WHEN AND WHERE IS THE RIGHT TIME TO
START PALLIATION IN ELDERLY PATIENTS?
Ramona Stefaniu, Ana Voica
Department of Clinical Geriatrics, “Dr. C.I. Parhon” Hospital,Iasi
PALLIATION
Palliative care is an approach that improves
the quality of life of patients and their families
facing the problem associated with lifethreatening 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 (OMS)
PALLIATION
 At first it was designed for the oncologic patient,
terminally ill
 Patients with illnesses without response to
curative measures
 The elderly, considering the number of
comorbidities and their symptoms.
Paliative care– why?
 Maintains and enhances quality of life
 Pain relief
 Setting care that respects the patients values
and wishes
Patient S.I., 84 years old
Presented with:
 Tromboflebitis right leg
Hystory :
 Stroke
 Right side hemiplegia
Clinical exam:
 Obesity
 Fair medical condition, afebrile
 Immobilized patient ,conscious, oriented
 Right leg edema with local signs of inflammation
 BP=140/80mmHg; HR= 80bpm, rhythmic
Paraclinical examination
BLOOD TESTS
WBC
33.970/mm3
ESR
48mm/1h
GGT
246 u/l
TGO
89 u/l
TGP
48 u/l
FDP
+
Paraclinical examination
Doppler ultrasound:
- Superficial femoral vein, popliteal vein, posterior tibial veins thrombosis,
- Saphenous vein thrombosis 1/3 distal end
Paraclinical examination
Low intensity opacity in the left upper lobe
Paraclinic
Abdominal ultrasound
Ficat – Low echogenic portion with 21,6/24,4mm in the left
hepatic lobe. Multiple lesions of the same nature in the right
hepatic lobe.
DIAGNOSTIC DE ETAPA
 THROMBOPHLEBITIS RIGHT LEG
 RIGHT UPPER LOBE PNEUMONIA
 RECENT ISCHEMIC STROKE
 RIGHT SIDE HEMIPLEGIA
 OBS: HEPATIC METASTASES
Thoracic CT scan:
• Right and left pleural effusion
• Consolidation area with aeric bronchogram present in
the right upper lobe
Abdominal CT scan
• Multiple hypoattenuating liver lesions ill defined
• Tumor in the pancreatic body size : 67/33 mm
• Left ovarian cyst
• Intramuscular oedema of the right lateral abdominal
wall
DIAGNOSIS
 Pancreatic tumor with liver and pulmonary metastasis
 Right leg thrombophlebitis
 Right side hemiplegia
 Recent ischemic stroke
 Left ovarian cyst
Treatment
 Treatment of the infection and the thrombosis is initiated with good
outcome
 Do to the neurologic and hemodynamic state of the patient, the
oncological consult suggests starting palliative care
 After receiving all the information regarding treatment options and
possible outcome, the patient expresses her wish to start palliative
care.
 Palliative care is initiated, with pain relief treatment and
interventions to prevent and treat the consequences of prolonged
bed rest, after registering the patient on a waiting list for a place in
a palliative care clinic
Patient J.I., 82 years old
Presented with:
 Signs of congestive heart failure
History :
 High blood preassure grade 3 stage 2 very high risk
 Dilated Cardiomyopathy Ischemic and Toxic
 Extrasystolic arrhythmia
 Chronic toxic hepatitis
 Cataract surgery – both eyes
Medication
 Diurex 50 1cp/zi
 Perindopril 5mg 1 cp/zi
 Carvedilol 6,25mg ½ cp/zi
 Mononitron 60mg 1cp/zi
Pacientul J.I., 82 ani, mediul urban
Clinical examination
 Pitting edema of the lower leg bilateral
 Jaundiced sclera and skin
 Crackels in the inferior ½ of the right and left side





hemithorax
Turgid jugular veins
BP= 130/70mmHg; HR=80bpm, arrhythmic
Tender hepatomegaly of 3-4 cm below right costal margin
Hepatojugular reflux
Severe hearing loss
Paraclinical exam
Blood tests
HB
11,2 g/dl
ESR
90mm/h
Total Protein
62g/l
TGO
126 u/l
TGP
88 u/l
GGT
515 u/l
Total Bilirubin
10,24 mg/dl
Direct Bilirubin
6,52 mg/dl
Indirect Bilirubin
3,72 mg/dl
Paraclinic
Abdominal ultrasound
Perihepatic fluid collection
Gallstones, Bile duct= 20,5mm: Intrahepatic bile ducts
dilatation
Head of pancreas 32mm
Obs: Tumor in the head of the pancreasTumora cap de
pancreas
Surgical consult:
- Considering all the comorbidities, any surgical intervention is
postponed and recomands external biliary drain
DIAGNOSTICS
 CONGESTIVE HEART FAILURE
 TOXIC AND ISCHEMIC DILATED CARDIOMYOPATHY
 ACUTE CHOLECYSTITIS WITH OBSTRUCTIVE
JAUNDICE
 NEOPLASM IN THE HEAD OF THE PANCREAS
 SECONDARY ANEMIA
COURSE OF TREATMENT
 The patient is informed on the risks and benefits of the
surgery.
 Patient’s family requests the surgical treatment, but the
patient refuses any invasive measure of treatment and
asks to be released from the hospital to start palliative
care at home
 Medication to control the pain and digestive symptoms
is administered
DISCUSSION
CASE 1
CASE 2
- No family support
- No means to take care of
herself
- Chooses palliative care in a
specialized clinic
- Family support
- No means to take care of
himself
- Chooses palliative care at
home
DISCUSSION
 Access to palliative care is the right of any patient
 The right moment to start palliative care is decided by
the patient, him being the one that decides when a vital
risk intervention is no longer beneficial.
 The patient decides when treatment stops and palliative
care begins, no matter what the family’s or the
physician’s wish might be.
 If the patient is unable to express their wish, the
decision is made by the family. A form of expressing
their wish for the patient when they are still able to
express it is beneficial, making the family’s burden
lighter.
DISCUȚII
 Lack of financial and family support in the first patient’s
case, make continuing palliative care difficult and
forces her to remain admited in an acute geriatric clinic.
 For disadvantaged people, with no family support it is
necessary to develop a social assistance network that
can supply these patients with home care or facilitate
their admission in a specialized clinic for palliative care.
CONCLUSION
 It is necessary to find a formal way for the patient to
express their wish when they are still of sound mind.
 Specialized clinics in palliative care that address elderly
care are necessary, and also a more involved attitude
from local authority and social assistence is needed.