End of Life Public Forum 2 - Dr. Andrew Knight - Feb. 6, 2014


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A presentation made by Dr. Andrew Knight during the free public forum "Continuing the Conversation: a discussion on preparing for end-of-life care" on February 6, 2014 at the United Steelworkers Hall in Sudbury, Ontario.

Dr. Knight is a General Practitioner at the Northeast Cancer Centre and he is the Education Co-chair of the Palliative Care Education Committee and is an Assistant Professor of Family Medicine at the Northern Ontario School of Medicine. He is a Past Chair of the Canadian Association of General Practitioners in Oncology (CAGPO) and is currently the Palliative Care Lead for LHIN 13.

Learn more about the forum at http://www.hsnsudbury.ca/events

Published in: Health & Medicine
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End of Life Public Forum 2 - Dr. Andrew Knight - Feb. 6, 2014

  1. 1. Medical Aspects of Palliative Care – A Conversation With Your Physician Andrew C Knight, MD Sudbury End-of-Life Forum February 6, 2014
  2. 2. Palliative Care • an approach to care (culture of caring) • not restricted to a particular location • can be combined with active care of any patient with life limiting or life threatening illness
  3. 3. • “What should I know about you as a person to help me take the best care of you that I can?” Harvey Chochinov, MD
  4. 4. • “If you don’t know your options, you don’t have any!” Lauren Vary
  5. 5. • Why introduce palliative care early?
  6. 6. Temel et al: • newly diagnosed metastatic… lung cancer (n=151) • early palliative care consultation or standard end of life referral
  7. 7. Patients with early palliative care consultation had: … • less depression • • • • • less anxiety better quality of life received less aggressive treatments lower health care costs & lived 3 months longer!
  8. 8. Temel J, et al. Early Palliative Care for Patients with Metastatic Non–Small Cell Lung Cancer. NEJM 2010; 363:733-42
  9. 9. • 1193 pts, newly diagnosed metastatic lung or colorectal cancer (stage IV) • alive 4 months later, receiving chemotherapy • questionnaire to assess prevalence of belief treatment curative: lung: 69% colorectal: 81%
  10. 10. • serious misunderstanding • may compromise ability to make informed treatment decisions • decisions be inconsistent with preferences or goals of care • MDs may be able to correct misperception, often at cost of patient’s satisfaction • could early palliative care consultation improve understanding of prognosis?
  11. 11. Early Palliative Care • • • • • better symptom management may live longer better quality of life & care lower rates of depression improved understanding of prognosis & less likely to receive chemotherapy at EOL
  12. 12. The Pathway to Death ( in Advanced Cancer) • • • • • • • • • weight loss (cachexia, NOT starvation) reduced appetite / reduced nutritional intake increasing weakness / reduced activity reduced fluid intake / reduced urine output ineffective cough / swallowing / weakened voice confusion (delirium), reduced alertness airway secretions cooling of extremities, mottling of skin ± bowel / bladder incontinence
  13. 13. Cardiac Arrest • cessation of cardiac activity & respirations • failure of cardiovascular & respiratory centres located in brain stem • usual consequence of multisystem failure – liver & kidney failure; acid loading; high potassium levels • impaired cellular function • cardiac arrest is final result • CPR futile endeavour (CPR may not be futile if cardiac arrest in trauma / cardiac disease)
  14. 14. Preparing for Death At Home • • • • • • • • • • • supportive spouse / family adaptable physical surroundings CCAC & nursing services DNR status confirmed in home pronouncement symptom relief kit (SRK) effective pain & symptom management 24/7 support – nursing & medical back-up plan (hospital / hospice / NOT ER) DO NOT CALL 911! funeral arrangements
  15. 15. Barriers • • • • fragmented home care services no 24/7 support (crisis management) family dysfunction / caregiver incapable unendurable symptoms1: N=120, 52.5% @ 48hrs – delirium – severe shortness of breath / low oxygen levels – bowel obstruction (persistent vomiting) – severe pain 1Ventafridda, 1990
  16. 16. Cancer Pain & Associated Symptoms (n=1635) • • • • • • • • pain insomnia (59%) anorexia (48%) constipation (33%) sweating (28%) nausea (27%) short of breath (24%) swallowing difficult (20%) Grond et al, 1994 • • • • • • • • neuropsychiatric (20%) vomiting (20%) urinary (14%) indigestion (11%) weakness (10%) diarrhea (6%) itching (6%) skin (3%)
