The document discusses palliative care and end-of-life issues. It summarizes a study that found patients with early palliative care consultations had less depression, anxiety, and better quality of life compared to those receiving standard care. They also received less aggressive treatments and had lower healthcare costs and lived 3 months longer. The document outlines the physical decline patients experience in the last weeks and months of life, barriers to dying at home, and the importance of advance care planning to ensure patients' wishes are known and respected.

1. Medical Aspects of Palliative Care –
A Conversation With Your Physician
Andrew C Knight, MD
Sudbury End-of-Life Forum
February 6, 2014

2. Palliative Care
• an approach to care (culture of caring)
• not restricted to a particular location
• can be combined with active care of any
patient with life limiting or life threatening
illness

3. • “What should I know about you as a person to
help me take the best care of you that I can?”
Harvey Chochinov, MD

4. • “If you don’t know your options, you don’t
have any!”
Lauren Vary

6. • Why introduce palliative care early?

8. Temel et al:
• newly diagnosed metastatic… lung cancer
(n=151)
• early palliative care consultation or standard
end of life referral

9. Patients with early palliative care consultation had:
…
•
less depression
•
•
•
•
•
less anxiety
better quality of life
received less aggressive treatments
lower health care costs
& lived 3 months longer!

10. Temel J, et al. Early Palliative Care for Patients with Metastatic
Non–Small Cell Lung Cancer. NEJM 2010; 363:733-42

12. • 1193 pts, newly diagnosed metastatic lung or
colorectal cancer (stage IV)
• alive 4 months later, receiving chemotherapy
• questionnaire to assess prevalence of belief
treatment curative:
lung: 69%
colorectal: 81%

13. • serious misunderstanding
• may compromise ability to make informed
treatment decisions
• decisions be inconsistent with preferences or
goals of care
• MDs may be able to correct misperception,
often at cost of patient’s satisfaction
• could early palliative care consultation
improve understanding of prognosis?

15. Early Palliative Care
•
•
•
•
•
better symptom management
may live longer
better quality of life & care
lower rates of depression
improved understanding of prognosis &
less likely to receive chemotherapy at EOL

16. The Pathway to Death
( in Advanced Cancer)
•
•
•
•
•
•
•
•
•
weight loss (cachexia, NOT starvation)
reduced appetite / reduced nutritional intake
increasing weakness / reduced activity
reduced fluid intake / reduced urine output
ineffective cough / swallowing / weakened voice
confusion (delirium), reduced alertness
airway secretions
cooling of extremities, mottling of skin
± bowel / bladder incontinence

17. Cardiac Arrest
• cessation of cardiac activity & respirations
• failure of cardiovascular & respiratory centres
located in brain stem
• usual consequence of multisystem failure
– liver & kidney failure; acid loading; high potassium
levels
• impaired cellular function
• cardiac arrest is final result
• CPR futile endeavour
(CPR may not be futile if cardiac arrest in trauma / cardiac disease)

19. Preparing for Death At Home
•
•
•
•
•
•
•
•
•
•
•
supportive spouse / family
adaptable physical surroundings
CCAC & nursing services
DNR status confirmed
in home pronouncement
symptom relief kit (SRK)
effective pain & symptom management
24/7 support – nursing & medical
back-up plan (hospital / hospice / NOT ER)
DO NOT CALL 911!
funeral arrangements

20. Barriers
•
•
•
•
fragmented home care services
no 24/7 support (crisis management)
family dysfunction / caregiver incapable
unendurable symptoms1: N=120, 52.5% @ 48hrs
– delirium
– severe shortness of breath / low oxygen levels
– bowel obstruction (persistent vomiting)
– severe pain
1Ventafridda,
1990

21. Cancer Pain & Associated Symptoms (n=1635)
•
•
•
•
•
•
•
•
pain
insomnia (59%)
anorexia (48%)
constipation (33%)
sweating (28%)
nausea (27%)
short of breath (24%)
swallowing difficult (20%)
Grond et al, 1994
•
•
•
•
•
•
•
•
neuropsychiatric (20%)
vomiting (20%)
urinary (14%)
indigestion (11%)
weakness (10%)
diarrhea (6%)
itching (6%)
skin (3%)

22. Potential Interventions
drug infusions (pain, sedation)
urinary catheter
oxygen
skin care
nasogastric tube
paracentesis / thoracentesis

23. Hot Button Issues
•
•
•
•
nutrition
hydration
airway secretions
pain pumps (patient controlled… but family
imposed)
• delirium

24. Organ Donation
• in cancer patients, restricted to corneal tissue
if other disqualifying conditions not present
• some exceptions (lymphomas, leukemias)
• for transplant, harvest within 12 hrs (& blood
sample)
• or teaching / research purposes

25. How long do I have to live?
• MDs frequently over-estimate survival
• survival rates apply to groupings of patients,
not individuals
• related complications & disease progression
unpredictable
• Surprise question: would you be surprised if
this patient would die in the next 6 to 12
months?

