Care of the dying patient Dying well by sofiaie

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									 Care of the dying patient:
Are our patients dying well?

        Rachel Cooper Şen
      Dokuz Eylül Üniversitesi
     Radyasyon Onkolojisi ABD
              İzmir
              Ankara 2003
     Palliative Therapy - Aim

 Maximum benefit with minimum
          treatment

Avoid increasing morbidity with treatment or
                investigations


                   Ankara 2003
    Aims of Palliative Therapy
Symptomatic brain mets (SCLC)

                                  Europe          USA

Extend Life                        23%            48%
Relieve Symptoms                   87%            96%
Prevent Symptoms                   39%            80%
„Give Hope‟                        20%            44%

                                           Maher et al 1992
                    Ankara 2003
           Care of the Dying
Summary points
  • Too many patients die an undignified death
    with uncontrolled symptoms
  • Diagnosing dying is an important clinical skill
  • Transfer of best hospice practice to other
    settings
  • Education of all health care professionals
  • Allow death with dignity - resources
  • National indicators for care of the dying patient
    should be identified and monitored
                       Ankara 2003
    Barriers to Diagnosing Dying
• Hope that patient may get better
• No definitive diagnosis
• Continuation of unrealistic interventions
• Disagreement about patient‟s condition
• Failure to recognise key symptoms and
  signs
• Lack of knowledge about how to prescribe
                   Ankara 2003
    Barriers to Diagnosing Dying
• Poor communication
• Concerns about withdrawing treatment
       • Artificial nutrition
       • Hydration
•   Fear of shortening life
•   Concerns about resuscitation
•   Medicolegal issues
•   Cultural and spiritural issues
                            Ankara 2003
           Diagnosing Dying
• Functional / Performance status
• „Terminal cancer syndrome‟
     • Anorexia
     • Weight loss
     • Dysphagia / dry mouth
• Cognitive failure and confusion
• Site of primary and metastatic disease
• Clinical predictions – Over optimistic
                       Ankara 2003
               Predicting Survival
    Study          No.       Median       Median     Estimated
                 Patients   estimated     survival    / actual
                             survival     (weeks)       ratio
                             (weeks)
 Parkes „72        168          4.5         2.5         1.8
 Heyes „87          50           8           2           4
 Forster „88       108           7          3.5          2
 Maltoni „94       100           6           5          1.2
 Vigano „99        210         15.3        14.2        1.08
Christakis „00     468         18           3.4         5.3
                            Ankara 2003
         Prognostic Index - NSCLC
Prognostic factors
     •   Stage                I-II vs III
     •   Performance status   > 70 vs >/= 70
     •   Symptoms             none / local vs general / metastatic
     •   Tumour size          < 7 cm / vs >/= 7 cm
     •   Haemoglobin          > 12.5 vs < 12.5
  Risk Factor                 Median survival (months)
     0                                27
     3                                8
     5                                4
                                                      Wigren T 1997
                              Ankara 2003
                Prognostic Index
• Primary cancer site                • ESAS appetite
         –   Breast                              –   0
         –   Prostate                            –   1-3
         –   Lung
                                                 –   4-7
         –   Other
                                                 –   8-10
• Site of metastases
         – Bone only
                                     • ESAS shortness of
         – Others                      breath
• ESAS fatigue                                   –   0
         –   0                                   –   1-3
         –   1-3                                 –   4-7
         –   4-7                                 –   8-10
         –   8-10
                    Chow et al Int J Radiat Oncol Biol Phys 2002: 53; 1291
                              Ankara 2003
Prognostic Index - Score




       Chow et al Int J Radiat Oncol Biol Phys 2002: 53; 1291
             Ankara 2003
Prognostic Index – Number of
           Factors




