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.