Introduction to oncology

palliative care
Lecturer: Nadia shamasnah
What is palliative care?
• Palliative care is an approach that improves the quality o
patients (adults and children) and their families who are
problems associated with life-threatening illness.
• It prevents and relieves suffering through:
• the early identification,
• correct assessment
• and treatment of pain and other problems.
• Palliative care is the prevention and relief of suffering of
physical, psychological, social, or spiritual – experienced
children living with life-limiting health problems.
• It promotes dignity,
• quality of life
• and adjustment to progressive illnesses, using best avail
Who needs palliative care?
• Globally, it is estimated that palliative care is needed in 40-60
deaths .
• Palliative care is required for patients with a wide range of life
health problems.
• The majority of adults in need of palliative care have chronic
as:
• cardiovascular diseases (38.5%),
• cancer (34%),
• chronic respiratory diseases (10.3%),
• AIDS (5.7%) and diabetes (4.6%).
• Patients with many other conditions may require palliative care,
• kidney failure,
• chronic liver disease,
• rheumatoid arthritis,
• neurological disease,
• dementia,
• congenital anomalies
• and drug-resistant tuberculosis.
• Children may have a high incidence of congenital anomalies and
conditions and mortality is highest in the neonatal period.
• Each year an estimated 20 million people are in need of
in the last year of their life, with many more requiring pa
prior to the last year of their life.
• Of these people in need, 78% live in low- and middle-inc
countries.
• For children, 98% of those needing palliative care live in
middle-income countries with almost half of them living
• In 2014, it was estimated that only 14% of people need
care at the end of life, actually receive it .
• Pain is one of the most frequent and serious symptoms
by patients in need of palliative care.
• Opioid analgesics are essential for treating the pain and
common distressing physical symptoms associated with
advanced progressive conditions.
• For example, 80% of patients with AIDS or cancer, and 6
patients with cardiovascular disease or chronic obstructi
disease will experience moderate-to-severe pain at the e
lives.
•
• In 2011, 83% of the world’s population lived in countries
non-existent access to opioid pain relief .
• Psychosocial support is another common need in palliati
• Patients with life-threatening or terminal illness and the
go through great stress, and health professionals treatin
to be adequately trained or prepared to help them man
stress.
• In the WHO Global Action Plan for the Prevention and C
Noncommunicable Diseases (NCDs) 2013-2020, palliativ
explicitly recognized as part of the comprehensive servic
for the Noncommunicable diseases.
• Governments acknowledged the need to improve acces
care in the Political Declaration of the High-Level Meetin
General Assembly on the Prevention and Control of
Noncommunicable Diseases in 2011, and access to opio
medicines is one of the 25 indicators in the global monit
framework for NCDs.
‫ت بالحاجة إلى تحسين الوصول إلى الرعاية التلطيفية في اإلعالن السياسي •‬
‫يع المستوى للجمعية العامة لألمم المتحدة بشأن الوقاية من األمراض غير‬
‫في عام ‪ ، 2011‬والوصول إلى أدوية األلم أفيونية المفعول هو واحد من‬
‫‪ 25.‬مؤشرً ا في إطار الرصد العالمي لألمراض غير المعدية‬
• Palliative care medicines, including those for pain relief,
in WHO’s list of essential medicines for adults and childr
should be made accessible to all who need them.
• These lists include opioid and non-opioid medicines for
well as medicines for the most common symptoms in pa
• Ensuring the accessibility of palliative care is not just an ethical
health systems; it is also an obligation under international hum
• The right to palliative care and pain relief is recognized under th
to health.
• Under international drug control conventions, ‫مكافحة‬88‫لدولية ل‬88‫اقياتا‬
‫ت‬8‫لمخدرا‬88‫ا‬countries have a dual obligation to ensure that controlle
are accessible for medical purposes, at the same time as protec
populations against dependence and misuse.
• Unfortunately, countries have paid far more attention to their o
prevent abuse than to their obligation to ensure access for med
• Palliative care may often be seen simply as giving painkil
medicines. The rationale for palliative care certainly incl
for relief from pain and other distressing symptoms, but
further to include efforts to enhance the quality of life, a
influence the course of illness in a positive way.
• Life is affirmed and dying is regarded as a normal proces
integrating physical, psychological, social, cultural and sp
aspects.
• Patients are helped to live as actively as possible until de
support system offers help to the family to cope both du
patient’s illness and during bereavement.
• Palliative care is not intended to hasten or postpone dea
ethical principles, shared decision-making and advanced
planning to identify patients’ priorities and goals for the
end of life.
• A team approach is used and many kinds of health and s
providers, as well as volunteers, can be involved.
• It is important that palliative care should not be conside
something that only hospitals can do.
• It can be provided in any health-care setting and also in
homes and can be successfully implemented even if reso
limited.
Palliative care services should, theref
minimum:
• Identify patients who could benefit from palliative care;
• Assess and reassess patients for physical, emotional, so
spiritual distress and (re)assess family members for emo
or spiritual distress;
• Relieve pain and other distressing physical symptoms;
• Address spiritual, psychological and social needs;
• Clarify the patient’s values and determine culturally app
of care.
