palliative care introduction for health care workers

1. PALLIATIVE CARE
• Palliare- “to cloak, deceive, or cover”
• Palliate- “to lessen or mitigate without curing”
• Palliative Care- term first coined in 1974 by Dr. Balfour
Mount

2. PALLIATIVE CARE
• Provides relief from pain and other symptoms
• Affirms life and regards dying as a normal process
• Intends neither to hasten death nor postpone death
• Integrates the psychological and spiritual aspects of
patient care

3. PALLIATIVE CARE
• Offers a support system to families, including
bereavement
• Uses a team approach
• Enhances quality of life and at times may positively
influence the course of a disease
• Is applicable early in the course of an illness and in
conjunction with other life prolonging therapies
• Hospice is one facet of palliative care

4. INTEGRATING PALLIATIVE CARE
INTO CHRONIC LIFE-LIMITING
DISEASE MANAGEMENT
“best care possible”
Bereavement
Death
Terminal phase
Time
%
clinical
efforts
100
0

5. PALLIATIVE CARE & HOSPICE
Palliative
Care Hospice
Comfort
Care

6. HOSPICE
• Support and care for patients and families in the last
phase of an incurable illness
• Attempt for patients to live as fully and comfortably as
possibly
• Focus on quality of life and symptom management
• Continue to care for the patient, with a shift in focus

7. HOSPICE
• Interdisciplinary approach-nurse driven
• 24 hour on call RN
• Supplies, equipment, most medications are paid for
• Hospice takes over medical care
• Respite care
• Do not have to be DNR

8. HOSPICE
• Most care provided in home
• May be provided in NH or residential hospice
• Two physicians must certify that survival is anticipated
if the disease trajectory continues it’s expected course
• Patients may stay in hospice more than six months

9. HOSPICE
• Care in an inpatient setting for pain or other symptom
management
• Cannot be managed in other settings
• Intended to be a short term intervention
• Hospice makes determination of eligibility
• It is not an “automatic” level of care for imminently dying
patients
• Examples are pain crisis on IV meds and delirium with
behavioral issue
• Cap on these for each hospice

10. EARLY INTEGRATION OF
PALLIATIVE CARE IN PATIENTS
WITH SERIOUS ILLNESS
• Palliative Care is not just for patients at the end of life
• The goal of palliative care is to improve quality of life throughout the
trajectory of a serious illness
• Focus is on symptom management, advance care planning,
psychosocial support, and relief of suffering

11. EARLY INTEGRATION OF
PALLIATIVE CARE….
• A recent study in patients with advanced lung cancer
and early palliative care revealed improvement in
quality of life and survival
• Palliative Care can be provided with concurrent target-
directed therapy
• American Society of Clinical Oncology recommends
palliative care be integrated early in cancer patients

12. EARLY INTEGRATION OF
PALLIATIVE CARE
• Generally focus on symptom management initially
• Patients want to have relief of symptoms and know
you care- this helps build trust
• Advance Care Planning (ACP) can come later
• ACP is a conversation about the right medical
treatment for your patient

13. EARLY INTEGRATION OF
PALLIATIVE CARE….ACP
• Improves patient compliance
• Reduces hospitalizations at the end of life
• Leads to greater patient satisfaction
• Is longitudinal, iterative, incremental, and almost always changes over
time
• Slow is sometimes best-patients can only assimilate so much
information

14. TAKE HOME MESSAGE
Palliative Care is appropriate for patients with
serious illness at any stage of their disease process

15. CASE 1
A 72 y/o woman is admitted to the CCU after
sudden cardiac arrest. She has severe anoxic brain
injury with status myoclonus and minimal brain stem
reflexes present.
Palliative Care is consulted for goals of care. Family
doesn’t “get it” and insists on “doing everything”.

