This document provides an overview of end-of-life care and the role of family physicians. It covers principles of palliative care including symptom management, communication with patients and families, and ensuring comfort at the end of life. The document emphasizes treating the whole person and providing support for physical, psychosocial and spiritual needs as life-threatening illness progresses. Opioids are identified as important to relieve pain, and other medications are discussed to manage common symptoms like dyspnea, anxiety, and nausea.

1. END OF LIFE CARE
SMITH, K.D
FAMILY MEDICINE RESIDENT
02/07/20

2. Learning objectives
• Appreciate the general principles of end of life care
• Identify the needs of a terminally ill patient
• The role of family physicians in end of life care
• Palliative care principles
• Symptom management in palliative care and prescription of opiods
• Breaking bad news, assessing structure and function of a family

4. Background
• The impact of death in our society is easily underestimated
• Ensuring a good death for all is a major challenge for clinicians and the
society
• In terminally ill patients the focus should be on delivery of high quality
care rather than seeking the cure when there is limited likelihood of
success
• Patients are often more willing to accept death than the physicians who
treat them

5. Background (1)
Every clinician at one point faces these important questions:
• How can I be most helpful to a person in need when hope appears lost?
• What is the best way to deliver news of a terminal diagnosis?
• How can I develop a reasonable and thoughtful plan for end-of-life care?

7. What’s your role as a physician?
• Give emotional support
• Listen and be receptive to unexpressed ‘messages’
• Treat the sufferer normally, openly, enthusiastically and confidently
• Show empathy and compassion
• Employ good communication skill
• Give honest answers without labouring the point or giving false hope
• Provide opportunities for questions and clarification.

8. What’s your role as a physician? (1)
• Show an understanding of the patient’s needs and culture
• Adopt a whole-person approach: attend to physical, psychosocial and
spiritual needs
• Anticipate and be prepared for likely problems
• The patient needs a feeling of security
• Provide reassurance that the patient will not suffer unnecessarily
• Facilitate care and involve other important members of the team

9. Inspire hope, not fear

10. “To enable a person to live in dignity, peace and comfort
throughout their illnesses means responding to physical,
psychological, emotional, social and spiritual needs.”
E Fairbank , T Banks , Palliative C are : The Nitty Gritty Handbook

11. “The concept of quality care does not always demand that
death be regarded as an enemy to be fought with every
weapon at a physician’s disposal.’’

12. Palliative care
Is an approach that improves the quality of life of patients and their
families facing the problems 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

13. Fundamental principles of palliative care
• Management planning
• Symptom control
• Emotional, social and spiritual support
• Medical counselling and education
• Patient involvement in decision making
• Support for carers

14. Who qualifies for Palliative care?
• Incurable malignant diseases and HIV/AIDS
• Patients with end-stage organ failure (heart failure, kidney failure,
respiratory failure and hepatic failure) and degenerative neuromuscular
diseases.

15. Why FM specialist is the ideal person to
manage palliative care
• Availability to facilitates care
• Knowledge of the patient and family
• Relevant psychosocial influences

17. Palliative care services in Botswana
• Majority of services are available in the south of the country
• Palliative care service delivery is done through:
• PMH (confined to oncology ward)
• Three hospices (Holy Cross Hospice, Pabalelong Hospice and the
hospice at Bamalete Lutheran Hospital)
• Home based care programs

19. Adapted from Jan 2015 Webinar: Palliative Care by Dr Jean S. Kutner, MD

23. Management of symptoms
• Physician’s involvement should increase when fewer therapeutic options
are available
• Alleviating the fear, symptoms, and family stress is critical
• A good death means being free of pain and unpleasant symptoms
• Symptom severity can be decreased if anticipated and treated early
• Quality of dying associated with adequate symptom management and
communication of the expected outcome to the family members

24. Symptom control
Common symptoms
• boredom (the commonest
symptom)
• loneliness/isolation
• fear/anxiety
• Pain-physical, emotional,
spiritual and social
• anorexia
• nausea and vomiting
• constipation

27. Key points in pain management
• Analgesics should be given regularly in adequate doses
• Analgesics will not cause addiction or respiratory depression when titrated
appropriately
• Oral morphine is the drug of choice for severe pain.
• Bone or joint pain NSAIDs
• Neuropathic pain antidepressants or anticonvulsants
• Cramping abdominal pain or bladder spasms anticholinergics
• Restlessness and confusion antipsychotics (low dose haloperidol)

31. Dyspnea
• Identify the cause and r/o other organic causes
• Adjust the patient’s posture
• O2 helpful for hypoxic pts but may be less convenient and more expensive
than opioids.
• Morphine can be used for intractable dyspnoea
• May be helpful to provide cool, moving air (open window, fan) and keep
an unobstructed line of sight between the patient and the outside

32. Anxiety and depression
• If anxiety is severe enough benzodiazepines such as lorazepam may be
effective
• SSRIs and SNRIs effective for depression
• Psychostimulants can relieve depression and pain in some terminally ill
pts
• Quetiapine beneficial for bipolar disorder and schizophrenia, can also be
used as an adjuvant antidepressant.

33. Nausea and vomiting
• Look for reversible causes
• Metoclopramide is a drug of choice for slow gastric emptying
• Promethazine and haloperidol (low dose) can be used
• Parenteral fluids administered subcutaneously may provide some relief
from the nausea and correct mild to moderate dehydration
• Baclofen, chlorpromazine, metoclopramide and haloperidol can be used
for hiccups

35. Think about patients you have managed in
your ward?
• How did you approach those who were candidate for palliative/hospice care?
• Were you comfortable with withholding treatment?
• What was your reaction during the last days or hours of death?

36. THANK YOU

37. References
• Rakel R, Textbook Of Family Medicine
• Murtagh’s General Practice
• Palliative care: WHO
• LaVigne A W et al, Palliative care in Botswana: current state and
challenges to further development
• Ellershaw J & Ward C, Care of the dying patient: the last hours or days of
life
• Huffman J C & Stern T A. Compassionate Care of the Terminally Ill