PALLIATIVE CARE Presentation for resdient doctors especially those practising in Nigeria

1. Palliative Care and Principles of
Management of Terminally Ill
Patients
Dr. Itanka U.C.
Supervising Senior Registrar: Dr. Shittu

2. Outline
• Introduction
• Aims of Palliative Care
• Domains of Palliative Care
• Classification
• Indications
• Contraindication
• Principle of Management of the Terminally Ill
• Ethical Considerations
• Locoregional Challenges
• Current Trends
• Conclusion
• References

3. Introduction
• Derived from the Latin word Pallium- To cloak/cover
• To palliate means to lessen the severity of the symptoms of an
illness without curing or removing the underlying cause.
• 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, psychological and spiritual.
• Gaining grounds the world over due to increasing advanced cancer
burden.

4. • Palliative medicine has been recognized as a specialty in
• UK since 1987
• Australia and New Zeland since 1988
• more recently in USA 1996.
• Nigeria- 2003 in UCH.
• The approach to patients care is “holistic”, hence
multidisciplinary.

5. Definition of Terms
• Terminally Ill Patients
• One with a confident diagnosis that cure is not possible
• Prognosis usually in months or less
• Treatment is aimed at relief of symptoms
• Most of such patients have an advanced malignancy but non malignant
diseases also fall into this like
- ESRD, Chronic obstructive Airway Disease, Multiple Sclerosis, Motor neuron disease etc

6. Definition of Terms
• Critical Illness: A state of ill health with vital organ dysfunction, a high
risk of imminent death if care is not provided and the potential for
reversibility

7. Definition of Terms
• Surgical Palliative Care
• The treatment of suffering and promotion of quality of life for terminally ill patients
under surgical care.
• Palliative Surgery
• A surgical procedure done with the primary intention of improving Quality of Life
and/or relieving symptoms caused by an advanced disease.
• Effectiveness judged by the presence and durability of patient acknowledged
symptom resolution.
• Hospice is a “type” of palliative care for those who are at the end of their
lives.

9. Statement of Surgical Importance
• With an increasing population of cancer patients and most of them
invariably needing palliative care at a point, the practising surgeon
must be armed with the principles of caring for the terminally ill.

10. Historical Perspective
• Cure sometimes, treat often,
comfort always – Hippocrates.
• Dame Cicely Saunders founded
Hospice care 1967.

11. Aims of Palliative Care
• Provide relief from pain and other distressing symptoms.
• Affirm life and regard dying as a normal process.
• Neither to hasten or postpone death.
• Integrate the psychological and spiritual aspects of patient care.
• Offer a support system to help patients live as actively as possible until
death.
• Offer a support system to help the family cope during the patient's illness
and in their own bereavement.
• Use a team approach to address the needs of patients and their families,
including bereavement counseling, if indicated.
• Enhance the quality of life, and may also positively influence the course of
illness.

12. Domains of Palliative Care

13. Classification of Palliative Care
• Based on Timing of Intervention
• Downstream: Care assessed at later part
• Upstream: Patients palliative care needs are assessed early in their trajectory
• Based on approach
• Consultative
• Integrative

15. Indications of Palliative Care

16. Contraindication
• Patient’s refusal

17. Principle of management
• Pre-Care
• Palliative Care
• Post Palliative Care

18. Evaluation
• Establish an Indication
• Assess for common symptoms of the terminally ill
• Proper counseling
• Communication
• Prognosis
• Goals of Care - Palliative

20. Evaluation
• Goals of Care – Palliative
• Not always restricted to medical care
• Advance Care planning – Clear understanding of the wishes of the patient eg
DNR, will.
• Treatment options, outcomes and likely adverse effects
• Review

21. Symptoms of the Terminally ill
• General
• Pain
• Numbness
• CNS
• Insomnia
• Dizziness
• Respiratory System
• Cough
• Dyspnoea
• GIT
• Anorexia
• Nausea and Vomiting
• Dysphagia
• Constipation
• Diarrhoea
• Hiccups
• Urogenital System
• Incontinence
• Loss of libido
Integuments/MSS
• Pruritus

22. Psychological Symptoms
• Anxiety
• Depression
• Irritability
• Delirium
• Confusion

23. Principle of Management of Pain
• Evaluation – History (SOCRATES)
• Measure the pain –
• N/B children
• Cause of pain – concept of TOTAL PAIN

25. Pain
• Management can be modified in most patients
• Not all pain require analgesia
• Limit unnecessarily painful procedures
• Analgesics should be prescribed regularly to preempt pain
• Prescribe p.r.n. Doses of analgesics in
• Breakthrough pain
• Incident pain

27. Surgical Management of Pain

28. Dyspnoea
• Suction secretions if present
• Positioning, loose clothing.
• Limit volume of IVF; consider
diuretics if fluid
overload/pulmonary edema.
• Behavioural strategies like
breathing exercises.
• Look for the cause and manage.
Fatique
• Sleep hygiene
• Gentle exercise
• Address potentially contributing
factors like anemia, depression,
side effects of medications.