16. GOALS OF CARE
• A common reason for Palliative Care consultation
• Often elderly patients with multiple medical problems
and large symptom burden
• Not just at end of life

17. GOALS OF CARE…..
• Complex interaction requiring an intricate knowledge
of the clinical realities as well as prognosis
• Necessitates understanding your patient’s values,
preferences, and priorities
• Skill at responding to emotion, breaking bad news,
and using a shared decision making model

18. GOALS OF CARE-HOW TO
CONDUCT THE DISCUSSION
• Through compassionate listening, establish a bond by making a non-
medical connection
• Have your patient share their narrative-this can be both diagnostic and
healing
• Understand their perception of their medical condition (Ask-Tell-Ask)
• Ask about the “Big Picture”
• Give small pieces of information and check in

19. GOALS OF CARE GUIDE
• If your health worsens, what are your most important
goals?
• What are your biggest fears and worries about the
future of your health?
• What abilities are so critical to your life that you can’t
imagine living without them?
• If you become more ill, how much are you willing to go
through for the possibility of gaining more time?

20. RELATIONSHIPS- PEARLS
• Partnership- “We are going to work on this together”, “I will be here for
you”
• Empathy- “You appear sad”, “I wish things were different”, “I imagine
this is very hard”, “Tell me more”
….silence….head nodding….emotive vs.
cognitive….never respond to an
emotion with a fact…..state the
obvious…..

21. COMMUNICATION…PEARLS
• Acknowledge/Apologize- “You have done a wonderful
job caring for your mother”, “ I am sorry I am running
late and made you wait”
• Respect- “We may disagree, but I respect what you
are telling me”, “I can’t tell you how great it is to see
you doing some exercise, that’s really important”

22. COMMUNICATION PEARLS…
• Legitimize- “Anyone in your situation would be
tearful”, “It is normal to have the frustrations you are
experiencing now”
• Support- “ I am going to call your doctor so she knows
we are all working together on this”, “Here is my
contact information. I am here to work with you.”

23. COMMUNICATION…HELPFUL
PHRASES
• “Before we talk about your medical issues, tell me a
little about yourself”
• “How do you understand the big picture of your health
right now?”
• “What are your expectations of the time we have
together today?”
• “What else?”
• “Is there anything we haven’t talked about that I should
know to help care for you?”

24. COMMUNICATION….HELPFUL
PHRASES
• “I think I am beginning to understand what is
bothering you”
• “Go on”
• “Uh huh” with head nodding
• “So what I heard is…”
• “Let me be sure I got this right”
• “I share your sorrow. I consider your father a good
friend.”
• “Just so we are on the same page…”

25. CASE CONTINUED…
• 72 y/o woman with anoxic brain injury
• What did I do?

26. TAKE HOME MESSAGE
• Goals of Care conversation requires knowing your
patient, listening to their story, and understanding their
values and preferences
• Showing empathy and responding to emotion are
essential features of communication
• Using a shared decision making model, making a
recommendation when appropriate is beneficial

27. CASE 2
A 28 y/o man is admitted with pain, dyspnea,
nausea, and altered mental status. He was diagnosed 3
years ago with melanoma and now has widely
metastatic disease including brain mets. No further
disease specific therapy is warranted. He has spent
most of the past 6 weeks in bed and for the past 5 days
has experienced the aforementioned symptoms. His
family can no longer care for him at home. You are
consulted for symptom management.

28. CARE AT THE END OF LIFE
• Being present at the bedside of a dying patient is one
of the most meaningful acts a physician can perform
• Sit on the bed, touch your patient, express kindness
both verbally and non-verbally
• Listen to what is said….and not said
• Talk about the end of life, dying, and what they can
expect

29. TERMINAL PHASE OF LIFE

30. Introduction:
• The terminal phase may present new aspects of physical, psychological,
spiritual care of the patient
• If the patient has received good palliative care it does not automatically
mean that the terminal phase is taken care of
• Poorly relieved suffering in the days before a person dies is always
remembered by relatives and can cause intense distress to them for
months and years to come, often obliterating their recollections of all the
good care their loved one received before that.

31. How do we recognize the terminal phase?
• As the patient gets near to death he/she:
Becomes increasingly weary, weak, and sleepy;
Becomes less interested in getting out of bed or receiving visitors;
Becomes less interested in things happening around him/her
Often becomes confused, occasionally with features of agitated anguish
• It may be difficult to differentiate the terminal phase from an acute on chronic,
potentially reversible condition.
• However it may help to know that many of the above signs will simultaneously
present in the terminal phase.

