Dr Yong Woon Chai - Palliative Approach to Wound Management
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Transcript of Dr Yong Woon Chai - Palliative Approach to Wound Management
SLH 25/5/2012
Palliative Care Approach in Wound
management
Content
What is palliative care?
When is palliative care appropriate?
Who do we look after?
How do we look after (Approach)?
Where do we look after them?
There are only 2 things certain in
life: death & taxes
Benjamin Franklin
What is palliative care?
WHO Definition of Palliative Care
Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening 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.
http://www.who.int/cancer/palliative/definition/en/
WHO Definition of Palliative Care
provides relief from pain and other distressing symptoms;
affirms life and regards dying as a normal process;
intends neither to hasten or postpone death;
integrates the psychological and spiritual aspects of patient care;
offers a support system to help patients live as actively as possible until death;
http://www.who.int/cancer/palliative/definition/en/
WHO Definition of Palliative Care
offers a support system to help the family cope during the patients illness and in their own bereavement;
uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated;
will enhance quality of life, and may also positively influence the course of illness;
is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications.
http://www.who.int/cancer/palliative/definition/en/
Who are we?
Who are we?
Patient &
family
Doctors
Nurses
Allied Health
Pharmacists
Social worker
Psychologists
Chaplains
Dietitian
When is palliative care suitable?
EVOLUTION OF PALLIATIVE CARE
1960s – 1970s
Early
detection Diagnosis/treatment
Palliative
Care Death
1980s -- present
Preventio
n
Early
detection
Diagnosis/treatment
Palliative care
Death
EVOLUTION OF PALLIATIVE CARE
The Future
Diagnosis Death
Disease-modifying
therapies
Symptom control
Death preparation
Family support
Mr Gan told The Straits Times that he has appointed Prof Pang to head a task force to study the recommendations and how to implement them.
The task force will look into integrating palliative care with curative medical treatment.
This means patients with terminal illnesses will get palliative care while being treated for their conditions, instead of having it kick in only when nothing more can be done to prevent the illness from getting worse.
The report noted that patients identified for palliative care at a late stage usually do not fare well, and often endure unnecessary hospitalisation.
It also pointed to the need to educate people on palliative care, given that many associate it with giving up hope and treatment.
Singapore to promote palliative care
Salma Khalik The Straits Times Publication Date : 06-01-2012
http://www.asianewsnet.net/home/news.php?id=25940&sec=7
& How do we look after them?
(Approach)
Who do we look after?
Causes of mortality in Singapore 2010 http://www.moh.gov.sg/content/moh_web/home/statistics/Health_Facts_Singapore/Principal_Ca
uses_of_Death.html
Total no of death 17610
Cancer 28.5%
Ischaemic Heart Disease 18.7%
Pneumonia 15.7 %
Cerebrovascular Disease (including stroke) 8.4 %
Accidents, Poisoning & Violence 5.5 %
Other Heart Diseases 4.8 %
Chronic Obstructive Lung Disease 2.5 %
Urinary Tract Infection 2.5 %
Nephritis, Nephrotic Syndrome & Nephrosis 2.2 %
Diabetes Mellitus 1.0 %
Palliative care
2020, more than 10,000 people a year would
need palliative care here, up from 8,000 in 2009.
Who do we look after?
Cancer
Organ failures
Frailty
Typical illness trajectories for people with progressive chronic illness.
Murray S A et al. BMJ 2005;330:1007-1011
©2005 by British Medical Journal Publishing Group
Prognosis – identifying the stages
Prognosis of main illness
Prognosis of wound
Prognosis of coormorbidities
If possible, always aim for curative in conjunction
with palliative
Prognostication
“The physician who
can foretell the
course of the illness
is the most highly
esteemed”. Hippocrates
Prognostication
It is about recognising the process ( of transition
from living to dying)
Understanding of the illness
Understanding of the patient ( more difficult)
Ds specific tool
General tool
Prognostication Cancer
Advanced Cancer B12-CRP Index via Pallimed
Breast Adjuvant! Online
Lung Adjuvant! Online
Colon Adjuvant! Online
Paraneoplastic/Complications via EPERC Fast Facts
Congestive Heart Failure Seattle Heart Failure Model via University of Washington
EFFECT (Enhanced Feedback for Effective Cardiac Treatment) via CCORT
Prognostication COPD
BODE Index via EPERC Fast Facts
Dementia Mortality Risk Index or MDS-12 via EPERC Fast Facts
Liver Disease MELD Score (Model for End Stage Liver Disease) via Mayo Clinic
Primary Biliary Cirrhosis via Mayo Clinic
HIV and HAART ART Cohort Collaboration
Prognostication
Intensive Care Unit
APACHE II via SFAR
SAPS via SFAR
ProVent Score
Renal Patients
Modified Charlson Comorbidity Score via EPERC
Fast Facts
Prognostication Hospice/Palliative Care Patients
Palliative Performance Scale v2 (Victoria Hospice) in conjunction with the tables found in these two articles:
Harrold J, Rickerson E, Carroll JT, et al. Is the palliative performance scale a useful predictor of mortality in a heterogeneous hospice population? J Palliat Med. Jun 2005;8(3):503-509.
Lau F, Downing GM, Lesperance M, Shaw J, Kuziemsky C. Use of Palliative Performance Scale in end-of-life prognostication. J Palliat Med. Oct 2006;9(5):1066-1075.
