Palliative and End of life care

1. PALLIATIVE AND END OF LIFE CARE
MODERATOR : Dr.(Prof)NAGAPPA

2. OUTLINE
• INTRODUCTION
• NEED FOR PALLIATIVE CARE
• MILESTONES IN INDIA
• CONCEPT OF PALLIATIVE CARE
• AIMS AND OBJECTIVES
• MEDICAL EMERGENCIES
• PRESENTING SYMPTOMS
• END OF LIFE CARE

3. “From inability to let well alone, from too much zeal for the
new and contempt for what is old, from putting knowledge
before wisdom, science before art and cleverness before
common sense, from treating patients as cases and from
making the cure of the disease more grievous than the
endurance of the same, good Lord deliver us.” – Sir Robert
Hutchinson
“Cure sometimes, treat often, comfort always “ -Hippocrates

5. INTRODUCTION
• More than 80% of death usually occur after a certain
period of debility.
• The condition leading to this could be Non
communicable disease, most commonly Cancer,
Diabetes, Cardiovascular disease , chronic respiratory
disease , renal failure , neuropsychiatric illness.
• These patients need more of supportive care and are
usually sent home “We cannot do anything more for
him/her”

6. CONTD
• Palliative care is derived from the word palliare = “to
cloak”
• It is a multi-disciplinary approach and specialized
medical care for people with chronic and serious
illness
• The goal of therapy is to improve the quality of life.
• It focusses on providing relief from symptoms, pain
,physical and mental stress.

7. DEFINITION
• “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.”- WHO

8. NEED FOR PALLIATIVE CARE
• In India the life expectancy has doubled from 32 years
at independence.
• It is estimated that by 2050 there will be more than
320 million people above the age of 60 years
comprising 20% of the population.
• The age related issues and comorbidities will form the
largest group needing palliative care.
Elderly in India- 2016. Central Statistics Office Ministry of Statistics and Programme Implementation,Government of India
(www.mospi.gov.in)

9. MILESTONES IN INDIA
• 1986 – “Shanti Avedana Ashram “ in Mumbai
• 1990 – Cancer relief India (CRI) UK charity founded –
Provide education to doctors and nurses in palliative
care
• 1994 - Pain and palliative clinic at Calicut
• 1994 –Indian association of palliative care aimed at
propogating palliative care in india along with
facilitating education initiatives and drug availability

10. • 1997 – CAN support , delhi ( First palliative care home
in north india )
• 2001 –Neighborhood Network in palliative care (
NNPC) a network of 150 clinics with 10000 trained
volunteers , 85 doctors, 270 nurses looking after
25000 people at any point
• 2008- Palliative care policy in Kerala
• 2012- National program for palliative care
• 2017- health policy of the Government of India has
identified palliative care as one of the key areas

13. Strategies for Palliative Care in India (Expert group report). 2012. Directorate
General of Health Services,Ministry of Health & Family Welfare, Govt of India.

14. AIMS
• To eliminate or reduce discomfort
• Improve Quality of life
• To improve mood
• To decrease fatigue
• To decrease pain

15. • Cancer
-Any patient whose cancer is metastatic or inoperable
• Heart Disease
-CHF at rest, EF <20% , New dysrhythmia, Cardiac arrest,
syncope or CVA, Frequent ER visits
• Pulmonary disease
-Dyspnea at rest, Signs/Symptoms of Right heart failure, O2
sat on O2 <88%; pCO2 >50; Unintentional weight loss.
Identifying a candidate for palliative Care
1

16. Identifying a candidate for palliative Care
• Dementia
-Inability to walk; Incontinence ;Fewer than 6 intelligible words;
Albumin <2.5 , decreased PO intake ; Frequent ER visits.
• Liver disease
-PT >5 seconds, Albumin <2.5; Refractory ascites ;SBP;
Jaundice; Malnutrition and muscle wasting
• Renal disease
-Not a candidate for dialysis, eGFR <15ml/min ; Creatinine >6.0
1

17. BREAKING BAD NEWS : “P-SPIKES” PROTOCOL
• P-Preparation
• S-Setting
• P-Perception
• I-Invitation
• K-Knowledge
• E-Emotion
• S-Summarise
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18. 1

19. 1

20. Goals of Care
Avoid saying :
• “withdraw care”
• There is nothing left to do
• I think it is time to stop aggressive care
Instead say
• “We will always care for you(your loved one)”
• “Sometimes the burden of therapy far outweighs the
benefit “
1

21. MEDICAL EMERGENCIES IN PALLIATIVE CARE
•Neutropenic Sepsis
•Spinal Cord Compression
•Superior vena Cava Obsruction
•Hemorrhage
•Convulsions
•Hypercalcemia
1

