End-of-Life Comfort Dr. Giovanna Sirianni Staff Palliative Care Physician Princess Margaret Hospital - PowerPoint PPT Presentation

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End-of-Life Comfort Dr. Giovanna Sirianni Staff Palliative Care Physician Princess Margaret Hospital


End-of-Life Comfort Dr. Giovanna Sirianni Staff Palliative Care Physician Princess Margaret Hospital UHN Pain Conference Tuesday, February 27, 2007 – PowerPoint PPT presentation

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Title: End-of-Life Comfort Dr. Giovanna Sirianni Staff Palliative Care Physician Princess Margaret Hospital

End-of-Life Comfort Dr. Giovanna SirianniStaff
Palliative Care PhysicianPrincess Margaret
  • UHN Pain Conference
  • Tuesday, February 27, 2007

  • Define palliative care and appreciate its
    evolving role
  • Understand that comfort at the end-of-life
    requires a multi-factorial assessment of patients
    and treatments directed beyond physical pain
  • Understand the concepts of total pain, a good
    death and suffering, appreciating how they may
    apply to providing comfort at the end-of-life
  • Develop basic skills and strategies in managing
    pain and symptoms in patients at the end-of-life

Our Overall Goals
  • Optimal relief of pain and suffering are the
    first two morally mandatory obligations of any
    physician who cares for the incurably ill.

Case Review
  • Mrs. G. is a 45 year-old woman diagnosed with
    metastatic breast cancer several years ago.
    Despite optimal treatment with surgery, radiation
    and multiple lines of chemotherapy, her disease
    continued to progress. She has evidence of known
    metastases to the liver, bones and brain. She is
    married and has two young daughters.

Case Review
  • She is admitted to the medical oncology ward
    because of an inability to cope at home due to
    limitations in her functioning. There do not
    appear to be any reversible causes for her
    progressive weakness and no further treatment is
    indicated at this point. Mrs. G. is distraught by
    the news.

What role do we have in helping this patient and
her family?
  • What approach should we take in addressing the
    issues she is facing?

Definition of Palliative Care
  • Definition of palliative care continues to evolve
  • Lack of clarity in terminology
  • Health Canada (1989)
  • Palliative care primarily directed to the
    dying and bereaved to meet the physical,
    emotional and spiritual needs through death and

Definition of Palliative Care
  • World Health Organization (2002)
  • Palliative care is an approach that improves the
    quality of life of patients and their families
    facing the problems associated with
    life-threatening illness, through the prevention
    and relief of suffering by means of early
    identification and impeccable assessment and
    treatment of other problems, physical,
    psychosocial and spiritual.

Definition of Palliative Care
  • Canadian Hospice Palliative Care Association
  • Combine words hospice palliative care as one
  • Complex, six part definition
  • Aims to relieve suffering and improve the
    quality of living and dying
  • Treat all active issues Prevent new issues from
  • May either complement disease-modifying
    treatment or become the total focus of care

Is it Palliative Care or End-of-Life Care?
  • Initially, considered synonymous terms
  • End-of-Life care a newer term
  • No consensus on which term more accurately
    reflects reality
  • Personal opinion
  • Palliative care the overarching concept
  • End-of-Life care a component

Views on Death
  • The lighter side
  • I dont want to achieve immortality through my
    work I want to achieve it through not
    dying. Woody Allen
  • Its either the wallpaper or me. One of us has
    to go. Oscar Wildes last words
  • Things turn out best for the people who make the
    best of the way things turn out. Art

Views on Death
  • The inspiring side
  • The tragedy of life is not death, but what dies
    inside us while we live. Norman Cousins
  • Watching a peaceful death of a human being
    reminds us of a falling star one of a million
    lights in a vast sky that flares up for a brief
    moment only to disappear into the endless night
    forever. Elizabeth Kubler-Ross

What is a Good Death?
  • No objective measure
  • Determined by the patient, an intensely personal
    and unique experience
  • Impact of dying resides with family during
    bereavement, arguably also with staff
  • Health professionals should be aware of the
    feelings provoked by death, in patients and in

What is a Good Death?
  • Life happens before death, being no less
    important than other aspects of a patients life
  • Our role is to help people to live until they
    die, to see death in life and life in death
  • Experience of death should be valuable and
    meaningful for the person and his or her family
  • How can this be achieved?

