Palliative Care

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Palliative Care

• Dr GB Crawford
• Clinical Head of Palliative Care
• Lyell McEwin Health Service

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Who is Palliative Care for?
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Breast cancer
THE DYING
PSYCHIATRIC DISEASE
Bowel cancer
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DEMENTED
LUNG FAILURE
HEART FAILURE
RENAL FAILURE
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Impact on care
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Cancer death
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COAD/Respiratory failure
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Sudden death
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Who needs what?

• Palliative approach
• Specialised Palliative Service Provision
• Terminal care

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Palliative approach

• When
• Is acute intervention the opposite of palliative?
• Where
• Community
• Hospital
• Residential care
• Who

ALL OF YOU
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Palliative approach

• Attitude
• Knowledge
• Skills

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Attitude

• Centrality of symptoms as experienced by the
  patient rather than diagnosis
• Communication with patient and family
• Teamwork
• Respecting differences
• Assessment
• Attention to detail

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Knowledge Skills

• Symptom assessment
• Pain management
• Nutrition hydration
• Cachexia
• Psychological support
• depression, anxiety, delirium
• Family support
• Cultural issues
• Spiritual support

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Knowledge Skills

• Volunteer support
• End-of-Life care
• Bereavement support

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WHO Definition of Palliative Care

• 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.

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WHO Definition of Palliative Care

• Palliative care
• provides relief from pain and other distressing
  symptoms
• affirms life and regards dying as a normal
  process
• intends neither to hasten or postpone death
• integrates the psychological and spiritual
  aspects of patient care
• offers a support system to help patients live as
  actively as possible until death

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WHO Definition of Palliative Care

• Palliative care
• offers a support system to help the family cope
  during the patients illness and in their own
  bereavement
• uses a team approach to address the needs of
  patients and their families, including
  bereavement counselling, if indicated
• will enhance quality of life, and may also
  positively influence the course of illness.

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WHO Definition of Palliative Care

• Palliative care
• is applicable early in the course of illness, in
  conjunction with other therapies that are
  intended to prolong life, such as chemotherapy or
  radiation therapy, and includes those
  investigations needed to better understand and
  manage distressing clinical complications.

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So what do we call ourselves?

• Terminal care movement
• Hospice movement
• Palliative Care
• Supportive Care
• BUT nothing changes what we do

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Consent to Medical Treatment and Palliative Care
Act

• To refuse medical treatment
• To have clear explanations given
• To appoint a Medical Agent
• To make an Advanced Directive
• Not to end lives with/ or without consent
• Doctrine of double effect

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Drugs

• Opioids
• pain
• breathlessness
• Anti-emetics
• Neuropathic agents
• Ketamine S8

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Opioids

• Immediate-release Opioids
• Morphine
• Ordine 2, 5, 10mg/ml
• Sevredol 10, 20mg tabs
• Oxycodone
• OxyNorm caps 5, 10, 20mg
• OxyNorm liquid 5mg/5ml x 250mls
• Hydromorphone
• Dilaudid 1mg/ml x 473 mls

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Opioids

• Sustained-release Opioids
• MS Contin 5, 10, 15, 30, 60, 100mg tab
• MS Contin suspension 20, 30, 60, 100mg
• MS Mono 30, 60, 90, 120mg cap
• Kapanol 10, 20, 50, 100mg cap
• OxyContin 10, 20, 40, 80mg tab
• Durogesic (Fentanyl patch) 12, 25, 50, 75,
  100mcg/hr

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Availability of medication

• Inequities especially for non-public patients
• Common drugs not on PBS
• No ability to promote some products
• Little evidence
• Non-commercial usage
• Bureaucracy not responsive
• Combined COSA/PCA/ANZSPM Therapeutics Committee

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Medications

• Coloxyl with senna
• Midazolam
• Clonazepam
• Hyoscine
• Gabapentin
• Fentanyl injection
• Ketamine

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PBS Palliative Care Drugs

• A patient with an active, progressive,
  far-advanced disease for whom the prognosis is
  limited and the focus is the quality of life.

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PBS Palliative Care Drugs

• Dry mouth
• Aquae mouth spray
• Colicky abdominal pain
• Buscopan
• Antiemetics
• Promethazine
• Laxatives
• Bisalax, Durolax, Fleet, Coloxyl, Granocol,
  Microlax, Glycerol

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PBS Palliative Care Drugs

• Analgesics
• Paracetamol suppositories
• Anti-epileptics
• Clonazepam
• prevention of epilepsy

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How to care for yourself
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What Is Burnout?

• Progressive loss of idealism and commitment to
  work, leading to reduced
• Energy and purpose
• Role dissatisfaction
• Negative attitudes towards patients, colleagues
  and oneself
• It may culminate in exhaustion, depressive
  disorders and post-traumatic stress disorders

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Care Provider

• Protective characteristics
• Training and Communication skills
• Personal philosophy
• Personal resilience

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Care Provider

• Vulnerability characteristics
• Poor supports
• Younger providers engaged in full-time care
• Stressful life-events
• PHx of depressive or psychiatric disorder
• Compulsive care giving
• Propensity to self-medicate

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Patient

• Protective characteristics
• Good symptom control
• Open communication style
• Good psychological adjustment
• Well-supported by family and friends

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Patient

• Vulnerability characteristics
• Poor symptom control
• Psychiatric disorders or difficulties with
  adjustment
• Personality disorder
• Dysfunctional family
• Social isolation

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Work Environment

• Protective characteristics
• Teamwork
• Role definition
• Supportive conditions
• Appropriate staff structure

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Work Environment

• Vulnerability characteristics
• Work overload
• Role ambiguity or conflict
• Poor teamwork
• Administrative problems

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Warning Signs

• Fatigue
• Boredom
• Frustration
• Low morale
• Sleep disturbance

• Decreased empathy
• Increased absenteeism
• Interpersonal problems
• Physical symptoms

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What can we do?
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Have some really good friends
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Have family time
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Keep a childlike heart
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Work in a team
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Be confident and proud of yourself
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Avoid indecisiveness
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Work from time to time
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Respect the weak
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Be willing to help others
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Get on with different kinds of people
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Forgive others
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Set realistic targets and goals
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Smile
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Share the happiness with others
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Keep your sense of humour
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Keep calm whatever happens
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Learn to accept your own limitations
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Indulge yourself, sometimes
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What Can We Do?

• Training
• Limit work load
• Vary work
• Health
• Take leave

• Interests/hobbies/ creativity
• Think positive
• Kindness
• Realistic expectations

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What can we do?

• Sense of purpose/personal philosophy
• Debrief
• Recognize incompatibility

• Grieve
• Recognize stress
• Ask for help
• Laugh!!!!! (Especially in a crisis)

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What can our organisations do?

• Resources
• Trained staff
• Team building and support
• Enhance communication
• Quality assurance
• Administrative, financial and managerial support
• Continuing education

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