22. SYMPTOMS IN PALLIATIVE CARE
PHYSICAL PSYCHOLOGICAL
1. Pain
2. Fatigue and weakness
3. Dyspnea
4. Insomia
5. Dry mouth
6. Nausea, vomiting
7. Constipation
8. Cough
9. Pruritus
10.Diarrhea
11.Tinging Numbness in
hands/feet
1. Anxiety
2. Depression
3. Hopelessness
4. Meaninglessless
5. Irritability
6. Impaired concentration
7. Confusion
8. Delirium
9. Loss of Libido

23. PAIN
• an unpleasant sensory and emotional experience
associated with actual or potential tissue damage or
described in terms of such damage
• Pain is the “fifth vital sign”
• It is most common and distressing symptom in cancer
• It can be classified into
-Duration ( acute and chronic)
-Etiology (Nociceptive,
-Severity : Mild , moderate , severe

25. Concept of “TOTAL PAIN”

27. ABBEY PAIN SCALE

28. PAIN RELIEF LADDER
• STEP 1 : paracetamol
/ibuprofen/naproxen/diclofenac
• STEP 2: Tramadol
• STEP 3 : Morphine/codeine

29. NON PHARMACOLOGIC THERAPIES
• Radiotherapy
• Physiotherapy
• Psychological techniques
• Stimulation therapies
• Herbal medicine and homeopathy
`

30. GI symptoms
SYMPTOM CAUSE TREATMENT
Coated tongue Rule out candida Mouthwash/pineapple/VitC
Xerostomia Drugs, candida, dehydration ,
mouth breathing, oxygen
therapy
Underlying cause
Pilocarpine(Avoid glaucoma,
BAHeart failure)
Oral pain Infection , Ulceration,
mucositis,
Choline oral paste,
chlorhexidine wash(?)
Ketamine( neuropathic)
Oral ulcers Trauma, nutritional , infectious Self limiting.Evalaute if
persistnant
Aphthous ulcers - Topical steroids(5 d)
tetracycline mouthwash
Infection Candida, HSV,
coliforms/streptococcus ,
Nystatin susp, Metronidazole
400mg tid

31. SYMPTOM CAUSE TREATMENT
Constipation Multifactorial Osmotic-Lactulose
Stimulant-Bisacodyl/Dantron
Surface -Docusate
Diarrhea Laxative, drugs, Fecal
impaction, radiotherapy,
malabsorption, Rectal
tumor, endocrine tumor
Underlying cause
Hiccups Irritation of diaphragm (
vagus, phrenic, Systemic
cause)
Gastric distention-
metaclopromide
Smooth muscle relax-
nifedipine
Induce gag
Ascites Malignant ascites Paracentesis, diuretics

32. NAUSEA AND VOMITING
STEP DRUG
STEP 1 Narrow –
Metaclopromide,
cyclizine, haloperidol
STEP 2 Ondansetron/combinati
on
Broad
:Levomepromazine

33. PSYCHIATRIC ASPECTS
• Requires a comprehensive team approach with a
psychiatrist and psychologist
• Periodic assessments by the multi-disciplinary team
• Organic causes always considered first before
• Anxiety , Depression , Delirium are the most common
psychiatric symptoms encountered.

34. END OF LIFE CARE
• A significant amount of people who die in hospital are
shifted to Critical care unit prior to death
• “Comfort care” vs “Therapeutic strategies” represents
a continuum of care in a patient with a life-
threatening illness
• End of Life(EOL) life support interventions might add
to agony , distress and not mitigate the suffering .
`

36. • Aggressive intervention at EOL drain resources of
patients and family
• Non availability of EOLC and rising costs have forced
78% patients to leave hospital against medical advice
• There is increasing awareness and recognition on the
avoidance of inappropriate use of aggressive
interventions.
• The Supreme court judgement in the case of Aruna
Shanbag recognizes the legality of with holding life
support.

37. GUIDELINES SUMMARY
1. Physicians objective & subjective assessment of
medical futility.
2. Consensus among all the care givers
3. Honest , accurate and early disclosure of the
prognosis to the family
4. Discussion and communication of modalities of EOLC
with the family
5. Shared decision making – Consensus through open
decision making

38. 6.Transparency and accountability through accurate
documentation
7.Ensure consistency among care givers
8.Effective and compassionate palliative care to patient
and appropriate support to the family
9. After death care
10.Bereavement care/support
11. Review of care process
End-of-life care policy: An integrated care plan for the dying , ISSCM( IJCCM Sep 2014)