Palliative Care Approach in Wound management

SLH 25/5/2012

Content
What is palliative care? When is palliative care appropriate? Who do we look after? How do we look after (Approach)? Where do we look after them?

There are only 2 things certain in life: death & taxes

Benjamin Franklin

What is palliative care?

WHO Definition of Palliative Care

Palliative care is an approach that improves the quality of life of patients and their families facing the problem 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.

http://www.who.int/cancer/palliative/definition/en/

WHO Definition of 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;

http://www.who.int/cancer/palliative/definition/en/

WHO Definition of 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; 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.
http://www.who.int/cancer/palliative/definition/en/

Who are we?

Who are we?

Doctors Dietitian Nurses

Chaplains

Patient & family

Social worker

Allied Health

Psychologists

Pharmacists

When is palliative care suitable?

EVOLUTION OF PALLIATIVE CARE

1960s 1970s

Early detection

Diagnosis/treatment

Palliative Care

Death

1980s -- present
Diagnosis/treatment Palliative care Preventio Early detection n Death

EVOLUTION OF PALLIATIVE CARE

The Future
Diagnosis
Disease-modifying therapies Symptom control Death preparation

Death

Family support

Mr Gan told The Straits Times that he has appointed Prof Pang to head a task force to study the recommendations and how to implement them. The task force will look into integrating palliative care with curative medical treatment. This means patients with terminal illnesses will get palliative care while being treated for their conditions, instead of having it kick in only when nothing more can be done to prevent the illness from getting worse. The report noted that patients identified for palliative care at a late stage usually do not fare well, and often endure unnecessary hospitalisation. It also pointed to the need to educate people on palliative care, given that many associate it with giving up hope and treatment.

Singapore to promote palliative care Salma Khalik The Straits Times Publication Date : 06-01-2012 http://www.asianewsnet.net/home/news.p hp?id=25940&sec=7

Who do we look after?

& How do we look after them? (Approach)

Causes of mortality in Singapore 2010

http://www.moh.gov.sg/content/moh_web/home/statistics/Health_Facts_Singapore/Principal_Ca uses_of_Death.html

Total no of death 17610 Cancer 28.5% Ischaemic Heart Disease 18.7% Pneumonia 15.7 % Cerebrovascular Disease (including stroke) 8.4 % Accidents, Poisoning & Violence 5.5 % Other Heart Diseases 4.8 % Chronic Obstructive Lung Disease 2.5 % Urinary Tract Infection 2.5 % Nephritis, Nephrotic Syndrome & Nephrosis 2.2 % Diabetes Mellitus 1.0 %

Palliative care
2020, more than 10,000 people a year would

need palliative care here, up from 8,000 in 2009.

Who do we look after?

Cancer Organ failures Frailty

Typical illness trajectories for people with progressive chronic illness.

Murray S A et al. BMJ 2005;330:1007-1011

2005 by British Medical Journal Publishing Group

Prognosis identifying the stages

Prognosis of main illness Prognosis of wound Prognosis of coormorbidities If possible, always aim for curative in conjunction

with palliative

Prognostication
The

physician who can foretell the course of the illness is the most highly esteemed. Hippocrates

Prognostication
It is about recognising the process ( of transition

from living to dying) Understanding of the illness Understanding of the patient ( more difficult) Ds specific tool General tool

Prognostication
Cancer

Advanced Cancer B12-CRP Index via Pallimed Breast Adjuvant! Online Lung Adjuvant! Online Colon Adjuvant! Online Paraneoplastic/Complications via EPERC Fast Facts

Congestive Heart Failure

Seattle Heart Failure Model via University of Washington EFFECT (Enhanced Feedback for Effective Cardiac Treatment) via CCORT

Prognostication
COPD

BODE Index via EPERC Fast Facts Dementia Mortality Risk Index or MDS-12 via EPERC Fast Facts Liver Disease MELD Score (Model for End Stage Liver Disease) via Mayo Clinic Primary Biliary Cirrhosis via Mayo Clinic HIV and HAART ART Cohort Collaboration

Prognostication
Intensive Care Unit

APACHE II via SFAR SAPS via SFAR ProVent Score

Renal Patients

Modified Charlson Comorbidity Score via EPERC Fast Facts

Prognostication

Hospice/Palliative Care Patients Palliative Performance Scale v2 (Victoria Hospice) in conjunction with the tables found in these two articles: Harrold J, Rickerson E, Carroll JT, et al. Is the palliative performance scale a useful predictor of mortality in a heterogeneous hospice population? J Palliat Med. Jun 2005;8(3):503-509. Lau F, Downing GM, Lesperance M, Shaw J, Kuziemsky C. Use of Palliative Performance Scale in end-of-life prognostication. J Palliat Med. Oct 2006;9(5):1066-1075. Or you can use the Victoria Hospice Prognostat, based on their collective knowledge of PPS scores and survival over the last 10+ years.