32. Physical symptoms Common symptom include-
Pain, asthenia, anorexia, nausea,
constipation, confusion, agitation, tracheal
cluttering, breathlessness.
Psychosocial and spiritual suffering

33. DEFINITION
AN UNPLEASANT SENSORY AND EMOTIONAL
EXPERIENCE ASSOCIATED WITH ACTUAL OR
POTENTIAL TISSUE DAMAGE OR DESCRIBED IN
TERMS OF SUCH DAMAGE (INTERNATIONAL
ASSOCIATION FOR THE STUDY OF PAIN, 1979)
PAIN IS THE FIFTH VITAL SIGN

34. NOCICEPTIVE PAIN
Mechanism Pathophysiology Example Quality of pain
Nociceptive
pain
Activation of the peripheral
nerve fibres sensitive to
noxious
(Nociceptive) stimuli in
somatic or visceral
structures
Somatic:
Bone pain/soft
tissue
Visceral pain:
Liver capsular
pain
Mesenteric
stretch
Bowel
involvement
Sharp, Dull
aching, gnawing,
occasionally
throbbing,
localized pain
Dull aching, sharp,
gnawing, localized
pain
Diffuse, cramping
or colicky pain

35. NEUROPATHIC PAIN
Mechanism Pathophysiology Example Quality of pain
Neuropathic pain Disease or
dysfunction of
somatosensory
system
Brachial plexus
neuropathy, Spinal
cord compression,
Phantom pain,
Herpetic neuralgia
Chemotherapy
induced peripheral
neuropathy
Shock like, burning,
tinging pain
Pain radiates along
the distribution of
the nerve
Burning pain,
tingling pain, sharp
shooting pain.
Paresthesia/dysesth
esia, hypoeralgesia
and allodynia
present

36. IDIOPATHIC AND ANTICIPATORY
PAIN
Mechanism Pathophysiology Quality of pain
Idiopathic pain
Anticipatory pain
•Pain which is not explained by
organic pathology
•Pain that occurs even before a
particular procedure or
treatment.
•This could be influenced by
patient’s past experience
Anti-anxiety drugs like
benzodiazepines,
antidepressant or
antipsychotics may
benefit

37. A thorough pain history and shared goal setting are
critical components of effective pain management
that will lead to beneficial outcomes

38. ASSESSMENT OF PAIN

39. OPQRST OF PAIN
• Onset duration and progression
• Site: Patient can complain of pain at multiple sites at one time or
different time points of assessment
• One must be alert about the manifestation in order to scrupulously
manage pain
• It will be essential to know the underlying causative factor leading to
pain
•

40. Severity
• Numerical rating scale /Edmonton Symptom Assessment/Visual
analogue scale: Both assess score of 0-10
• Wong-Baker Faces Scale:

41. FLACC BEHAVIORAL SCALE FOR PAIN
ASSESSMENT
• The Face, Legs, Activity, Cry, Consolability scale (FLACC
scale) is a measurement used to assess pain for children between
the ages of 2 months and 7 years
• Also in individuals that are unable to communicate their pain.

42. • The scale is scored in a range of 0–10 with 0
representing no pain.
• The scale has five criteria, which are each assigned a
score of 0, 1 or 2

43. Criteria Score 0 Score 1 Score 2
Face
No particular
expression or smile
Occasional grimace or
frown, withdrawn,
uninterested
Frequent to
constant quivering
chin, clenched jaw
Legs
Normal position or
relaxed
Uneasy, restless,
tense
Kicking, or legs
drawn up
Activity
Lying quietly, normal
position, moves
easily
Squirming, shifting,
back and forth, tense
Arched, rigid or
jerking
Cry
No cry (awake or
asleep)
Moans or whimpers;
occasional complaint
Crying steadily,
screams or sobs,
frequent
complaints
Consolability Content, relaxed
Reassured by
occasional touching,
hugging or being
talked to, distractible
Difficult to console
or comfort
FLACC Behavioural scale

