Palliative Care in Neurological Disease
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Palliative care in Neurological
DiseaseSurat Tanprawate, MD, FRCPT
Division of Neurology, Department of MedicineChiang Mai University
04-10-2011, Chaing Mai, ThailandThursday, October 6, 2011
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“Palliative care”
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End of Life CareThursday, October 6, 2011
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Patients with terminal cancer
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Patients with terminal cancer
So many neurologic illness are progressive and incurable
It should be recognized as an important concept in the
management of any patient with a progressive, incurable illness
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Who do the neurologists see?
}Thursday, October 6, 2011
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Who do the neurologists see?
Worried well, headache/migraine, numbness,
dizziness, etc
}Thursday, October 6, 2011
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Who do the neurologists see?
Worried well, headache/migraine, numbness,
dizziness, etc
Chronic neurological disorder: MS, spinal
cord, dementia
}Thursday, October 6, 2011
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Who do the neurologists see?
Worried well, headache/migraine, numbness,
dizziness, etc
Chronic neurological disorder: MS, spinal
cord, dementia
Acutely ill patients }
Thursday, October 6, 2011
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Thursday, October 6, 2011
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ART > SCIENCEThursday, October 6, 2011
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What we have to learn?
Thursday, October 6, 2011
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What we have to learn?
• Learning process, not just knowledge
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What we have to learn?
• Learning process, not just knowledge
• Different diseases have different problems >> the same goal
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What we have to learn?
• Learning process, not just knowledge
• Different diseases have different problems >> the same goal
• Humanity diversity
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What we have to learn?
• Learning process, not just knowledge
• Different diseases have different problems >> the same goal
• Humanity diversity
• Knowing your function, and connect with others
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The different viewNeurologist view
Palliative care team view
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The different view• Holistic approach(physical,
psychological, cultural, spiritual)
• Experience in symptoms control
• End of life decision
• Community center
• In-patient facilities for terminal care/respite
• Day hospice facilities
• Complementary therapies
• Bereavement counselling
Neurologist view
Palliative care team view
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Neurologist
ยกตัวอย่างการดูแลผู้ป่วยโรคอัลไซเมอร์
Palliative care
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Neurologist
รู้จักโรคอัลไซเมอร์
ยกตัวอย่างการดูแลผู้ป่วยโรคอัลไซเมอร์
Palliative care
Thursday, October 6, 2011
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Neurologist
รู้จักโรคอัลไซเมอร์
ยกตัวอย่างการดูแลผู้ป่วยโรคอัลไซเมอร์
เข้าใจผู้ป่วย ญาต ิสิ่งแวดล้อม สังคม
Palliative care
Thursday, October 6, 2011
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Neurologist
รู้จักโรคอัลไซเมอร์
ยกตัวอย่างการดูแลผู้ป่วยโรคอัลไซเมอร์
เข้าใจผู้ป่วย ญาต ิสิ่งแวดล้อม สังคม
Palliative care
รู้จักและเข้าใจผู้ป่วยโรคอัลไซเมอร์Thursday, October 6, 2011
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Distress physical symptoms
Feeling and psychological
symptoms
Patient Health care
Family member
Social
Intervention
- Pharmacological
-Non-pharmacological
Improve QOL
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Thursday, October 6, 2011
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Common neurological problems
• Cognitive dysfunction, dementia> Alzheimer’s disease, other dementia
• Physical disability >stroke, motor neuron disease, Parkinson’s disease, spinal cord disease, neuromuscular weakness
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Dementia and Alzheimer’s disease
“แม้ความจําจะเลือนลาง แต่ความสุขไม่ลางเลือน”
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Dementia(โรคสมองเสื่อม)
• Decline of cognitive function (พุทธิปัญญา)
• Cognitive function: memory, language, motor ability, calculation
• It’s also involved psychological and behavioral symptoms: depression, anxiety, hallucination, sleep problem, pain
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Alzheimer’s disease
• Most common cause of dementia
• AD is a neurodegenerative disorder presented with progressive dementia
0
5
10
15
20
25
30
35
40
Percent of Age Group
30-6
4
65-6
9
70-7
4
75-7
9
80-8
4
85-8
9
90-9
4
95-9
9
Years
Female
Male
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Alzheimer’s disease
Cognitive impairment
Psychiatric and behavioral symptoms
Activity daily living
Physical disability-late stage
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Stage of AD
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Thursday, October 6, 2011
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Management strategies
• Prognostication, and dying from dementia
• Cognitive and communication ability decline
• Behavioral and psychological problems
• Challenging caregiver stress and bereavement issues
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Prognostication questions in dementia
• Patient’s question: “How long do I have before my mind is shot?”
• Health professional’s question: “Is s/he eligible for palliative care?”
• Family’s question: “How long does s/he have to live ?”
• Caregiver’s question: “ I am exhausted. How much longer can I do this?”