Victoria Hospice has a number of great prognostic tools on their website as part of the Victoria Palliative Research Network.
Palliative Prognostic (PaP) Score requires evaluation of dyspnea, anorexia, KPS, clinical estimate of survival, total WBC, and lymphocyte percentage. Groups into 3 categories of chance at 30d survival. (Via EPERC Fast Facts) Palliative Prognostic Index requires PPS, estimate of oral intake, and evaluation of edema, dyspnea, and delirium. See page 4 of this PDF for the scale.

Prognostication
Declining Palliative Performance Status Momentum of decline Are you surprise ..

Prognostication
Take a good history =

communication !

Why is prognostication important?

Establish goal of care Goal changes as the illness

changes

Prognosis (survival)
Days

- symptoms control alone Weeks - mainly focusing on symptoms control Months - symptoms control + wound healing if possible Years - symptoms control + wound healing if possible

Care of the dying

We have a large number of [nurses who havent

trained in the UK] & one of the biggest challenges for them was the idea that you could actually have a planned death. Because in their culture you do everything you can to sustain lifeso that was a bit of a challenge there for them to understand that there was a time to diethat we werent assisting death but planning for the inevitable. [NHB Manager] - St.Christophers
o Adapted from slides from Prof Scott Murray

Approach to palliation

Active Palliative Care

Palliative Care with limited interventions

Full palliative mode

Approach to palliation
Always ask yourself:

What is the goal & extend of care of the patient?

Approach based on the following principles

Treat the PATIENT, including family and other related persons, not just the disease or the debility. Patient autonomy Beneficence Nonmaleficence Justice The above need to be applied against a background of respect for life and acceptance of the ultimate inevitability of death.

Principle of Guidance for treatment

Medical Indications Patients preference

Quality of life

Contextual

Approach to palliation
Advanced care planning - BIPAP, antibiotics, NG tubes, extend of invasive

procedures (e.g PCN insertion for hydronephrosis) - Hospitalisation, location of care

Medical opinion

- Reversibility of illness
- Stages of patient

Wound care

Cancer

Non-cancer patient

Cancer
Malignant wound (direct invasion vs skin mets)

- eg.fungating breast tumour; SCC; Melanoma

Treatment related wound

- Radiotherapy - Post-operative

Malignant wound
Disease control if possible Systemic chemotherapy (+/- hormonal

therapy/targeted therapy etc)

Radiation therapy

Treatment related wound

Aim for healing if possible Usually reversible (acute wound)

Always ask yourself (or your colleague)

Can the underlying cause be treated? Can the wound be treated?

Malignant wound- Common problems

Pain Odour/Exudate Bleed Self-image/Psychosocial

Pain
Nociceptive v.s neuropathic pain Pain history (assessment) Opioids systemic vs topical

Bleeding
Friable Slow ooze (microvascular fragmentation) vs

bleeder ( vascular disruption)

Avoid surface tear

Alginate dressings, topical adrenaline

compression, silver nitrate, or cautery.

Non-cancer wound care

Can the underlying cause be treated? Can the wound be treated?

Where do we look after them?

How do we decide?
Advance care planning Medical condition Resources/coping of the family

Where?
Community - Home - Community hospital - Inpt hospice - Nursing home Institution

- Acute hospital

PALLIATIVE CARE SERVICES

In-patient Hospices Dover Park Hospice Assisi Home and Hospice St. Josephs Home Bright Vision Hospital Home Care Hospice Care Association Assisi Home and Hospice Spore Cancer Society Methodist Hospice Fellowship Metta Home Care DPH (selected cases)

Day Care
Hospice Care Association Assissi Home and Hospice

Home hospice
Referral criteria: prognosis less than 1 year

symptomatic patient Mainly lead by nurses Role: provide medical input equipment loan psychosocial support Usually visit once weekly or once every 2 weekly Wound care normally will need to be done by the helper/family/HNF/others 24hour access/support

Inpatient Hospice
Referral criteria: prognosis of less than 3 months

symptomatic no dedicated caregiver at home E.g. : Large SCC of the face Fungating breast lumps with pain Impending carotid blowout ( impending big bleed)

St. Josephs Home

Run by the Canossian Sisters located at Jurong Road

22 beds for hospice patients, 108 beds for NH residents

Hospice section started 1985 Only inpatient services Supported by a GP group; no resident doctors

Assisi Home and Hospice

Established 1969 Owned by the Franciscan

Missionaries of the Divine Motherhood (FMDM) Sisters An outreach service of Mt Alvernia Hospital 40 beds (19 single-bedded rooms)

Bright Vision Hospice

Weve discussed
What is palliative care? When is palliative care appropriate? Who do we look after? How do we look after (Approach)? Where do we look after them?

Palliative Care- In summary

Good clinical care, recognising our advances and

limitation in healthcare
Caring for patient and family Helping them find meaning in suffering Listening to them & planning ahead