44. QUALITY OF PAIN
Bone metastasis/soft tissue
metastasis
Dull aching boring/nagging
pain/gnawing
Pleural/liver capsular stretch Dull aching boring/nagging
pain/gnawing
Disease in the peritoneum Dull aching pain
Intestinalobstruction/bladder
irritation
Colicky abdominal pain or
cramping pain
Nerve root/cord involvement Shock like pain/burning
pain/tingling
May be associated with
paresthesia/allodynia/hyperalgesia

45. Radiating/Localized
• Does the pain radiate? Where?
• Does it feel like it travels/moves around?
• Did it start elsewhere and is now localized to one spot?

46. Temporality of pain
• When/at what time did the pain start?
• How long did it last?
• How often does it occur: hourly? daily? weekly? monthly?
• Is it sudden or gradual?
• What were you doing when you first experienced it?
• When do you usually experience it: daytime? Night
• Are you ever awakened by it?

47. Provocative/Relieving factors:
• What makes it better or worse?
• What seems to trigger it? Ex. Position? Certain activities?
• What relieves it? Medications, massage, heat/cold, changing position,
being active, resting?

48. Associated factors:
• Does the pain affect his functional activities like
going to the bathroom, walking, eating, restricting his
hobbies etc.
• Does the pain affect his sleep
• Affect family, social, financial and spiritual factors and
thus QOL

49. PAIN MANAGEMENT
Type of pain Structure involved Treatment
Nociceptive
 Somatic
 Visceral
 Bone pain
 Soft tissue
 Liver capsular/renal
pain/mesenteric
 Intestinal cramps
NSAID+/-
opioid+bisphosphonates
NSAID+/- opioids
NSAID+/-opioids
Anticholinergic
medications/somatostatin
analogue
Neuropathic Neuromas or nerve
infiltration
Spinal cord compression
Herpetic/diabetic
neuropathy
Complex regional pain
syndrome
Anticonvulsants/antidepre
ssants
NMDA Blockers
Corticosteroids(if cancer)
Paracetamol
Opioids
TENS

50. WHO PAIN LADDER

51. STEP 1 (PAIN +; MILD PAIN)
NSAID Dosage Frequency Contraindications
Paracetamol Adults: 500mg-1gm
Children:15mg/kg
Q6h-q4h
Q6h
Contraindicated in
hepatic
failure(especially
alcohol induced)
Concurrent use with
5HT3blockers may
reduce the analgesic
effect
Ibuprofen Adult: 400mg-800mg
Children: 5 – 10
mg/kg
Q8h C/I:Peptic ulcer
disease,
thrombocytopenia
and severe renal
failure and Heart
failure
Caution:
Renal impairment
Severe Hepatic
impairment*
Naproxen* 5 mg/kg/day (max,
1gm)
every 12 hours
Etoricoxib Adult: 60-120mg Q24h-q12h C/I: heart disease,

52. STEP 2 (PAIN ++, MODERATE PAIN)
Weak opioids Dosage Frequency Side effects and
contraindications
Codeine Adult: 15-60mg
0.5 – 1 mg/kg (max
(1m-12y-240mg/day)
Q6h Caution: Cardiac
arrhythmias/acute
abdomen
Dose modification in
liver and renal
dysfunction
Tramadol Adult: 50-100mg
Children: 1 – 2
mg/kg (max,
400mg/day)
Q6h-q4h Caution:
Raised ICT, epilepsy,
Severe renal and
hepatic impairment
Lowers seizure
threshold

53. STEP 3 (PAIN +++, SEVERE
PAIN)
Strong opioids Dosage Frequency Side effects and
contraindications
Morphine Oral: SC : IV =
3:2:1
Dose adjustment in
renal and hepatic
failure
No major
contraindication in
palliative care
0.2–0.5mg/kg every 4 hours
<1year: 0.8–0.2
mg/kg
every 4 hours
1–2 years: 0.2–
0.4mg/kg
every 4 hours