26. •
•
•
•
•
10,772 ESAS
7,882 PPS
Mean age: 65 years
Functional decline gradual from
70%
Rapid decline after 50% (last 2
– 3 weeks of life)
Mean PPS Score
Cancer patients
seen at Cancer
outpatient clinics
across Ontario
Time Before Death (in weeks)
Seow H et al. JCO 2011;29(9):1151-1158

27. Palliative Performance Scale (PPS)
ECOG
Functional Status PPS
Self-Care
Intake
Level of
Consciousness
100
Full
Normal activity
No evidence of disease
Full
Normal
Full
Full
Normal activity
Evidence of disease
Full
Normal
Full
Full
Normal activity with effort
Evidence of disease
Full
Normal/
Reduced
Full
70
Reduced
Unable to do normal work
Evidence of disease
Full
Normal/
Reduced
Full
60
Reduced
Unable to do house work
Significant disease
Occasional
Assistance
Normal/
Reduced
Full or
Confusion
50
Mainly
Sit/Lie
Unable to do any work
Evidence of disease
Considerable
Assistance
Normal/
Reduced
Full or
Confusion
40
Mainly in
Bed
As Above
Mainly
Assistance
Normal/
Reduced
Full or Drowsy
or Confusion
30
Stable
Activity & Evidence of
Disease
80
Transitional
Ambulation
90
0
%
Totally Bed
Bound
As Above
Total Care
Reduced
Full or Drowsy
or Confusion
20
As Above
As Above
Total Care
Minimal
Sips
Full or Drowsy
or Confusion
10
As Above
As Above
Total Care
Minimal/nil
Drowsy or Coma
1
2
End-of-life
3
4
Ma C, et al. Eur
J Cancer 2010
27

30. Interventions
• participants were randomized to receive usual care
or usual care plus facilitated advance care planning.
• advance care planning aimed to
– assist patients to reflect on their goals, values, and
beliefs;
– to consider future medical treatment preferences;
– to appoint a surrogate;
– and to document their wishes.

31. Conclusions
• “a coordinated, systematic model of patient centred
advance care planning using non-medical …
facilitators assists in identifying and respecting
patient’s wishes about end of life care, improves
such care from the perspective of the patient and the
family, and diminishes the likelihood of stress,
anxiety, and depression in surviving relatives.”

32. Family Members Responses –
Intervention Group
• “His death was really peaceful, and everyone knew what to
do.”
• “We had a clear plan so could just relax and enjoy time with
Dad.”
• “Even though we already knew what he wanted it was great
to be given the opportunity to talk about it and get it out into
the open.”
• “We felt really comfortable making decisions because we had
discussed it with him.”
• “He had a very peaceful death, just as it should have been and
I would like to thank all staff for this.”

33. Family Members Responses –
Control Group
• “He knew he was dying, and it was very hard for him. We
should have talked with him about it.”
• “He should have had more say. He couldn’t do the
rehabilitation. He knew he was dying, but the doctors didn’t
seem to get it.”
• “The hospital has a responsibility to talk with patients about
these things. My sister never got a say and that is wrong.”
• “They wouldn’t let her go. They kept doing tests and things
she would not have wanted.”
• “Mum didn’t want heroics. She knew she was dying. I was
horrified when I heard she got 45 minutes of CPR. She did not
want it. All anyone had to do was ask. I feel very hurt and hurt
for mum and my sister.”

34. “While I very much hoped not to die
in space….. Before my last space
flight..... I reviewed my will, made
sure my financial affairs and taxes
were in order, and did all the other
things you’d do if you knew you were
going to die. But that didn’t make me
feel like I had one foot in the grave. It
actually put my mind at ease and
reduced my anxiety about what my
family’s future would look like if
something happened to me. Which
meant that when the engines lit up
at launch, I was able to focus entirely
on the task at hand: arriving alive.”
(p 61)