            Ankara 2003
                          Chow et al 2002
              Diagnosing Dying
Failure to diagnose dying effects on patient/family
• Unaware of imminent death
• Loss of trust
• Conflicting messages from different doctors
• Patient dies with uncontrolled symptoms
• Death distressing and undignified
• Patient and family dissatisfied
• Inappropriate resuscitation / treatment / investigations
                          Ankara 2003
           Communication
• Regional variation in communication with
  cancer patients
• 84% of healthy Turkish patients want to be
  informed of cancer diagnosis
• 63% want their relatives to know
• 44% would make life changes if diagnosed
  with cancer
                    Şen et al 1997. Cetingoz et al 2002
                   Ankara 2003
Many people find that when they are
told that they will not recover from their
cancer, they are overcome by thoughts
of all the things they still want to do and
unfinished business which they need to
sort out. The most important advice at
this stage is to go ahead and do all the
things which you are fit enough to
enjoy. This is not a time for delaying - if
you really want to do something, then
do it and enjoy it now!
   Cancer BACUP UK Dying with cancer. Advice book for patients
                         Ankara 2003
               Care of the Dying
Goals of physical treatment
• Symptoms assessed
• Current medication assessed
       • Discontinue non essential
•   Consider non-oral routes
•   Discontinue inappropriate interventions
•   Discontinue vital sign measurements
•   Consider resuscitation status

                              Ankara 2003
Care of the Dying - Investigations
 54 patients all died <7 days after last visit
 Patient number           Investigation / treatment
  40/54 (74%)                           X-rays
  50/54 (93%)                         Blood tests
   2/54 (4%)                      Isotope scan
  17/54 (31%)                    Chemotherapy
   1/54 (2%)                         Radiotherapy
  40/54 (74%)                         Analgesics

   “More attention paid to the cancer than patient”
                       Ankara 2003                  Holli et al 1989
Patients maybe
more willing to
accept
investigations

   BUT

Will the results
alter your
management ?


                                 Meystre et al BMJ 1997:315;1202
                   Ankara 2003
Care of the Dying - Investigations
Patient decision making
• 917 patients
      • NSCLC stage III / IV
      • Colon cancer with liver mets
• Patients who believed they would live > 6 months
  more likely to favour aggressive treatment
• Highest in patients who believed 90% chance of
  living 6 months but physicians believed 10%
• No difference in survival for aggressive versus
  symptomatic treatment
                                          Weeks JAMA 1998:279;1709
                            Ankara 2003
    Care of the Dying – Hydration
       and Artificial Nutrition
•   No evidence to show prolongs life
•   Benefit is limited
•   Assessment of patient. Better communication
•   Improve oral hygiene
•   Change food type
•   Help family patient interaction
•   Corticosteriods to improve appetite
•   Prokinetic agents
•   Treat nausea and vomiting
                       Ankara 2003
Care of the Dying - Resuscitation
• 0-10% of cancer patients survive
  resuscitation to discharge
• Younger doctors more likely to resuscitate
      • Less experience of poor outcome
      • More value to long life versus quality of life
• Doctors experienced in terminal care less
  likely to resuscitate
• Patients / relatives directives of great help
                          Ankara 2003
Care of the Dying - Resuscitation
                                      Cardiac Arrest and resuscitation
                                                  n=244


                Anticipated arrest                           Sudden arrest        Died
                  n=171 (70%)                                 n=73 (30%)          n= 57


Return of circulation                 Died                Return of circulation
       n=22                          n=149                       n=16


 Hospital discharge                                    Discharged from Hospital
        n=0                                                     n=16


                                               Ankara 2003
                                                                      Ewer et al Cancer 2001
Care of the Dying - Resuscitation
• What is the patients prognosis?
• Is the current situation reversible?
• Will resuscitation prolong suffering?
     • Especially if patient is transferred to ITU
• Has resuscitation been discussed with the
  family / patient?
• What are the resource implications?
                         Ankara 2003
    Care of the Dying Psychological
                Support
• Assess insight into condition
       • Patient
       • Relatives
•   Assess how patient will be told of condition
•   Identify how family and friends will be told
•   Explain plan of care
•   Respect patients requests
•   Don‟t raise expectations unreasonably
                      Ankara 2003
 “The ultimate goal of
   palliative care is the
 achievement of the best
quality of life for patients
   and their relatives”
                         WHO 1990


           Ankara 2003
It is possible to die well




          Ankara 2003

								
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