54. Strong
opioids
Dosage Frequenc
y
Side effects and
contraindications
Fentanyl Patch (in micrograms)
12.5 / 25 / 50 / 125 mcg
Patch dose calculation:
(Cumulative 24-hour dose of
oral morphine × 10) divided
by 24
e.g., 30mg 24hour dose of
oral morphine = 12.5 mcg
Fentanyl patch.
This gives us an idea of the
nearest possible dose of the
patch to use.
Every 72
hours
Continue morphine(dose
equivalent of the patch) for first 8
– 12 hours until which the steady
plasma levels of Fentanyl is
achieved.
Apply patch on non- hairy, non-
inflamed areas: upper back or
chest wall preferred
Dose adjustment in liver failure.
For breakthrough pain use the
dose equivalent of morphine. For
example for Patch strength of
12.5mics the dose of oral
morphine for breakthrough pain
will be 5mg.

55. BREAKTHROUGH DOSING
• Transitory flares of pain, called “breakthrough pain,” can be expected
both at rest and during movement.
• When such pain lasts for longer than a few minutes, extra doses of
analgesics, i.e., breakthrough or rescue doses, will likely provide
additional relief.

56. • To be effective and to minimize the risk of adverse
effects, consider an immediate-release preparation of
the same opioid that is in use for routine dosing.
• When morphine or transdermal Fentanyl is used, it is
best to use an alternative short-acting opioid, e.g.,
morphine as the rescue dose.

57. • An extra breakthrough dose can be offered once every 1 hour(keep a
gap of one hour between BTP dose of morphine and routine dose of
morphine) if administered orally, or possibly less frequently for frail
patients, every 30 minutes if administered subcutaneously, or
intramuscularly, and every 10 to 15 minutes if administered
intravenously
• Longer intervals between breakthrough doses only prolong a
patient’s pain unnecessarily

58. MANAGEMENT OF OPIOID SIDE
EFFECTS
Side effects Drug of choice
Nausea and Vomiting 1st DOC: Metoclopramide(100mic/kg) and
2nd DOC: Haloperidol (25-85mic/kg over
24hours)$
Constipation Combination of stimulant and stool softener
is a must like Syp. Cremaffin Plus or Syp
Laxit Plus (>3years- 10-40mg/day; 3-6years:
20-60mg/day; 6-12years: 40-120mg/day. All
can be given in 1-4divided doses)#
Delirium R/O other medical cause
Use neuroleptics like haloperidol or
risperidone
Myoclonus Use benzodiazepine like
lorazepam(100mic/kg per dose and repeat
the dose as needed) or diazepam
(100mic/kg perdose and repeat the dose as
needed)

59. Side effects Drug of choice
Pruritis Use alternative opioid and can start on
5HT3 antagonist like Ondansetron
Drowsiness Methylphenidate can be given
Respiratory Depression This is an emergency;
If RR <10-12/min, patient is cyanosed
and non arousable then start Opioid
antagonist Naloxone (0.4mg ampoule of
naloxone should be diluted in 10ml NS to
obtain 40mic/ml solution to be
administered every 1-2mins till the
respiration picks up. If the RR dose not
pick up after 3-4doses we should look for
other putative factor.

60. ADJUVANTS
Drug Dosage Remarks
Dexamethasone Raised ICT: 8-16mg –early
morning
Intestinal obstruction: 6-16mg-
eary morning
Spinal cord compression:16mg-
early morning
Bone pain(metastasis): 4-6mg
early morning
Side effects:
Insomnia, Diabetes mellitus,
myopathy, infection: candidial,
herpes zoster shingles.
Cushing’s syndrome
Gabapentin 2-8mg/kg/dose q6h
Adult: 50mg-100mg TDS to
maximum dose of 3600mg/day
Children: 50mg -400mg/day
Increase the dose every 3days
Drowsiness and dizziness
Nystagmus, sedation, tremor,
ataxia, swelling
Pregabalin Adult: 75mg-600mg/day
Children: 1 mg/kg/dose (max
300mg/day)
Increase the dose every 3days
Amitriptyline 0.2mg/kg qhs increase every
3days
10mg-150mg
Antimuscarinic effects,
sedation, delirium,
hyponataemia