Or you can use the Victoria Hospice Prognostat, based on their collective knowledge of PPS scores and survival over the last 10+ years.
Victoria Hospice has a number of great prognostic tools on their website as part of the Victoria Palliative Research Network. Palliative Prognostic (PaP) Score requires evaluation of dyspnea, anorexia, KPS, clinical estimate of survival, total WBC, and lymphocyte percentage. Groups into 3 categories of chance at 30d survival. (Via EPERC Fast Facts) Palliative Prognostic Index requires PPS, estimate of oral intake, and evaluation of edema, dyspnea, and delirium. See page 4 of this PDF for the scale.
Prognostication
Declining Palliative Performance Status
Momentum of decline
Are you surprise …..
Prognostication
Take a good history =
communication !
Why is prognostication important?
Establish goal of care
Goal changes as the illness
changes
Prognosis (survival)
Days
- symptoms control alone
Weeks
- mainly focusing on symptoms control
Months
- symptoms control + wound healing if possible
Years
- symptoms control + wound healing if possible
Care of the dying
“We have a large number of [nurses who haven’t trained in the UK] & one of the biggest challenges for them was the idea that you could actually have a planned death. Because in their culture you do everything you can to sustain life…so that was a bit of a challenge there for them to understand that there was a time to die…that we weren’t assisting death but planning for the inevitable.”
[NHB Manager] - St.Christopher’s
o Adapted from slides from Prof Scott Murray
Approach to palliation
Active Palliative Care
Palliative Care with limited
interventions
Full palliative mode
Approach to palliation
Always ask yourself:
What is the goal & extend of care of the patient?
Approach based on the following
principles
Treat the PATIENT, including family and other related persons, not just the disease or the debility.
Patient autonomy
Beneficence
Nonmaleficence
Justice
The above need to be applied against a background of respect for life and acceptance of the ultimate inevitability of death.
Principle of Guidance for
treatment
Medical Indications
Patient’s preference
Quality of life
Contextual
Approach to palliation
Advanced care planning
- BIPAP, antibiotics, NG tubes, extend of invasive
procedures (e.g PCN insertion for
hydronephrosis)
- Hospitalisation, location of care
Medical opinion
- Reversibility of illness
- Stages of patient
Wound care
Cancer Non-cancer
patient
Cancer
Malignant wound (direct invasion vs skin mets)
- eg.fungating breast tumour; SCC; Melanoma
Treatment related wound
- Radiotherapy
- Post-operative
Malignant wound
Disease control if possible
Systemic chemotherapy (+/- hormonal
therapy/targeted therapy etc)
Radiation therapy
Treatment related wound
Aim for healing if possible
Usually reversible (acute wound)
Always ask yourself (or your
colleague)
Can the underlying cause be treated?
Can the wound be treated?
Malignant wound- Common
problems
Pain
Odour/Exudate
Bleed
Self-image/Psychosocial
Pain
Nociceptive v.s neuropathic pain
Pain history (assessment)
Opioids – systemic vs topical
Bleeding
Friable
Slow ooze (microvascular fragmentation) vs
“bleeder”
( vascular disruption)
Avoid surface tear
Alginate dressings, topical adrenaline
compression, silver nitrate, or cautery.
Non-cancer wound care
Can the underlying cause be treated?
Can the wound be treated?
Where do we look after them?
How do we decide?
Advance care planning
Medical condition
Resources/coping of the family
Where?
Community
- Home
- Community hospital
- Inpt hospice
- Nursing home
Institution
- Acute hospital
PALLIATIVE CARE SERVICES In-patient Hospices
• Dover Park Hospice
• Assisi Home and Hospice
• St. Joseph’s Home
• Bright Vision Hospital
Home Care
•Hospice Care Association
•Assisi Home and Hospice
•S’pore Cancer Society
•Methodist Hospice
Fellowship
•Metta Home Care
• DPH (selected cases)
Day Care
• Hospice Care Association
• Assissi Home and Hospice
Home hospice Referral criteria: prognosis less than 1 year
symptomatic patient
Mainly lead by nurses
Role: provide medical input
equipment loan
psychosocial support
Usually visit once weekly or once every 2 weekly
Wound care normally will need to be done by the helper/family/HNF/others
24hour access/support
Inpatient Hospice
Referral criteria: prognosis of less than 3 months
symptomatic
no dedicated caregiver at home
E.g. : Large SCC of the face
Fungating breast lumps with pain
Impending carotid blowout ( impending big
bleed)
St. Joseph’s Home
Run by the Canossian Sisters
located at Jurong Road
22 beds for hospice patients, 108 beds for NH residents
Hospice section started 1985
Only inpatient services
Supported by a GP group; no resident doctors
Assisi Home and Hospice Established 1969
Owned by the Franciscan
Missionaries of the Divine
Motherhood (FMDM)
Sisters
An outreach service of Mt
Alvernia Hospital
40 beds (19 single-bedded
rooms)
Bright Vision Hospice
We’ve discussed
What is palliative care?
When is palliative care appropriate?
Who do we look after?
How do we look after (Approach)?
Where do we look after them?
Palliative Care- In summary
Good clinical care, recognising our advances and
limitation in healthcare
Caring for patient and family
Helping them find meaning in suffering
Listening to them & planning ahead