Palliative Care

To cure sometimes, to relieve often, to comfort

always,
Dr. Edward Livingston Trudeau (1848 1915)
Founder of a tuberculosis sanatorium

Definition

A special kind of patient and family-centered

health care that focuses on effective management of
distressing symptoms, while incorporating
psychosocial and spiritual care according to
patient/family needs, values, beliefs and cultures.

 To anticipate, prevent and reduce suffering and

to support the best possible quality of life for
patients and their families, regardless of the stage of
the diseases or the need for other therapies.

Goals

Begins at diagnosis and shoud be delivered

concurrently with disease-directed, life-prolonging
therapies.
Becomes the main focus when other therapies are no
longer effective, appropriate, or desired.

Comprehensive Assesment

Assesment
and Care
Planning

Focus on evaluating the patients condition in four

domains affected by illness:

physical
psychological
social
spiritual.

Communication,esp. when giving bad news PSPIKES.

Assesment
and Care
Planning

Continuous Goal Assessment

Should become part of the routine patient reassessment
To integrate palliative care with curative care regardless of
prognosis

Assesment
and Care
Planning

Palliative care no longer conveys the message of failure,

having no more treatments, or giving up hope
Advanced Care Planning
A 2010 study of adults 60 y.o. who died between 2000
2006:
42% required decision-making about treatment in the final days
of life.
70% lacked decision-making capacity
one-third did not have advance planning directives

Such planning should occur before a health care crisis or the

terminal phase of an illness

Advanced
Care
Planning

 Physical Symptoms and Their Management

Intervention

 The 5th vital sign.

Frequency of pain varies widely, occurs in 3690% of
patients with advanced cancer.
A subjective experience

Pain

depending on the patients circumstances,

perspective, and physiologic condition

the same physical lesion or disease state can produce

different levels of reported pain.

 Etiology:
Nociceptive pain
Somatic
Visceral

Neuropathic
Mixed

Pain
Assessment

Systematic assessment includes:

1. Type: throbbing, cramping, burning, etc.;
2. Periodicity: continuous, with or without
exacerbations, or incident;
3. Location;
4. Intensity;
5. Modifying factors;
6. Effects of treatments;
7. Functional impact;
8. Impact on patient.

Pain
Manageme
nt

 Reported in up to 87% of patients requiring palliative

care.
Etiology many factors, including:

Constipatio
n

most frequently a predictable consequence of the

use of opioids and tricyclic antidepressants (from their
anticholinergic effects).
hypercalcemia,
inactivity
poor diet

If untreated pain, vomiting, confusion, delirium,

etc.
Whenever opioids and other medications known to
cause constipation are used, preemptive treatment
for constipation should be instituted.

 Establish the patients previous bowel habits:

Constipatio
n
Assessment

frequency,
consistency,
volume.

Identify etiology.
Abdominal and rectal examinations should be
performed to exclude impaction or acute abdomen.

Physical activity,
Adequate
hydration,
Dietary
treatments

Constipatio
n
Manageme
nt

May not be
applicable in most
seriously ill
patients.

 The subjective sensation

of wanting to vomit.
Up to 70% of patients
with advanced cancer
have nausea.

Nausea

Etiology stimulation
at one of following:
GI tract
Vestibular system,
Chemoreceptor trigger
zone (CTZ)
Cerebral cortex.

Medical treatments are

aimed at receptors at
each of these sites

Specific causes of
nausea
Metabolic changes
(liver failure, renal
failure,
hypercalcemia)
Bowel obstruction,
constipation
Infection
GERD
Vestibular disease
Brain metastases
Medications (including
chemotherapy)
Radiation therapy.
Anxiety

 A single specific cause is not found begin

treatment with a dopamine antagonist such as
haloperidol or prochlorperazine.
Decreased motility metoclopramide

Nausea
Treatment

Inflammation of the GI tract glucocorticoids

Chemotherapy and radiation therapy related 5-HT3
receptor antagonists (ondansetron, granisetron,
dolasetron) CINV guidelines.
Vestibular cause (motion sickness or labyrinthitis)
antihistamines (such as meclizine) or anticholinergics
(such as scopolamine).
Anticipatory nausea, benzodiazepine

 Physical wasting with loss of skeletal and visceral

muscle mass.
Very common.
Often preceeded by anorexia (losing the desire to eat)
although not necessarily so.

Cachexia

Caused by proinflamatory cytokines and tumorderived factors muscle proteolysis.

Leads to asthenia (weakness), hypoalbuminemia,
emaciation, immune system impairment, metabolic
dysfunction and autonomic failure.
Associated with failure of anti-cancer treatment,
increased treatment toxicity, delayed treatment
initiation, early treatment termination, shorter
survival and psychosocial distress.

Cachexia
Treatment

Cachexia
Treatment

 A subjective experience of being short of breath.

The most distressing physical symptoms, can be more
distressing than pain
Nearly 75% of dying patients experience dyspnea at
some point in their illness.