61. INTERVENTIONAL PAIN MANAGEMENT
Type of block Common indications
Stellate ganglion block
Phantom limb pain, causalgia
Cancer breast, Reflex
sympathetic
Dystrophy
Coeliac ganglion block
Cancer upper abdominal
structures like
Stomach, gall bladder,
pancreas, liver .
Sup. Hypogastric block Pelvic and genito-urinary
malignancies
Lumbar sympathetic
Block
Lower extremity malignancies,
Perineal and pelvic
malignancies

62. NON PHARMACOLOGICAL TECHNIQUES
• Hypnosis
• Mindfulness meditation,
• Transcutaneous electrical nerve stimulation,
• Acupuncture

63. Acute Stridor:
• This may be caused by haemorrhage into a tumour pressing on the trachea or it
may be the final stage of progressive tracheal compression.
• The patient needs to be sedated as speedily as possible with IV midazolam 5
to20 mg or rectal diazepam solution 10 to 20 mg (which relatives can be taught
to use in the home), both effective within minutes.
Massive Haemorrhage
• The commonest sites of such haemorrhage are the carotid (externally) and
major veins within the chest (internally)
• However, where it is recognized that such a haemorrhage might occur it is
prudent to have nearby a dark-coloured towel to make the amount of blood lost
less obvious to the patient and to have a fast-acting sedative drawn up for
immediate sedation.
• Midazolam 5 to 20 mg IV or propofol usually, by the time the drug has been
drawn up into a syringe and administered, the patient is unconscious and is
within a minute or so from death.

64. Multifocal myoclonus
• It is not uncommon in dying patients and can distress the relatives.
• Patients are often so ill that they seem unaware of it.
• It may be caused by dopamine antagonists such as metoclopramide
and the neuroleptics and by high-dose opioids, as well as by the
withdrawal of such drugs as benzodiazepines, barbiturates,
anticonvulsants, and alcohol.
• The treatment should include: Sedation with midazolam SC 5 to 10
mg every hour until the patient is settled.
• Alternatives are rectal diazepam solution 10 to 20 mg every hour or
clonazepam SC 0.5 mg hourly until settled.

65. Convulsions
• Ten per cent of patients experience grand mal convulsions in the terminal
phase
• Causes include known epileptics, post- neurosurgery or primary or
secondary cerebral malignancies , sudden withdrawal of long-term
anticonvulsants
• Usually, anticonvulsants must be continued, using either rectal diazepam
or SC midazolam via a syringe driver or aqueous solution of
phenobarbitone
Urinary retention
It is common in men with advanced disease and requires indwelling
continuous catheter.

66. Confusion
• Up to 40 percent of terminally ill patients experience confusion for a
variety of reasons
primary or secondary brain tumour
epilepsy
metabolic encephalopathy
electrolyte imbalance,
side effects of drugs,
infection,
nutritional deficiency,
paraneoplastic syndromes.

67. Management of confusion
• Treat any identifiable cause like hypercalcaemia, uraemia, hepatic encephalopathy,
sepsis, hyper- or hypoglycaemia, or even a change in surroundings, changes in
medication
• If the patient is dehydrated it is always worth a short trial of subcutaneous infusion
of saline.
• This will reverse confusion within 24 hrs.
• Create a quiet environment.
• Explain to the relatives and visitor the importance of this management.
• Explain to relatives how to converse with the confused person not trying to correct
them, not arguing with them.
• Consider a mild tranquilizer such as diazepam 5 to10 mg once daily, or midazolam
via a syringe driver. For agitated confusion haloperidol 2.5 to 5 mg may be used.

