(all married with young children)• Persistent cough in January 2005Persistent cough in January 2005• Dx : Large cancer R lungDx : Large cancer R lung• Treated with radiotherapy to control Treated with radiotherapy to control

size of tumour – not curativesize of tumour – not curative• No spread elsewhere, esp. brainNo spread elsewhere, esp. brain


• June 2005 – chest wall pain and increasing June 2005 – chest wall pain and increasing breathlessness, esp. on exertion.breathlessness, esp. on exertion.

• Referred to Mt Olivet Home Care ServiceReferred to Mt Olivet Home Care Service• 7/7/2005 Commenced on SR Morphine with 7/7/2005 Commenced on SR Morphine with

extra Morphine mixture, bowel medication, extra Morphine mixture, bowel medication, equipment arranged, domiciliary nurses. equipment arranged, domiciliary nurses.

• 3 weeks later, distressing productive cough, 3 weeks later, distressing productive cough, fever, increased pain, more breathless.fever, increased pain, more breathless.

• Probable chest infectionProbable chest infection


1/8/2005 Admitted to Palliative Care Unit1/8/2005 Admitted to Palliative Care Unit• ““I don’t want any treatment. I want to I don’t want any treatment. I want to

die”die”• Reasons explored –Reasons explored – Tired of feeling unwell, debilitatedTired of feeling unwell, debilitated Demoralised by pain and breathlessnessDemoralised by pain and breathlessness Not clinically depressedNot clinically depressed Enjoyed visits from work mates, Enjoyed visits from work mates,

grandchildren, watching sport on TV.grandchildren, watching sport on TV.


• Informed of pros and cons of Informed of pros and cons of antibiotics antibiotics

• Goals of treatmentGoals of treatment• Commenced on antibioticsCommenced on antibiotics• Morphine dose increasedMorphine dose increased• OxygenOxygen• Nebulised salineNebulised saline• PhysiotherapyPhysiotherapy → → good symptomatic improvement.good symptomatic improvement.


• Family meeting – decision Family meeting – decision →→ home home with extra supports, home oxygen.with extra supports, home oxygen.

• Pain well controlled, mobilising short Pain well controlled, mobilising short distances, using extra morphine for distances, using extra morphine for breathlessness on exertion.breathlessness on exertion.

• Mood reactive, accepting, dealing with Mood reactive, accepting, dealing with practicalities – will, EPOA, Advanced Health practicalities – will, EPOA, Advanced Health Directive.Directive.

• 12/8/2005 Discharged home12/8/2005 Discharged home


• Condition reasonably stable for next 2 weeksCondition reasonably stable for next 2 weeks• Relatively sudden onset of confusional state :Relatively sudden onset of confusional state :

no sleep for 2 nights, restless, disorientated, no sleep for 2 nights, restless, disorientated, refusing oxygen, not eating.refusing oxygen, not eating.

• 26/8/2005 Readmitted PCU - delirium26/8/2005 Readmitted PCU - delirium• Many potential causes – medication, infection, Many potential causes – medication, infection,

spread to brain, low oxygen levelsspread to brain, low oxygen levels• Investigations – ?reversible causeInvestigations – ?reversible cause


• Found to have high calcium levelFound to have high calcium level• ? Competent to make decision about ? Competent to make decision about

treatmenttreatment• Discussed with family :Discussed with family :

Best symptomatic treatment if effective, Best symptomatic treatment if effective, potentially life prolonging (AHD)potentially life prolonging (AHD)

• Treatment not administeredTreatment not administered• Managed with haloperidol (anti psychotic) Managed with haloperidol (anti psychotic)

and other medications as requiredand other medications as required

Case StudyCase Study• 28/8/2005 Condition deteriorating , 28/8/2005 Condition deteriorating ,

physically weaker, pain apparently physically weaker, pain apparently controlled, breathless at rest, still refusing controlled, breathless at rest, still refusing to keep oxygen on, sleep disturbance, to keep oxygen on, sleep disturbance, increasing confusion/disorientation, increasing confusion/disorientation, suspicious, irritable, unable to have lucid suspicious, irritable, unable to have lucid conversation with family.conversation with family.

• Family distressed Family distressed ++++++• 2 days later, found wandering in the 2 days later, found wandering in the

corridor, breathless and unsteady, abusive, corridor, breathless and unsteady, abusive, angry, physically aggressive, lashing out at angry, physically aggressive, lashing out at staff, overtly paranoid and fearful – telling staff, overtly paranoid and fearful – telling visitors he was going to be killed.visitors he was going to be killed.

• Danger to himself and others Danger to himself and others


• Discussion with family - probable Discussion with family - probable terminal restlessness, irreversible, terminal restlessness, irreversible, portent of approaching death.portent of approaching death.

• Joint decision made to sedate patientJoint decision made to sedate patient• Commenced on larger doses of Commenced on larger doses of

antipsychotic medication, sedative antipsychotic medication, sedative agents and analgesics in syringe driver.agents and analgesics in syringe driver.

• Remained drowsy with some periods of Remained drowsy with some periods of awareness, ? recognised family awareness, ? recognised family members.members.


• Over next few days appeared to be pain Over next few days appeared to be pain free, oxygen continuedfree, oxygen continued

• Minimal oral intake, sips of water when Minimal oral intake, sips of water when awake.awake.

• Daughter arrived from Melbourne – very Daughter arrived from Melbourne – very distraught at deterioration in father’s distraught at deterioration in father’s condition.condition.

• Accused staff of allowing him to die of Accused staff of allowing him to die of starvation and dehydration.starvation and dehydration.

• Explanation / reassurance.Explanation / reassurance.• Mouth CareMouth Care


• Medications continued, given extra Medications continued, given extra analgesia prior to bathing/ moving analgesia prior to bathing/ moving as appeared to grimace and moan.as appeared to grimace and moan.

• Medication for terminal secretionsMedication for terminal secretions• 5 days after commencing sedation 5 days after commencing sedation

died peacefully with family at the died peacefully with family at the bedside.bedside.

“Death should simply become a discrete, but dignified exit of a peaceful person from a helpful society without pain or suffering and ultimately without fear”

Phillipe Aires

“ You matter because you are you.

You matter to the last moment of your life and we will do all we can to help you-

Not only to die peacefully,

But to live until you die”

Cecily Saunders

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