Palliative care in stroke
Overview
Stroke demographics
 Palliative care
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Definition
 Role
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Palliative care in stroke
 Case studies
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FACT
Stroke Education Ltd (NZ) 2006
World effects

Stroke is the 2nd major cause of death worldwide and the leading cause of
long-term disability in adults.
(Donnan GA 2008)
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According to the WHO, 15 million people worldwide have a stroke ever year,
5 million of whom die and 5 million are permanently
disabled .

In the US alone, there are about 5.5 million stroke survivors and every 45
seconds someone has a stroke. Every 3 minutes someone in the
USA dies from a stroke, and about half of stroke survivors are
left disabled.

In Europe, approximately
650,000 people die of stroke.
UK effects

150,000 people have a stroke in the UK
each year.

There are over 67,000 deaths due to
stroke each year in the UK.
Office of National Statistics Health Statistics Quarterly
Men vs Women

Men are 25% more likely to suffer strokes
than women.

60% of deaths from stroke occur in
women.
Women live longer
 they are older on average when they have
strokes
 thus more often killed

(NIMH 2002)
Out of 10!

About 2 out of 10 people who have a stroke die
within the first month.

3 out of 10 die within the first year.
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5 out of 10 die within the first 5 years.

The more time that passes after a stroke, the
less is the risk of dying from it.
What is Palliative Care?
World Health Organisation

‘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:
early identification.
 impeccable assessment.
 treatment of pain.
 physical, psychosocial and spiritual.

Palliative Care
Affirms life and regards dying as a
normal process
Uses a team approach to address the needs
of patients and their families, including
bereavement counselling.
World health organisation 2010
Palliative Care
 Palliative
care
 Specialist palliative care
 Terminal Care
Who is involved in Palliative care?
Multi–disciplinary team
Doctors through to the kind word
from a domestic
Goals of palliative Care
Best quality of life.
 Support system to promote patients’ &
families’ self worth.

 Poor
care prior to death makes bereavement difficult
and has long term repercussions on the health of
family and friends.
Parkes CM (1998)
Provide relief from suffering.
 Symptom control.

What is good palliative care
Humanity
 Dignity
 Respect
 Good communication
 Clear information
 Best possible symptom control
 Psychological support when needed
 Continuity of care

Nurses role in palliative care

All nurses should be able to:
Undertake basic symptom assessment and
management.
 Understand the experience of the dying patient and
their families.
 Engage in communication regarding individual
needs and experiences.
 Consult the specialist palliative care practitioners if
the needs of patients are out of the nurses
experience.

Aranda S (2003)
Symptoms stroke patients experience
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Pain
Fatigue
Weakness
Lack of energy
Weight loss
Difficulty swallowing
Anorexia
Early Satiety
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Restlessness &
agitation
Dry mouth
Constipation
Respiratory secretions
Dyspnoea
Anxiety
Stages in palliative care.
Is their a role in stroke?
Case 1
71, male, independent.
 Found in bed unconscious, doubly
incontinent, dehydrated.
 Right lateral gaze, L-sided weakness,
extensive R-sided pneumonia, sore in his
L leg, swelling in R-side head/face.
 CT head: large L-sided intracerebral
haemorrhage.
 DNR, decided against feeding, withdraw
Abx- died 24hrs later.
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Terminal care
Case 1
Communication amongst health care
professionals.
 Symptom assessment & control:
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Dignity:
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Pain, agitation, restlessness, breathing
pressure sore management, mouth care
Liverpool Care Pathway.
All of the above can be managed by the MDT
Specialist input can be sought as a one of
measure if adequate symptom control is not
achieved.
Case 2
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84, female, wheelchair-bound, house-bound,
previous CVA.
Unconscious, L-sided weakness, pyrexia.
CT head: intracerebral haemorrhage.
Husband: ‘no life-prolonging measures’.
DNR, artificial feeding commenced, Abx given,
prognosis: likely soon death.
Still alive on day 15 - Abx stopped.
Still alive on day 25 - NG feed stopped.
Died on day 31 of admission.
Palliative care
Case 2

Communication

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Husband-medical team?
“No life prolonging measures” - Abx?, Feeding?, Hydration?
Ethical issues? Right / wrong?
Prolonging suffering?
 Quality of life?
 Would Specialist Palliative Care input
help?

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“the key to good palliative care is that the dying process is
actively managed rather than drifted into when all else fails”
(Jarrett, 1997)
Case 3
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39, female, business owner.
Decreased conscious level, quadriplegia.
MRI: bilateral ventral pontine infarction with
patent basilar artery- ‘Locked-in syndrome’.
5/52 ITU, then ASU-MDT care.
7/52 post-CVA: reliable voluntary movement in
upper limb & jaw, goal-directed PT possible.
Depressed, contractures, pain, functional gain.
3/12 post-CVA: rehab unit.
D/C 10/12 post-CVA with maximal community
support.
Stroke survivors
Case 3
A case for Specialist Palliative care?
 Chronic disease management
 Continuity of care:

 Community
support
 Psychological support / counselling
 1 in 5 stroke pt’s have suicidal thoughts
Symptom management
 Lack of palliative specialist / information in
stroke management: partnerships are
therefore required to ensure a holistic
approach to stroke management.

Best Practice Tools

Liverpool care pathway (LCP)
(Ellershaw & Wilkinson 2003)
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Gold standard framework (GSF)
(Thomas 2003)

Preferred Place of care Tool (PPC)
(Storey et al 2003)
Points to remember

Palliative care can be implemented by the
generic medical team.
 Limitations
to practise
 Ethical

Implementation of specialist palliative care early
on in acute management of patients.

More research is required to see if Specialist
Palliation is require for stroke survivors which
may in fact improve rehabilitation outcome.
Communication and
compassion
References / Bibliography

http://www.stroke-education.com/info/StrokeInfo.do
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National Institute of Neurological Disorders and Stroke (NINDS) (1999). "Stroke: Hope Through Research".
National Institutes of Health. http://www.ninds.nih.gov/disorders/stroke/detail_stroke.htm


.
Villarosa, Linda, Ed., Singleton, LaFayette, MD, Johnson, Kirk A. (1993). Black Health Library Guide to
Stroke. Henry Holt and Company, New York.
Murray CJ, Lopez AD (1997). "Mortality by cause for eight regions of the world: Global Burden of Disease
Study". Lancet 349 (9061): 1269–76. doi:10.1016/S0140-6736(96)07493-4. PMID 9142060.
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Donnan GA, Fisher M, Macleod M, Davis SM (May 2008). "Stroke". Lancet 371 (9624): 1612–23. doi:10.1016/S01406736(08)60694-7. PMID 18468545.
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The World health report 2004. Annex Table 2: Deaths by cause, sex and mortality stratum in
WHO regions, estimates for 2002.. Geneva: World Health Organization. 2004.
http://www.who.int/entity/whr/2004/en/report04_en.pdf.
Office of National Statistics Health Statistics Quarterly
2005 Coronary Heart Disease Statistics. British Heart Foundation
Royal College of Physicians, (2001),
http://www.omnimedicalsearch.com/conditions-diseases/stroke-introduction.html
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References / Bibliography

WHO guidelines: cancer pain relief 2nd ed.
Geneva: World health organisation: 1996