Palliative Care

Outline of Palliation
Outline of Communication
Palliation with Communication
Communication Skills
Withdrawing & Withholding Rx
End of Life Care
- including medication advice

Palliative Care Outline

Definition
Not just symptom control but end of life medicine.
- starts from point where decision made that treatment will not be curative
- surgical palliative interventions should not be equated with cure
Aims are:
- relieve whatever suffering
- optimise quality of life
- maximise benefit of time
- help find meaning
- affirming life, accepting death
Even aggressive surgery may be palliative as long as:
- it is seen as such
- they & family want it
- clear goals and reasons
- reviewed at outcome

Features
Pragmatism
Outcome focusd
- only intervene if it will help
Holism
- relieve psychological distress
Contextual
- family universe considered
Teamwork
- multidisciplinary

Symptoms in Palliation
A symptom is a complex interplay of stimuli
- pathological factor may be trivial
- fears, beliefs, experience, history may be major
- becomes problematic when can no longer be ignored
Hence be aware of symptom threshold
- eg pt cannot specify problem clearly
- fluctuates without apparent physical basis
- worsen when drs, family around
- evidence of tension elsewhere
Real results may be achieved through
- clear communication
- clear information exchange

Goals
Task completion
- jobs outstanding in a pts life should be a priority
Friendships
- including reconciliations
Resolution of beliefs
- beyond conventional religion
- crystallising views of material world.

Outline of Communication

Baselines
Say what you mean
Tell the truth
No manipulation or patronising
Show respect
Two-way dialogue
Listen

Dr-Pt Relationship
Confidential
Based on Trust
For best interests of patient
Pt brings needs, dr provides information and advice based on expertise
Produces understanding and/or truth

Communication Objectives
Develop the above relationship
Promote informed choice
Act in pts best interests

The Process
Context
- how much time do you have
- what state the pt is in
People
- nurse present
- family involved
Anticipate effects
- may react badly

Variables
Language, culture, values
Mental capacity for understanding
Stage of illness
- avoid time scales
- instead focus on stages of care

Palliation with Communication

The Meaning-Mechanism Gap
Mechanism
A Dr's mind
- assess
- investigate
- treat
--> cure or maintainance or incurable
Meaning
A Pt's mind
- why me?
- what will happen to my family?
- whose fault?
--> resolved or coping or crisis
The longer a pt has to accommodate bad news, the greater the chance they will resolve it.
- hope often must not come from treatment but from other sources of meaning.

3 Cycles of Miscommunication

1. Medical (Mechanism)
- but what is the diagnosis?
- but can I cure this?
--> should advise 'try again' or 'no more treatment', not sit inbetween.
2. Patient (Meaning)
- but what is wrong?
- but whose fault?
--> must either resolve issues or learn to cope (instead of remaining in crisis)
3. Guilt
- onging suffering
--> continues other two cycles for the worse. 

Common Ground
Truthfulness
Partnership
Pt's best interests

Decision Making
Curative
Diagnosis
Curability
Buying quantity time
Vs Palliative
Symptoms
Side effects
Buying quality time

Communicating Uncertainty
An outcome may be clear,
- eg a pt with hepatic mets will die
However the inbetweens are not.
We must avoid prisons of false hope and paralysing fear.
We must avoid wasting time with futile investigations and treatments.
But we must try to make remaining time as free of symptoms as possible.

Communication Skills

Communicating a Diagnosis
One appoach is to gauge pt's fears first.
- what do you think is happening?
- what is your worst fear?
- even: do you think you a dying?
Then follow up with truth.
- i hope i am wrong, but i this is probably going to be a type of cancer
- i can't be sure until the microscopy, but this looks like a cancer

Communicating Consent

Set aside plenty of time.
Discuss uncertainties and probabilites
- these are the scenarios we may should prepare for (eg Dukes A-C)
- always give advanced warning of baddest news.
- eg this is the worst scenario...

Communicating Bad News
Take more time, more sessions.
Ensure privacy, bring family
- this is a conversation i was hoping we wouldn't have
- you will recall our last conversation, i am afraid we are facing the worst.
Advice
- ask how much the pt wants to know
- give a clear account with diagrams
- ensure a nurse is present
- arrange follow-up simply to answer questions.

Communicating Palliative Options
May wish joint consult with palliative care Dr
- they may help with personal resolution aspects
The pt must know that continued denial is futile
Be clear and truthful
- i am pleased to say this time we may help with limited surgery
- i have to say it is not a long term solution
- it really is time for you to begin looking at the future
- the reality is you will die from this disease sooner or later
- we need to involve experts to help you manage at this difficult time.

Pure Palliative Communication
Quality of life care
Pt often miserable and 'wants to die'
- what do they mean?
- stop treatment or stop pretending?
- symptom control or nothing at all?
Often at this stage, pt can talk rationally about dying
- show an astonishing depth and calm
Communicate options as always
- if we leave things you will likely die in next few days.
- do you want symptom control?
- or should we try to prolong things with other treatments?

Withdrawing & Withholding Treatment

Be very explicit
- gather family
- anticipate religious rites

Pointers
Examine every aspect of care
- benefit or burden?
Communicate
- if communication is good, the decision is usually made with ease.
Dealing with dissent
- may arise from the pt not wanting to die
- or a family member scared or sad or guilty
- evidence based medicine gives us clear guidelines to respond with
- do not replace good communication with ongoing treatment.

End of Life Care

Remember
Memories of last days will endure
- may redeem or destroy past memories
Complete symptom control is a goal.

Prepare for dying
Check often
Interfere little
Talk to pt even if unconscious
Gather family
Good nursing
Privacy

Restlessness
List and treat causes
Sedate lightly
- midazolam 10mg/24hrs
- methotrimeprazine 12.5mg
- haloperidol 2.5mg/24hrs (good if hallucinating)
Advise

General
- titrate these meds to control regardless of dose
Morphine 10mg/24hrs
Vomiting
Cyclizine 50-150mg
Movement
NSAIDs

Breathing
Altered patterns
- leave alone
Secretions
- hyoscine 0.6-2.8mg/24hrs
- frusemide 20mg stat