WRHA Palliative Care Program
Dr. M. Harlos, Medical Director
L. Embleton, Program Director
April 30, 2014
http://palliative.info
The presenters have no conflicts of interest
to disclose
Objectives
• To provide an overview of the services offered
by the WRHA Palliative Care program
• To review considerations for Respiratory
Therapists in caring for palliative patients
Palliative Care is an approach to care which focuses on
comfort and quality of life for those affected by lifelimiting/life-threatening illness. Its goal is much more
than comfort in dying; palliative care is about living,
through meticulous attention to control of pain and
other symptoms, supporting emotional, spiritual,
and cultural needs, and maximizing functional status.
Role of WRHA Palliative Care Program
• WRHA Palliative Care Program is a clinical
program that:
– Provides and promotes quality palliative care for
patients/families with life limiting/threatening
illnesses
– Provides support to health care teams providing care
to palliative patients in any care setting
Role of WRHA Palliative Care Program
Two streams of service provided:
• Consultation
• Registration
Consultative Services
• available to any patient with a life-limiting/threatening
illness, at any time in the illness trajectory, in any care
setting for:
1. Symptom management
2. Assistance with planning care
3. Clarifying goals of care
• provided by inter-professional team members:
– Palliative Care Physician
– Palliative Care Clinical Nurse Specialist
– Psycho-social Support Specialist
Consultative Services
To access consult service:
• During business hours, all consults should be
directed to Palliative Care Program
204-237-2400
• After hours – MD to MD consults available 24
hours a day through St. Boniface Paging
204-237-2053
Registration on Program
Patients can be “registered” on the Palliative Care
Program if they meet program criteria:
– Prognosis of less than 6 months (approximately)
– No longer receiving aggressive treatment which
requires on-going monitoring for and treatment
of serious complications
– Have chosen a comfort-focused approach
including a decision to decline attempted
resuscitation
Registration on Program
Once registered with the program, patients are
eligible for:
– Case management through Palliative Care Coordinator
– Access to Community Palliative Care Nursing 24/7
• Palliative Care Nurses have access to Palliative Care
Physician
– Admission to Palliative Care Units (PCU) and Hospice – if
bed available
– Enrollment on Provincial Palliative Care Drug Access
Program
Inpatient Care settings
Palliative Care units:
– St. Boniface Hospital – 15 beds
• Tertiary Care Facility
– Riverview Health Centre – 30 beds
Hospices:
– Grace Hospice – 12 beds
– Jocelyn House – 4 beds
Community Palliative Care Program
• Approximately 400 patients at any one time
• Each community team considers patients in their
area as their “ward”
– Inclusive of all care settings – home, acute care and long
term care
– Team meetings are held to discuss patient care needs
(rounds)
• Focus on meeting needs in a proactive way
– Opportunity to strengthen networks with other care teams
to support patients and families including the opportunity
to model “palliative care”
Northwest
Northeast
7 Oaks
PCHs
PCHs
Patients at
home
Patients at
home
Central
Grace
Community Teams:
•Community
Nurses
•CNS
•MD
•Coordinator
•Psychosocial
Home
Community
Clinics
PCHs
Community
Clinics
HSC
PCHs
Concordia
Patients at
home
VGH
South
Community
Clinics
Pediatric Palliative Care
• Established in 2006
– Services provided by physician and CNS
• Consultative service –no dedicated beds
• ~ 80 new patients each year
Consult Service
Community Palliative Nursing
• Case Coordinator
• Admission Eligibility
• Medication Coverage
• comfort-focused
• prognosis “6 mo. or less”
• some treatment limitations
(DNAR, no TPN, no
chemoTx with high
adverse effects
• aggressive, often toxic
treatment focused on cure
or life-prolonging disease
modification
Diagnosis of
Life-Limiting
Illness
Transitioning
to Palliative
Palliative
Considerations For The
Respiratory Therapist In Caring
For Palliative Patients
Shared
Care
• Initiating and maintaining
ventilatory support
• Setting up and supporting O2
Resp.