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• Stage 7 or beyond according to the FAST scale
• Unable to ambulate without assistance
• Unable to dress without assistance
• Unable to bathe without assistance
• Urinary or fecal incontinence, intermittent or constant
• No meaningful verbal communication, stereotypical phrases only, or ability to speak limited to six or fewer intelligible words
• Plus one of the following within the past 12 months:
• Aspiration pneumonia
• Pyelonephritis or other upper UTI
• Septicemia
• Multiple stage 3 or 4 decubitus ulcers
• Fever that recurs after antibiotic therapy
• Inability to maintain sufficient fluid and calorie intake, with 10 percent weight loss during the previous six months or serum albumin level less than 2.5 g per dL (25 g per L)
Dementia hospice eligibility
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Cognition and ability decline-1
• Unrecognized symptoms-pain, physical illness
• to find the hidden problem: patient report, caregiver report, and direct observation
• change in behavior or mental status
• OA, peripheral neuropathy, other pain are common
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Cognition and ability decline-II
• Loss of functional ability
• unable to ambulate
• unable to bath, dress, or feed independently
• incontinent of bowel and bladder
• unable to communicate meaningfully
• (presence of medical complication)
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What does dying look like
• Decline in functional status
• Lack of desire to eat or drink
• Withdrawn
• Sleep- wake state
• Mottling of limbs
• Jaw movement
• Death rattle
• Co-morbid symptoms
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Tube feed or not tube feed? That’s the question
• The facts:
• Effect on life span is an open question
• Increases suffering
• Need for better pt/family education
• Discussing benefits and burdens of therapy
• Use neutral language
• Separate facts from your opinion
• Please offer your opinion
• Make allowances for special circumstances.
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Palliative care in stroke patient
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Stroke
• Stroke is one of the three biggest killers in Thailand.
• Two types:
• Infarction
• Hemorrhage
• Death range from 8-20% in first 30 days (higher for hemorrhage)
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Stroke care: palliative care aspect
• Palliative care’s role in stroke care
• Acute stroke: end of life care
• Long term care in stoke with severe disability
• Death is mainly from cardiac (AMI, arrhythmias) or respiratory (aspiration, pneumonia embolism)
• Brain swelling
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End of life care in acute stroke
• Ethical aspects of care - end of life issues including withdrawal of treatment
• Early decisions about withholding cardiopulmonary resuscitation are avoided.
• There is full discussion with the patient (if possible) and family/carer about reasons for withdrawal/futility of treatment to allow all concerned to understand treatment goals.
• There is accurate documentation of plans of care and discussions between the multidisciplinary team, the patient and family/carer.
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Various case of stroke with disability
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Various case of stroke with
disability
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Various case of stroke with
disability
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Various case of stroke with disability
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Palliative care in motor neuron disease
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--Motor Neuron Disease--Amyotrophic Lateral Sclerosis (ALS)
• Progressive, degenerative neurologic disease of unknown etiology
• Involve: upper and lower motor neurons
==: LMN: weakness, atrophy, fasciculation
==: UMN: hyperreflexia, spasticity due to lateral corticospinal tract degeneration
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--Motor Neuron Disease--Amyotrophic Lateral Sclerosis (ALS)
• Progressive, degenerative neurologic disease of unknown etiology
• Involve: upper and lower motor neurons
==: LMN: weakness, atrophy, fasciculation
==: UMN: hyperreflexia, spasticity due to lateral corticospinal tract degeneration
:Symptoms:Weakness of body muscles
causing:: limb weakness
:: dysphagia:: respiratory failure:: speech difficulty
Memory and Cognitive function are spared...
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Signs and symptoms
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Signs and symptoms
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Signs and symptoms
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Signs and symptoms
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Secretion management : decrease saliva production Medication use>>Benztropine, amitriptyline, artane : remove saliva>>increase fluid intake, humidified air
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Secretion management : decrease saliva production Medication use>>Benztropine, amitriptyline, artane : remove saliva>>increase fluid intake, humidified air
Dysarthria : speech therapyDysphagia : Decreased caloric and fluid intake may lead to worsening of symptoms, such as weakness, muscle atrophy, fatigue : Initially management includes the modification of food and liquid consistency : Discussion for PEG
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Secretion management : decrease saliva production Medication use>>Benztropine, amitriptyline, artane : remove saliva>>increase fluid intake, humidified air
Muscle spasm & weakness : Early PT/OTCramps : Quinine sulfate 200 mg twice daily, Tizanidine 2-4 mg twice daily
Dysarthria : speech therapyDysphagia : Decreased caloric and fluid intake may lead to worsening of symptoms, such as weakness, muscle atrophy, fatigue : Initially management includes the modification of food and liquid consistency : Discussion for PEG
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Secretion management : decrease saliva production Medication use>>Benztropine, amitriptyline, artane : remove saliva>>increase fluid intake, humidified air
Muscle spasm & weakness : Early PT/OTCramps : Quinine sulfate 200 mg twice daily, Tizanidine 2-4 mg twice daily
Dysarthria : speech therapyDysphagia : Decreased caloric and fluid intake may lead to worsening of symptoms, such as weakness, muscle atrophy, fatigue : Initially management includes the modification of food and liquid consistency : Discussion for PEG
Respiratory care : initiate discussion regarding the patients’s goals and how the goal can be best achieved : respect the right of patients to refuse or withdraw treatment
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To cure sometimes
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To cure sometimes
To relieve often
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To cure sometimes
To relieve often
To comfort always
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Thank You for Your Kind Attention
Dr.Surat Tanprawate, MD, MSc(Lond.), FRCP(T)Division of Neurology, Department of Medicine,
CMU
My Deep Gratitude to Ass. Prof. Siwaporn
Chankrachang
WWW.OPENNEURONS.COMThursday, October 6, 2011