Dyspnea

May not correlate with objective measures of PO2,

PCO2 or respiratory rate
Potentially reversible or treatable causes of dyspnea:

infection,
pleural effusions,
pulmonary emboli,
pulmonary edema,
asthma,
tumor encroachment on the airway

 Treat reversible etiologies if any, but mostly only

symptomatics.
Sitting the patient upright.
Removing smoke or other irritants such as perfume.
Ensuring supply of fresh air or oxygen with sufficient
humidity.

Dyspnea
Treatment

Minimizing other factors that can increase anxiety.

 Many people believe that depression is normal among

seriously ill patients because they are dying.
However, depression is not a necessary part of
terminal illness.

Depression

Sadness, anxiety, anger, and irritability in modest

intensity and transient normal responses to a
serious condition.
Persistent sadness and anxiety physically disabling
symptoms abnormal suggestive of major
depression.
75% of terminally ill patients experience depressive
symptoms only <25% have major depression.
Assessment should focus on the dysphoric mood,
helplessness, hopelessness, and lack of interest and
enjoyment and concentration in normal activities.

 Treat any physical symptom that may be causing or

exacerbating depression.
Fostering adaptation to the many losses.
Group or individual psychological counseling, and
behavioral therapies.

Depression
Treatment

Pharmacologic interventions remain the core of

therapy same medications are used as in non
terminally ill patients.
Psychostimulants (dextroamphetamine,
methylphenidate, modafinil, pemoline, mirtazapine)
Selective serotonin reuptake inhibitors (fluoxetine,
sertraline, paroxetine, citalopram)
Serotoninnoradrenaline reuptake inhibitors
(venlafaxine)
Atypical antidepressants (trazodone, bupropion)

 A global cerebral dysfunction characterized by

alterations in cognition and consciousness.
Relatively common in the hours and days before death.
Up to 85% of patients may experience terminal
delirium .
Still significantly underdiagnosed.

Delirium

Frequently preceded by anxiety, changes in sleep

patterns (especially reversal of day and night), and
decreased attention.
Hypoactive delirium characterized by sleepwake
reversal and decreased alertness.
Hyperactive delirium characterized by overt
confusion and agitation.
The etiology may be multifactorial.

 Metabolic encephalopathy arising from liver or renal

failure, hypoxemia, or infection
Electrolyte imbalances
Paraneoplastic syndromes

Delirium
Etiology

Dehydration
Brain tumors (primary or metastases), or
leptomeningeal spread of tumor
Side effects of treatments:
Radiation for brain metastases
Medications opioids, glucocorticoids, anticholinergic
drugs, antihistamines, antiemetics, benzodiazepines,
and chemotherapeutic agents

 A strong determinant of bereavement difficulties is

witnessing a difficult death terminal delirium
should be treated aggressively.

Delirium
Treatment

The family should be informed that delirium is

common just before death at the first sign of
delirium (slight changes in mentation), let the family
members know that it is time to be sure that
everything they want to say has been said.
If medications are suspected of being a cause of the
delirium, unnecessary agents should be discontinued.
Treat any reversible causes if any.
Pharmacologic management focuses on the use of
neuroleptics and, in the extreme, anesthetics.

Delirium
Medications

 Difficulty initiating sleep or maintaining sleep, sleep

difficulty at least 3 nights a week, or sleep difficulty that
causes impairment of daytime functioning.
Occurs in 1963% of patients with advanced cancer.
Medications antidepressants, psychostimulants,
steroids, and agonists, antihistamines and cafein
significant contributors to sleep disorders.

Insomnia

Should be screened for anxiety and depression.

The mainstays of intervention:
improvement of sleep hygiene encouragement of
regular time for sleep, decreased nighttime distractions,
elimination of caffeine and other stimulants and alcohol),
intervention to treat anxiety or depression.

When benzodiazepine are prescribed short-acting

ones (such as lorazepam) are favored over longer-acting
(such as diazepam).

 Prepare and educate families about dying process.

two different paths to death:

Care During
the Last
Hours

 Careful attention to oral swabbing, lubricants for the

lips, and use of artificial tears.
Loss of gag reflex and dysphagia accumulation of
oral secretions noises during respiration the
death rattle
Scopolamine can reduce the secretions.

Care During
the Last
Hours

Inform the family and caregivers death rattle

may occur and that it is not indicative of suffocation,
choking, or pain.
Physician should remind the family and caregivers
about the inevitability of events and the palliative
goals.
Emphasize that interventions may prolong the dying
process and cause discomfort withholding
treatments is both legal and ethical and that the
family members are not the cause of the patients
death.

 Hearing and touch are said to be the last senses to

stop functioning families and caregivers can be
encouraged to communicate with the dying patient
talk directly and hold the patients hand even if he
or she is unconscious can be an effective way to
channel their urge to do something for the patient.

Care During
the Last
Hours

When the plan is for the patient to die at home, inform

the family and caregivers how to determine that the
patient has died.
Inform whom (can be hospice, covering physician or
paliative care team) the family or caregivers should
contact when the patient is dying or has died.
Death of a spouse is a strong predictor of poor health,
and even mortality, for the surviving spouse alert
the spouses physician about the death so that he/she
is aware of symptoms that might require professional
attention.

Thank You