29. Weakness and Immobility
• Patient who is immobile and confined to bed loses muscle strength
• A normal person loses 10-15% muscle bulk when completely rested
and takes up to 60 days to regain this.
• Management
• Good nursing care and regular physiotherapy
• Special mattresses
• Wheelchair

30. Nausea and vomiting

31. Anorexia

32. Dysphagia

33. Symptoms
• Pruritus
• Moisturize skin
• Try specialized anti-itch lotions
• Apply cold packs
• Counter stimulation, distraction,
and relaxation.
• Evaluate for cause and palliate eg
Obstructive jaundice

34. Constipation
• Inactivity, anorexia, low-residue diet and analgesic drugs - -
(occupying opioid gut receptors) can all give rise to constipation.
Treated by combined faecal softener and peristalsis- inducing
(stimulant) laxative,
• Suppositories, enemas or manual disimpaction may also be required.
(Senokot or Dulcolax are also useful stimulant laxatives. Lactulose 15
ml twice daily is an osmotic stimulant – an alternative.)

35. • Diarrhoea
• Diarrhoea has many causes.
• It may be due to constipation with
overflow (spurious diarrhoea) and
treated .
• Treat the cause
• Convulsion
• Primary or secondary brain
deposits may produce fits and
convulsions. Treat with diazepam
l0mg three times a day, phenytoin
l00mg three times a day or sodium
valproate (Epilim) 200mg three
times a day.
• However. Dexamethasone may
reduce or eliminate the need for
anticonvulsants.

36. Anxiety
• Psychotherapy
• Depression
• Tender loving care is required, along with
mood-elevating prednisolone 5 mg twice
daily. Amitriptyline 25-75 mg daily is a
useful antidepressant. It potentiates the
analgesic effects of opiates in addition to
its inherent analgesic activity.
• When giving amitriptyline, oral hygiene is
important as it causes a dry mouth
Agitation/Terminal Restlessness
• Evaluate for organic or drug cause
• Educate family.
• Provide calm

37. Palliative surgeries
• General Surgery
• Toilet mastectomy
• Drainage procedures for ascites
• Endoscopic interventions for
stenting an obstructed lumen,
ablation of tumor, hemostasis
• Peritonectomy
• Laparotomy/laparoscopy and
bypass or resection for relief of
biliary or bowel obstruction.
1. Colostomy
2. Biliary stenting
• Cardiothoracic
• Closed-Tube Thoracostomy
Drainage for malignant pleural
effusion.
• Palliative thoracocentesis
• Oesophagus stenting

39. Palliative surgeries
• Urology
• Palliative cystectomy for
recalcitrant hematuria
• Urinary diversion
• Internal iliac artery embolization
• Cytoreductive Nephrectomy
• Orthopaedics
• Endoprosthesis
• Internal fixation
• Debulking surgeries
• Neurosurgery
• stereotactic radiosurgery (SRS)
hypophysectomy
• External ventricular drainage
• Intracranial metastasectomy

40. Other forms of Surgical Palliation
• Palliative Radiotherapy
• Palliative Chemotherapy
• IV
• Oral routes
• HIPEC

42. Post-Care/Bereavement
• Grief and mourning are natural responses to loss; most people will go
through that without clinical intervention
• Breaking Bad news
• Stages of grief
• Autopsy

45. Ethics of Palliative Care
• Patients diagnosed with terminal illness are vulnerable in their
emotional state and depend on their health care professionals (and
non-professionals) for compassionate empathetic care, sensitive
sharing of information to promote participation in decision-making
and effective symptom management.
• Their vulnerability should not be exploited

46. Foundations of the Ethical Care
• Respect for life
• Acceptance of the ultimate inevitability of death
• Relationship of honesty & trust between HCP & patient
• Beneficence and Non Maleficence
• Respect for Autonomy
• Justice

48. Ethical Challenges
• Euthanasia
• Consent for surgery
• Curative surgeries in metastatic disease – hepatic metastectomy.
• Voluntary Organ donation of healthy organs of the dead terminally ill
patient.
• Futility of care

49. Locoregional Perspective and Challenges
• 2003, first Palliative care inclusion in Nigeria.
• Limited Pain and Palliative care policy
• Poor health workers to patient ratio
• Members of MDT not knowing about the aim of care.
• Unavailability of palliative medicines like opioids

50. Current Trends
• Out-patient palliative Care

51. Conclusion
• Palliative care is care offered to the Terminally ill.
• Good communication and patient’s wishes should be respected.
• Multidisciplinary.
• Should be part of care of all terminally ill.

52. References
• National Policy and Strategic Plan for Hospice and Palliative Care,
2021.
• Past Update presentations
• https://www.slideshare.net/ooooottam/palliative-care-and-end-of-
life-care
• Postgraduate Surgery; The Candidate’s Guide, AlFallouji