Tutorial from Dr John Adler (Palliative Care Physician) 6/1/11

Palliative Care

28/12/10 SP notes Tutorial from Dr John Adler (Palliative Care Physician) – 6/1/11

- 10-20% of ICU patients will die - making the transition from cure to comfort is a difficult but important decision

Summary

(1) good communication (2) don’t hasten death but allow it to take place (3) drug therapy (4) ethical principles adherence

GENERAL PRINCIPLES

Good communication

- patient/family centred - complete and open discussion - open disclosure - sufficient information provision - sensitive but clear language - listen - value their input - support their emotions - support the family’s decision making process - respect

Conflict resolution

- conflict usually prevented by good communication - occasionally will require other ICU clinician input - allow time

Autonomy

- patients right to choose or refuse therapies - in critical care the family’s understanding of patients wishes are used as a surrogate

Beneficence

- obligation to act in patient best interests

Non-maleficence

Jeremy Fernando (2010) - obligation to no harm - this includes refraining from interventions which are more likely to harm than benefit

Justice

- fair allocation of societal resources

SPECIFICS

- cover what is involved in the transition to palliative care - plans regarding interventions (analgesics, removal of lines/ETT, not for futile procedures/therapies (ie CPR)) - extubation: stop fluids 6 hours prior to extubation, dexamethasone, buscopan, suction - explain: difference between withdrawing active treatment and transition to palliative care - explain: difference between allowing to die vs actions of hastening death - have an explicit plan - discontinue monitoring - provide a quite room - reassure that clinical care will be maintained - offer bereavement and support services - make sure you are treating the symptoms of the patient rather than the concerns of the family/nursing staff

DRUG THERAPY

- SC and IV doses are the same - death does not required an infusion of medication - need to make the distinction between the conscious and unconscious patient - if patient on chronic benzodiazepines or opioids then we need to continue them (also try and prevent withdrawal of they have been on sedation for a prolonged period of time in ICU ie. > 3 weeks)

Conscious

- can be very specific with PRN medication for symptom control - assess usage over 12 or 24 hours and then increase infusion as required

Unconscious

- often not in pain thus don’t require analgesia - look for facial grimacing, moaning not associated with breathing or localizing signs - noisy breathing and secretions are common and aren’t distressing to patients (may require explanation to families) - if unconscious because of sedation but patient is having active withdrawal -> we often will have to negotiate with family the continuation of sedation so patient doesn’t become distressed - gentle suction generally OK - no real place for nasopharyngeal or Guedel airways

Jeremy Fernando (2010) Drug Therapy for Symptoms

Pain and SOB

- opioids - morphine 2.5mg Q1hrly - fentanyl 12.5-25mcg Q30min (in renal impairment to avoid delirium, myoclonus and neuroexcitation with morphine)

Secretions

- muscarinic anticholinergic - buscopan 20mg Q2 hrly (max 120mcg/24 hrs) – doesn’t cross the BBB

Anxiety/Distress

- benzodiazepines - midazolam 1-2.5mg Q30 min - may develop tolerance quickly

N+V and Delirium

- D2 antagonists - haloperidol 0.5mg Q1 hrly (max 5mg) - levomepromazine 6.25mg Q4hrly (max 25mg) – increased sedating effects

PEACE Tool

Physical symptom control (pain, nausea, SOB, delirium) Emotive and cognitive symptoms (anxiety) Autonomy (sense of control and participation in decision making) Closure of life affairs (spent time with family and others) Economic issues (assistance, arrangements, insurance) and Existential issues (religious, spiritual)

CONSIDER STAFF

- some deaths can be difficult for staff: -> paediatrics -> staff member -> death from an error in medical management

- important to recognize and support: -> debriefing -> professional counselling -> teaching -> morbidity and mortality -> discuss with senior staff

Jeremy Fernando (2010)