At the core of any suffering is a glimpse of
death Life is a continual dance with change,
impermanence and loss.
Are pain and suffering the same?
  • They are quite different concepts, but also share
  • Pain has an immediate quality
  • Suffering often relates to the past or the future
  • One concept can exist without the other
  • Pain goes beyond the physical, incorporating
    thoughts and feelings
  • Suffering can be related to physical pain, but
    often goes beyond the physical realm

Are pain and suffering the same?
  • Suffering comes from a fear of losing what is
    valued and/or getting what is not wanted
  • Existential suffering is a discrepancy between
    ones belief of how the world should be and how
    life actually evolves
  • Take home point When assessing and managing
    pain, especially in the dying patient, you must
    think and assess beyond the physical

Responding to Suffering
  • Manage treatable pain effectively, in accordance
    with patients beliefs and wishes
  • Ask patients about their distress/suffering as
    you would for pain
  • Initiate a discussion, engage in dialogue
  • It may not be possible to fully remove or
    alleviate suffering

Cancer and Pain
  • 70 of patients with advanced cancer have pain
  • WHO estimates that 80 of people who die from
    cancer worldwide die with uncontrolled pain
  • Pain managed poorly because of patient, family
    and health professional factors

Total Pain
  • Patients experience of pain related to more than
    somatic factors
  • Components of Total Pain
  • Somatic source
  • Patients emotional status
  • Patients personality
  • Patients family
  • Patient and family ecology
  • Service providers

Physical Changes Approaching Death and Strategies
for Management
  • Pain may be difficult to assess in the last hours
    to days of life
  • Patient may have decreased level of consciousness
    or be comatose
  • Unconscious patient may be deemed to be in pain
    if they experience any two of
  • The patient groans
  • The patient is agitated
  • The patient shows signs of contortions of the
    face, hands and/or whole body

Physical Changes Approaching Death and Strategies
for Management
  • Preferred route for medication administration is
    subcutaneous (sc) at the end-of-life
  • Medication should be prescribed every 4 hours,
    with breakthrough medication available very 30-60
    minutes or via continuous subcutaneous infusion
  • If the patient is opioid naïve, start with
    morphine 5 mg sc or hydromorphone 1 mg sc every 4
    hours, as needed
  • If the patient is not opioid naïve, consider
    increasing their routine dose by 25-50 if pain
    is poorly controlled

Physical Changes Approaching Death and Strategies
for Management
  • Frequently re-assess whether pain well-controlled
    and whether breakthrough medication dose
  • If patient utilizing more than 3 breakthrough
    doses of pain medication in a 24 hour period, may
    need to increase the dose of their routine opioid
  • Avoid the use of Fentanyl patches at the
  • Difficult to titrate if unstable pain
  • Can take up to 12 hours before peak concentration
    of pain medication achieved

Physical Changes Approaching Death and Strategies
for Management
  • Consider the use of adjuvant medications
  • Most adjuvant medications are oral formulations
    and may not be appropriate at the end-of-life
  • Dexamethasone can be helpful as an adjuvant for
    visceral, bone and neuropathic pain
  • Dexamethasone is available via the sc route, dose
    generally between 4-16mg/day

Physical Changes Approaching Death and Strategies
for Management
  • Respiratory
  • Irregular patterns and apnea common
  • Upper respiratory secretions
  • Hemoptysis (rare)
  • Management
  • Irregular breathing patterns and apnea are not
    related to dyspnea. Reassure family.
  • Glycopyrrolate or Scopolamine 0.4mg sc q3hr prn
    for upper airway secretions
  • Dark towels, opioids and sedation for massive

