Care for End Stage Cancer Patients Dr. Peggy Lu. Determine the Level of Care Curative Care Palliative Care Comfortable care.

Care for End Stage Cancer Patients

Dr. Peggy Lu

Determine the Level of Care

• Curative Care

• Palliative Care

• Comfortable care

Health Care Worker Attitudes

• We should be able to fix it or cure it

• We must make people feels better

• If a patient dies we fail

• We have technology and drugs and there is always more we can do

What we need to learn

• We will die

• Life is finite

• Not all technology works

• How we want to die

• We must face our own mortality so we can help others face theirs

Nearing the End of Life

• What’s going to happen to me?• Have I done everything I should have done?• What are my other options?• How much control will I have over my life and my

death?• Will my wishes about my care be followed?• How much pain and suffering will I have?• What am I going to do about money?

“The Good End of Life”

• Preparation

• Clear decision-making

• Pain and symptom relief

• Contribution to others

• Completion

• Affirmation

Self-Determined Life Goals

-Who I am and what I am leaving behind

-What are my most important needs

-Where do I want to die

Assist the patient in meeting their end of life goals

The Elderly

-It is essential to ask elderly patients their wishes directly

-Medical personnel more often discuss these matters with surrogates or family members, neglecting to ascertain elderly patient’s opinions and therefore misunderstand patient's needs and wishes.

Why do you need an advance directive?

• Your have a right to be informed and decided for yourself

• Advance directives are for times you can’t speak for yourself.

• Free loved ones from making difficult decisions

Choosing DNR/DNI

• They want quality of the life they have left

• They want to avoid risks and harms of CPR

• They accept their prognosis and death

When is Hospice Care Appropriate?

• Life expectancy of 6 months of less

• Curative care is no longer effective or desired

• Goals are transitioned to comfortable and quality of life.

What can Hospice Care Provide?

• Minimized suffering

• Care is focused on pain and symptom management

• Coordination of care: The patient and family are supported by physicians, nurses, hospice aides, social workers, volunteers

• Spiritual Care

• Respite Care

• Bereavement Care

Communication, Control, Support

• Honest communication

• Allow as much control as possible

• Maintain patient dignity

• Address fear of unknown

• Listen, listen, listen

• Asses non-verbal cues

• Empower love ones to provide support

Emotions as Patients Near the End of Life

• Fear

• Anger

• Guilt and regret

• Grief

• Anxiety and depression

• Feeling alone

• Seeking meaning

Physical symptoms in the last 2-3 months of life

• Fatigue/weakness

• Pain

• Appetite changes

• Problems breathing

Physical symptoms in the last 2-3 months of life

• Nausea/vomiting

• Bowel obstruction

• Bowel/bladder incontinence

• Diarrhea or constipation

• Delirium/agitation/confusion

• Drowsiness and sleeping

Important Pain Management Concepts

• Medications are given according to physician’s orders and do not hasten the end of life

• Assess/reassess the duration and effectiveness of pain management

• Assess non-verbal patients

• Correct medications make the dying process more comfortable

• Always believe the patient’s report of pain.

Types of pain medications

• Long-acting time released forms

• Short-acting forms

• Patch

• Lozenges

• Liquid

• Rectal suppositories

• Pain medicine pump

Appetite Changes

• Happens to more than 8/10 of end stage cancer patients

• It is normal in the last months of life for parts of body to start slowing down and eventually shut down.

• Avoid family food battles

Problem Breathing

• Even thinking about breathing problem can be scary

• Patient may feel SOB or need breathe faster and harder than normal.

• Most often, severe symptom happens while the patient is unconscious and not aware.

• Things that can be done: Position, Oxygen, Decongestion, Medicines to reduce anxiety, Opioids

What Caregivers Can Do?

• Help patient turn and change position

• Try ice chips or sips of liquid if the patient is having trouble swallowing.

• Do not push fluids. Near the end of life, some dehydration is normal and also more comfortable for the patient.

• Pad the bed beneath the patient with layers of disposable waterproof pads.

What Caregivers Can Do?

• If patient is very restless, try to find out if they are having pain and give breakthrough pain medications if needed

• Gentle touching, caressing holding and rocking are usually helpful and comforting.

• Always assume the patient can hear you and continue to speak with and touch the patient to reassure them of your presence.

Saying the Four Things

• Please forgive me

• I forgive you

• Thank you

• I love you

• The 5th: Good bye

Signs that death has occurred

• Breathing stops

• Blood pressure can not be heard

• Purse stops

• Eyes stop moving and may stay open

• Pupils of the eyes stay large even in bright light

• Control of bowels or bladder may be lost as the muscles relax.

Life is pleasant.

Death is peaceful.

It is the transition that is troublesome.

Isaac Asimov (1920-1992)

Good Life and Good Death