Therapy
• Educate patient, families,
involved health care team
• Withdrawing ventilatory support
• Withdrawing O2
• Transport of palliative patients
• Nebulized meds (including
lidocaine)
Palliative
Care
Specific Issues
1. Role of O2 therapy in palliative patients
2. Noninvasive ventilation in ALS
3. Role of opioids in palliation of dyspnea
4. Transport of dying patients; role of Health Care
Directive, ACP
5. Withdrawal of life-sustaining treatments – ventilatory
support (invasive and noninvasive), oxygen
Role of O2 In Palliative Patients
•
•
•
•
•
•
•
not a straightforward issue
“hypoxia kills” – a common mantra in medical care
should also be mindful that “supplemental O2 prolongs the
natural dying process”
the awake hypoxic patient feels less air hunger and does
better physiologically with O2 supplementation
the unconscious/comatose patient does not likely experience
air hunger
what about the awake, dyspneic, non-hypoxic palliative
patient?
studies of “air vs. O2” used room air by nasal prongs and are
therefore not practical – “medical air” not available in clinical
practice, and dyspnea is helped by cool air in nasopharynx
• N = 32 non-dyspneic patients with Palliative Performance Scale ≤ 30%
(median survival 9 days or less), at risk of developing dyspnea (CA
lung, CHF, COPD, pneumonia)
• excluded if: mechanically ventilated, on high-flow O2 by FM;
tracheostomy; experiencing respiratory distress at study entry
• SpO2, end-tidal CO2 measured; dyspnea assessed using Respiratory
Distress Observation Scale
• patients were rotated blindly from O2, medical air, no-flow cannulae
• no difference in comfort between interventions
Campbell et al continued…
• results suggest that O2 need not be prescribed to patients
who are near death and not exhibiting respiratory distress
regardless of oxygen saturation.
• O2 can often be withdrawn when the patient makes a
transition from terminal illness to imminent death,
particularly as consciousness decreases.
• most patients tolerated a crossover from oxygen to air or
no flow, however 3 patients experienced distress that was
relieved by a return to oxygen.
 An inability to reliably predict which patient will
experience distress requires close clinical observation
when withdrawing O2
• generally our practice is to focus on comfort, not oximetry
- good O2 sats, patient uncomfortable: intervention
needed
- poor O2 sats, patient comfortable: no change needed
• often nasal prongs are better tolerated than mask,
regardless of oximetry
• if a patient feels benefit with O2 even though room air
oximetry is normal, we would use O2 if feasible
• in the unresponsive patient, consider tapering over a few
hours as tolerated
Noninvasive Ventilation in ALS
•
•
improved quality of life and survival, though this has not been
demonstrated in bulbar onset ALS
bulbar patients less tolerant of NIV (mouth leaks, sialorrhea)
Palliative Considerations Regarding NIV
•
tendency to gradually increase its use – eventually to 24/7;
the implications of this does not seem to be commonly
discussed
•
patient may be completely dependent on NIV, and unable to
remove mask in event of machine or power failure
•
the very patients who selected NIV rather than tracheostomy
often find themselves on “life-support” with NIV, having to
decide about withdrawal of ventilatory support
•
conversations around end-of-life issues should be included
when discussing any ventilatory support
•
care setting for patients dependent on NIV need to address:
- risk management around power / machine failure
- ability to address symptoms in context of acute distress
- ability to ensure comfort in context of withdrawal
Opioids And Dyspnea
Johnson MJ, Abernethy AP, and Currow DC. Gaps in the evidence base of
opioids for refractory breathlessness. A future work plan? J Pain Symptom
Manage. United States; 2012;43(3):614-24.