• The essential practices in primary palliative care can be
four categories:
• Physical care,
• Psychological/emotional/spiritual care,
• Care planning and coordination,
• Communication
Identify, evaluate, diagnose, treat, apply
measures for:
• Physical care needs: • Fatigue
• Pain (all types) • Anorexia
• Respiratory problems (dyspnea,
cough) • Anaemia
• Gastrointestinal problems • Drowsiness or sed
(constipation, nausea, vomiting, dry • Sweating
mouth, Mucositis, diarrhea)
• Delirium
• Wounds, ulcers, skin rash and skin
lesions
• Insomnia
• Psychological/emotional/spiritua • Spiritual needs and
l care needs: distress
• Psychological distress • Depression
• Anxiety • Bereavement supp
• Suffering of family or caregivers family/caregivers
CONSIDER AND MANAGE
• Care planning and coordination
• Identify support and resources available; develop and im
plan based on patient’s needs
• Provide care in the last weeks/days of life
• Facilitate the availability and access to medications (esp
opioids)
• Identify the psychosocial/spiritual needs of professiona
care (including self)
• Communication issues
• Communicate with patient, family and caregivers about
prognosis, treatment, symptoms and their management
relating to care in the last days/weeks of life
• Identify and set priorities with patient and family/careg
• Provide information and guidance to patients and careg
according to available resources
• It is important to start a palliative care approach as soon
problem is serious, complex or life-threatening, while di
modifying care may continue.
• Pain that disrupts daily life activities, breathlessness at r
functional decline are clinical indicators that should resu
care assessment, or even prompt the question “Would I
if this patient were to die in the next year?”
• If the answer is “no”, it may be worth having a conversati
patient and/or family, as culturally appropriate, to seek t
the quality of life.
The Edmonton Symptom Assessmen
What Are Palliative Care
Hospice Care?
Lecturer: Nadia shamasnsh
• Doctors can provide treatment to seriously ill patients in
a cure for as long as possible. These patients may receiv
for their symptoms, or palliative care, along with curativ
• A palliative care consultation team is a multidisciplinary
works with the patient, family, and the patient's other d
provide medical, social, emotional, and practical suppor
• The team is made of:
• palliative care specialist doctors
• and nurses,
• social workers,
• nutritionists, and chaplains.
• Palliative care can be provided in:
• hospitals,
• nursing homes,
• outpatient palliative care clinics
• and certain other specialized clinics,
• or at home.
• In palliative care, you do not have to give up treatment
cure a serious illness.
• Palliative care can be provided along with curative treat
may begin at the time of diagnosis.
• Over time, if the doctor or the palliative care team belie
treatment is no longer helping, there are two possibiliti
• Palliative care could transition to hospice care if the doc
the person is likely to die within 6 months
• Or, the palliative care team could continue to help with i
emphasis on comfort care.
• Increasingly, people are choosing hospice care at the en
Hospice can be provided in any setting—home, nursing h
assisted living facility, or inpatient hospital.
• At some point,
• it may not be possible to cure a serious illness,
• or a patient may choose not to undergo certain treatm
• Hospice is designed for this situation.
• The patient beginning hospice care understands that his
is not responding to medical attempts to cure it or to slo
disease's progress.
• Like palliative care, hospice provides comprehensive com
well as support for the family,
• but, in hospice, attempts to cure the person's illness are
Hospice is provided for a person with a terminal illness w
believes he or she has 6 months or less to live if the illne
natural course.
• Hospice care brings together a team of people with spec
among them nurses, doctors, social workers, spiritual ad
trained volunteers. Everyone works together with the pe
dying, the caregiver, and/or the family to provide the me
emotional, and spiritual support needed.
• A member of the hospice team visits regularly, and som
available by phone—24 hours a day, 7 days a week.
• It is important to remember that stopping treatment aim
an illness does not mean discontinuing all treatment.
• A good example is an older person with cancer. If the do
determines that the cancer is not responding to chemot
the patient chooses to enter into hospice care, then the
chemotherapy will stop. Other medical care may continu
is helpful. For example, if the person has high blood pres
she will still get medicine for that.
• Families of people who received care through a hospice
more satisfied with end-of-life care than are those of pe
not have hospice services.
• Also, hospice recipients are more likely to have their pai
and less likely to undergo tests or be given medicines th
compared with people who don't use hospice care.
• National Hospice and Palliative Care Organization
 Understanding Healthc
Decisions at the End of L
Lecturer: Nadia shamasnah
• It can be overwhelming to be asked to make healthcare
someone who is dying and is no longer able to make his
decisions.
• It is even more difficult if you do not have written or ver
• How do you decide what type of care is right for someon
when you have written documents, some decisions still
clear since the documents may not address every situati
face.
• Two approaches might be useful.
• One is to put yourself in the place of the person who is d
to choose as he or she would.
• This is called substituted judgment.
• Some experts believe that decisions should be based on
judgment whenever possible.
• Joseph and Leilani’s Story
• Joseph’s 90-year-old mother, Leilani, was in a coma after
major stroke. The doctor said damage to Leilani’s brain w
widespread and she needed to be put on a breathing ma
(ventilator) or she would probably die. The doctor asked
wanted that to be done. Joseph remembered how his m
disapproved when an elderly neighbor was put on a sim
after a stroke. He decided to say no, and his mother died
few hours later.
• Another approach, known as best interests, is to decide
be best for the dying person. This is sometimes combine
substituted judgment.
• Ali and Wadi’s Story
• Ali’s father, Wadi, is 80 and has lung cancer, as well as ad
Parkinson’s disease. He is in a nursing facility and doesn’
recognize Ali when he visits. Wadi’s doctor suggested th
remove part of a lung might slow down the course of th
give Wadi more time. But, Ali thought, “What kind of tim
would that time do for Dad?” Ali decided that putting hi
surgery and recovery was not in Wadi’s best interests. A
with Wadi’s doctors, Ali believed that surgery would not
father’s quality of life but would cause him pain and disc
• If you are making decisions for someone at the end of lif
trying to use one of these approaches, it may be helpful
about the following questions:
• Has the dying person ever talked about what he or she w
the end of life?
• Has he or she expressed an opinion about how someone
being treated?
• What were his or her values in life? What gave meaning
Maybe it was being close to family—watching them grow
memories together. Perhaps just being alive was the mo
thing.