  17. 17. Potential Interventions drug infusions (pain, sedation) urinary catheter oxygen skin care nasogastric tube paracentesis / thoracentesis
  18. 18. Hot Button Issues • • • • nutrition hydration airway secretions pain pumps (patient controlled… but family imposed) • delirium
  19. 19. Organ Donation • in cancer patients, restricted to corneal tissue if other disqualifying conditions not present • some exceptions (lymphomas, leukemias) • for transplant, harvest within 12 hrs (& blood sample) • or teaching / research purposes
  20. 20. How long do I have to live? • MDs frequently over-estimate survival • survival rates apply to groupings of patients, not individuals • related complications & disease progression unpredictable • Surprise question: would you be surprised if this patient would die in the next 6 to 12 months?
  21. 21. • • • • • 10,772 ESAS 7,882 PPS Mean age: 65 years Functional decline gradual from 70% Rapid decline after 50% (last 2 – 3 weeks of life) Mean PPS Score Cancer patients seen at Cancer outpatient clinics across Ontario Time Before Death (in weeks) Seow H et al. JCO 2011;29(9):1151-1158
  22. 22. Palliative Performance Scale (PPS) ECOG Functional Status PPS Self-Care Intake Level of Consciousness 100 Full Normal activity No evidence of disease Full Normal Full Full Normal activity Evidence of disease Full Normal Full Full Normal activity with effort Evidence of disease Full Normal/ Reduced Full 70 Reduced Unable to do normal work Evidence of disease Full Normal/ Reduced Full 60 Reduced Unable to do house work Significant disease Occasional Assistance Normal/ Reduced Full or Confusion 50 Mainly Sit/Lie Unable to do any work Evidence of disease Considerable Assistance Normal/ Reduced Full or Confusion 40 Mainly in Bed As Above Mainly Assistance Normal/ Reduced Full or Drowsy or Confusion 30 Stable Activity & Evidence of Disease 80 Transitional Ambulation 90 0 % Totally Bed Bound As Above Total Care Reduced Full or Drowsy or Confusion 20 As Above As Above Total Care Minimal Sips Full or Drowsy or Confusion 10 As Above As Above Total Care Minimal/nil Drowsy or Coma 1 2 End-of-life 3 4 Ma C, et al. Eur J Cancer 2010 27
  23. 23. Interventions • participants were randomized to receive usual care or usual care plus facilitated advance care planning. • advance care planning aimed to – assist patients to reflect on their goals, values, and beliefs; – to consider future medical treatment preferences; – to appoint a surrogate; – and to document their wishes.
  24. 24. Conclusions • “a coordinated, systematic model of patient centred advance care planning using non-medical … facilitators assists in identifying and respecting patient’s wishes about end of life care, improves such care from the perspective of the patient and the family, and diminishes the likelihood of stress, anxiety, and depression in surviving relatives.”
  25. 25. Family Members Responses – Intervention Group • “His death was really peaceful, and everyone knew what to do.” • “We had a clear plan so could just relax and enjoy time with Dad.” • “Even though we already knew what he wanted it was great to be given the opportunity to talk about it and get it out into the open.” • “We felt really comfortable making decisions because we had discussed it with him.” • “He had a very peaceful death, just as it should have been and I would like to thank all staff for this.”
  26. 26. Family Members Responses – Control Group • “He knew he was dying, and it was very hard for him. We should have talked with him about it.” • “He should have had more say. He couldn’t do the rehabilitation. He knew he was dying, but the doctors didn’t seem to get it.” • “The hospital has a responsibility to talk with patients about these things. My sister never got a say and that is wrong.” • “They wouldn’t let her go. They kept doing tests and things she would not have wanted.” • “Mum didn’t want heroics. She knew she was dying. I was horrified when I heard she got 45 minutes of CPR. She did not want it. All anyone had to do was ask. I feel very hurt and hurt for mum and my sister.”
  27. 27. “While I very much hoped not to die in space….. Before my last space flight..... I reviewed my will, made sure my financial affairs and taxes were in order, and did all the other things you’d do if you knew you were going to die. But that didn’t make me feel like I had one foot in the grave. It actually put my mind at ease and reduced my anxiety about what my family’s future would look like if something happened to me. Which meant that when the engines lit up at launch, I was able to focus entirely on the task at hand: arriving alive.” (p 61)