68. Tracheal cluttering:
It is seen in 25 to 92 per cent of dying patients.
This term describes the gurgling, bubbling noise made when a
terminally ill patient has secretions at the back of the throat and is too
weak either to swallow them or expectorate them.
Mechanical suction gives short lived relief.
Glycopyrrolate or octreotide are the best options for either through
boluses or CIVI

69. Planning and teamwork are essential for proper
management in the terminal phase
The essential steps include;
• Review all medication: Certain drugs like antihypertensives, laxatives,
antacids, hypoglycemics vitamins, antidepressants can be omitted
• Changing the route of administration of drugs: The oral route
becomes increasingly unreliable. Other routes like subcutaneous
infusion, iv infusion, per rectal administration sublingual may be tried
• Communication:
•At this stage it is important to speak to the patient so that she can
convey his/her hopes and wishes and express fears.
•It is important to assure the patient that he/she will not be allowed to
suffer and that her wishes (advance directives) will be respected.

70. • Place of care
Upto 75% of patients may prefer to die at home in a familiar and non-
threatening environment. Feasibility of care at home must be assessed.
Options for care elsewhere are-hospital, hospice/palliative care unit, or nursing
home must be explored.
Particularly when the patient is in hospital must it be decided whether any
further investigations (even simple blood tests or chest X-rays) are likely to help
or are ethical.
• Needs of the relatives as the patient is dying
We must realize that the caregivers may face the following problems-
fatigue, anger at not being fully informed, not knowing how they can help
the patient, not knowing whether the patient has died , financial problems
The relatives also face several difficulties at this time and need continued
support explanations and guidance

71. END OF LIFE…WHAT PATIENTS
WANT
• Be as comfortable as possible
• Be free of pain, dyspnea, and anxiety
• Be clean
• Know what to expect
• Have someone who will listen
• Maintain dignity
• Say goodbye
• Deal with unreconciled issues

72. END OF LIFE…WHAT PATIENTS
WANT
• Trust their physicians and nurses
• Physical touch
• Share time with friends and family
• Say “I love you”
• Say “I am sorry”
• Be sure their family is prepared
• Little things matter

73. END OF LIFE…ASSESSMENT
AND MANAGEMENT
• Pain
• Dyspnea
• Nausea
• Delirium
• Secretions
• Agitation
• Anxiety/Depression
• Existential Distress/Anticipatory Grief

74. END OF LIFE…ASSESSMENT
AND MANAGEMENT
• Grimacing
• Tachypnea
• Work of Breathing
• Delirium
• Death Rattle
• Mottling
• Pulses
• Body temperature

75. END OF LIFE MEDICATIONS
• Pain- opioids, steroids, ketamine
• Dyspnea- opioids, benzodiazepines
• Delirium- haloperidol
• Nausea- haloperidol, steroids, ondansetron
• Anxiety- Benzodiazepines
• Secretions- scopolamine, glycopyrrolate
• Cachexia, Fatigue- Steroids
• Depression- Methylphenidate, SSRI, ?ketamine

76. TAKE HOME MESSAGE
• Patients and families have expectations we should
meet and they deserve
• Be present
• Prepare the patient and family
• Aggressively assess and manage symptoms

77. OBJECTIVES
• Describe the role of palliative care in patients with
serious illness
• Understand the use of communication tools in patient-
physician interactions
• Discuss assessment and management of actively
dying patients

78. ADVANCE DIRECTIVES
• Legal documents that give direction to a patient’s care
when they are unable to make their own decisions
• Apply only when they have lost decision making
capacity
• Surrogate decision maker- durable healthcare power
of attorney
• Preferences for future care- living will

80. INDICATORS FOR MONITORING PALLIATIVE CARE DEVELOPMENT
DIMENSION AND INDICATORS
A. Integrated palliative care services:
This refers to the capacity of the national health and social system to meet the
needs of adults and children with serious health-related suffering. This entails
services integrated into primary care and specialized services (hospice, home
care, hospital, outpatient), its interaction with other areas of the health
system, accessibility and commitment to private sector providers. E.g.
I. Number of specialized palliative care programmes in the country per
population.
II. Number of specialized palliative programmes for children in the country per
population.
III.Availability of monitoring systems to evaluate the quality of palliative care
programmes.
IV.Estimated number of patients receiving specialized palliative care at the
national level.