Physical Changes Approaching Death and Strategies
for Management
  • Neurological
  • Decreased level of consciousness until death
  • Delirium, restlessness
  • Twitching/myoclonus
  • Seizures (rare, unless prior seizures with brain
  • Management
  • Anti-psychotic medication for delirium (e.g.
    methotrimeprazine Nozinan 6.25mg-12.5mg sc q4hr
    prn or haloperidol Haldol 0.5mg-1mg sc q4hr
    prn) as starting dose
  • Benzodiazepines for twitching/seizures

Physical Changes Approaching Death and Strategies
for Management
  • Gastrointestinal
  • Food/fluid intake will decrease to zero
  • Risk of choking
  • Dry mouth
  • Management
  • Excellent mouth care, with sponge sticks, sodium
    bicarbonate mouthwash and artificial saliva
  • Re-assure family that decreased food/fluid intake
    part of the natural process of dying

Physical Changes Approaching Death and Strategies
for Management
  • Cardiovascular
  • Decreasing blood pressure
  • Rapid, weak heart rate
  • Arrhythmias
  • Pulmonary edema
  • Management
  • Treat pulmonary edema with diuretics for comfort
  • No other interventions indicated
  • Re-assure family regarding the cardiovascular
    changes that are expected

Physical Changes Approaching Death and Strategies
for Management
  • Skin
  • Pale, blue, mottled skin
  • Cool or febrile to the touch
  • Skin breakdown
  • Management
  • Turn q4hr, as tolerated by patient, to prevent
    skin breakdown
  • Order appropriate pressure relief mattresses, if
    prognosis expected to be longer than days

Physical Changes Approaching Death and Strategies
for Management
  • Genitourinary
  • Incontinence
  • Reduced urine output, dark colored urine
  • Management
  • Incontinence pads, Foley catheter

Case Review
  • Mrs. G. is referred to the palliative care team.
    Her issues at present include pain, likely
    secondary to her bone metastases and marked
    fatigue, causing her to be bed bound. She is also
    significantly distressed by the thought of her
    daughters growing-up without their mother and
    concerned her husband will be unable to cope
    without her. She has not been able to speak to
    her daughters about her advanced stage of

Case Review
  • Her pain is managed with the use of opioids and
    dexamethasone as an adjuvant for bone pain. You
    decide to involve a team specialized in grief and
    bereavement for children who have helped
    facilitate a discussion between Mrs. G. and her
    children regarding her advanced illness. You have
    also referred the family to a local hospice who
    will help provide support in the home.

Case Review
  • Mrs. G. begins to develop an altered level of
    consciousness and exhibits changes which are in
    keeping with the last hours to days of life. She
    is moved to a private room where her family and
    friends can be with her at all hours. All her
    medications are changed to the sc route. The
    family is taught how to provide good mouth care
    to minimize sensations of thirst. The staff are
    supportive and helpful as they prepare the family
    for Mrs. G.s imminent death.

  • Palliative medicine has evolved beyond
    end-of-life care
  • Educating patients about the expanding role of
    palliative care is important
  • Multi-factorial assessment of pain and symptoms
    at the end-of-life should go beyond somatic
  • Comfort at the end-of-life goes beyond simply
    using opioids

  • Downing GM, Wainwright W. Medical Care of the
    Dying. 4th ed. Victoria, British Colombia
    Victoria Hospice Society 2006.
  • Librach SL, Squires BP. The Pain Manual
    Principles and Issues in Cancer Pain Management.
    Revised Ed. Montreal, Quebec Canadian Cancer
    Society 2002.
  • Pereira J, Bruera E. Alberta Palliative Care
    Resource. Calgary, Alberta Alberta Cancer
    Foudation 1997.
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