American College Of Chest Physicians Consensus
Statement On The Management Of Dyspnea In Patients
With Advanced Lung Or Heart Disease - 2010
• Regarding fear of respiratory depression –
• higher doses of opioids and benzodiazepines used in the
withdrawal of life-sustaining treatment were not associated with
a decreased time from withdrawal of life support to death
• Of 11 studies providing information on ABGs or O2 sat, only one
study reported any significant changes in oxygenation after
opioid administration
• Recommend that:
• Oral and/or parenteral opioids can provide relief of dyspnea.
• Opioids should be dosed and titrated for the individual patient
with consideration of multiple factors (e.g., renal, hepatic,
pulmonary function, and current and past opioid use) for relief
of dyspnea.
•
Official American Thoracic Society Statement: Update on
the Mechanisms, Assessment, and Management of
Dyspnea – 2012
- Opioids have been the most widely studied agent in the
treatment of dyspnea. Short-term administration reduces
breathlessness in patients with a variety of conditions,
including advanced COPD, interstitial lung disease,
cancer, and chronic heart failure
• Canadian Thoracic Society Clinical Practice Guideline
2011: Managing Dyspnea In Patients With Advanced
Chronic Obstructive Pulmonary Disease
- “We recommend that oral (but not nebulized) opioids be
used for the treatment of refractory dyspnea in the
individual patient with advanced COPD”
Thorax. England; 2014;69(4):393-4.
• “Failure to properly treat chronic refractory breathlessness with
opioids as outlined in specialist clinical guidelines is now
substandard medical care and is also a breach of clinicians'
ethical and legal duties to the patient” … “considered negligent”
• In addition to being a breach of professional, ethical and legal
duties, failure to treat chronic refractory breathlessness
adequately should be viewed as a breach of human rights.
Common Concerns About Aggressive Use
of Opioids at End-Of-Life
• How do you know that the aggressive use
of opioids for dyspnea doesn't actually bring
about or speed up the patient's death?
• “I gave the last dose of morphine and he
died a few minutes later… did the
medication cause the death?”
1. Literature: the literature supports that opioids
administered in doses proportionate to the degree
of distress do not hasten death and may in fact
delay death
2. Clinical context: breathing patterns usually seen in
progression towards dying (clusters with apnea,
irreg. pattern) vs. opioid effects (progressive
slowing, regular breathing; pinpoint pupils)
3. Medication history: usually “the last dose” is the
same as those given throughout recent hours/days,
and was well tolerated
• may reduce overall oxygen demand
• “The administration of sedatives (midazolam and morphine) has been
associated with decreases in oxygen demand and the attenuation of the
cardiopulmonary response associated with increased work of breathing”
• see also: Endoh H et al; Effects of naloxone and morphine on acute
hypoxic survival in mice. Crit Care Med; 1999;27(9):1929-33
-
significantly lower oxygen consumption and improved survival in
morphine treated rats subjected to acute hypoxic hypoxia
Transporting Palliative Patients
•
risk of patient death during transport
•
a Health Care Directive or Advance Care Plan is an
important tool in preventing unwanted/inappropriate
resuscitation attempts
•
clear “what-if” plans need to be prepared, with involvement of
patient and/or family
-
•
e.g. limited bagging but no chest compressions, or allow
natural death
medications on hand for symptom management
* SDM = Substitute Decision Maker
Withdrawal Of Ventilatory Support
•
allowing the natural course of illness to unfold, in contrast to
euthanasia
•
RT not always included in the decision-making process, yet
may still be involved – can be a difficult role to serve
•
in a palliative care setting, we may need RT to help with the
machine settings, extubation, perhaps suctioning
•
comfort is paramount – biggest threat to comfort is air hunger
•
preemptive & reactive opioids and sedatives are main
pharmacologic interventions
•
no specific predetermined dose – essentially only 3 possible
doses: not enough; perfect; too much
-
the correct dose is the one that is effective, avoids harm if
possible, and is proportionate to the need
• “…respect and protect the legal rights of the patient,
including the right to informed consent and refusal
or withdrawal of treatment.”