81. INDICATORS FOR MONITORING PALLIATIVE CARE DEVELOPMENT
DIMENSION AND INDICATORS
B. Health policies:
This refers to the political commitment and leadership expressed in governance and
policy frameworks (strategies, standards, guidelines). It includes the development of a
legal framework and regulations that guarantee the rights of patients, access to palliative
care services and essential medicines, and the financing and inclusion of palliative care
in the national health service and benefits package. It also includes health system design
and health care organization, in addition to stewardship and multi-stakeholder action.
Eg.
I. Existence of a current national palliative care plan, programme, policy, or strategy with
defined implementation framework.
II. Existence of a legal framework to ensure access to and regulation of palliative care
III. Inclusion of palliative care in the list of health services provided at the primary care level
in the national health system.
IV. Existence of national standards and norms for the provision of palliative care services.
V. Existence of national coordinating authority for palliative care (labelled as unit, branch,
department) in the Ministry of Health (or equivalent) responsible for palliative care

82. INDICATORS FOR MONITORING PALLIATIVE CARE
DEVELOPMENT
DIMENSION AND INDICATORS (cont)
C. Use of essential medicines:
This refers to the availability and access to essential medicines for palliative
care across all levels of the health system, with special emphasis on the use of
opioids for the management of pain and other symptoms, supported by
respective risk management strategies. This list of essential medicines
includes non-opioids and non-steroidal anti-inflammatory medicines; opioids
analgesics; and medicines for other common symptoms in palliative care.
I. Reported annual opioid consumption – excluding methadone – in oral morphine
equivalence (OME) per capita.
II. Availability of essential medicines for pain and palliative care at all levels of
care.
III.General availability of immediate-release oral morphine (liquid or tablet) at the
primary care level

83. INDICATORS FOR MONITORING PALLIATIVE CARE
DEVELOPMENT
DIMENSION AND INDICATORS (cont)
D. Education and training:
This refers to the availability of undergraduate education resources
(integrated into curricula) in medicine and nursing schools, the existence of
a specialization in palliative medicine and the existence of continuing
education programmes for the development of basic and advanced skills in
the care and treatment of people with palliative needs.
I. Proportion of medical and nursing schools with palliative care formal
education in undergraduate curriculum.
II. Specialization in palliative medicine for physicians

84. INDICATORS FOR MONITORING PALLIATIVE CARE
DEVELOPMENT
DIMENSION AND INDICATORS (cont)
E. Empowerment of people and communities:
This relates to the capacity of a country to empower individuals,
families and communities as partners in the development of health
and social services as well as in the engagement in shared decision-
making about their own health. This entails the availability of
advocacy resources to protect and enhance the participation of
patients and caregivers in the development of palliative care
programmes.
I. Existence of policy or guideline addressing advance care planning of
medical decisions for use of life-sustaining treatment or end-of-life care.
II. Existence of groups dedicated to promoting the rights of patients in need
of palliative care, their families, their caregivers, and disease survivors

85. INDICATORS FOR MONITORING PALLIATIVE CARE DEVELOPMENT
DIMENSION AND INDICATORS (cont)
F. Research:
This is related to the development of research oriented to palliative care. Research
aims at improving the level of scientific evidence to guide the care of people and
decisions about the organization of health services.
I. Existence of congresses or scientific meetings at the national level specifically related to
palliative care.
II. Palliative care research on the country estimated by peer reviewed articles

87. Evaluation of palliative care coverage ( Kolkata, India) (group Isolated provisions )
Densely populated community, Existing palliative care facilities, large pediatric
population, resource constrained health budget.
DIMENSION AND
INDICATORS Indicators selected for my area
Integrated
palliative care
services
I. Number of specialized palliative programmes for children in
the country per population.
Health policies I. Existence of national standards and norms for the provision
of palliative care services
Use of essential
medicines
I. Reported annual opioid consumption – excluding
methadone – in oral morphine equivalence (OME) per
capita.
Education and
training
I. Proportion of medical and nursing schools with palliative
care formal education in undergraduate curriculum.
Empowerment of
people and
communities
I. Existence of groups dedicated to promoting the rights of
patients in need of palliative care, their families, their
caregivers, and disease survivors
Research I. Palliative care research on the country estimated by peer

88. THANK
YOU