Please click here (1.5MB) - Hong Kong Society of Palliative Medicine

More documents

Recommendations

Info

Newsletter of Hong Kong Society of Palliative MedicineEnd of Life Care for Old Age HomesDr Raymond Lo,Consultant,Geriatrics and Palliative Medicine, Shatin Hospital; Chief of Service, Bradbury Hospice.Care for the dying is a litmus test for ourhealth and social services, and is a measure ofsociety in looking after our sick and vulnerablecitizens. There should be no ageism in thisregard. Significant proportion of our olderpopulation spent their end of life in old agehomes, and should receive appropriate supportregardless of their diseases conditions andtrajectories. Ageing and dying is a priority issue.The residential care setting is different fromcountry to country, and our local set up has itsunique features to consider when applyingpalliative care principles in day to day care.Currently there are over 500 private old agehomes and over 140 subvented and contracthomes. The number of elderly residing in theselong term care facilities has more than doubledduring the last decade to more than 70,000 in2007. Appropriate palliative support for old agehome residents is a pressing issue.Older people have palliative needs which canbe similar yet different from the younger agegroups. Pain is always a top concern by patientsof all ages. Yet symptom profiles may bedifferent especially in elderly with non-cancerconditions. Use of medications need to be withcaution, especially with alternative opioids.Psychological well- being does not necessarilyhave to be poor for the elders in residentialhomes, but the social and family support is notguaranteed. Quality of life issues are equallyrelevant in older age groups, and existentialissues such as dignity, meaning of life, self–perceived burden are pertinent issues in longterm care setting. Our local data revealed thatQOL scores of vulnerable elderly in old agehomes could be poorer than dying cancerpatients in hospitals.guaranteed. Quality of life issues are equallyrelevant in older age groups, and existentialissues such as dignity, meaning of life, self–perceived burden are pertinent issues in longterm care setting. Our local data revealed thatQOL scores of vulnerable elderly in old agehomes could be poorer than dying cancerpatients in hospitals.Yet application of palliative care to old agehomes needs to be well thought out andplanned. Skills, knowledge and attitude of localold age home staff must be explored. Perceptionand concerns of all ranks of workers, includingpersonal care assistants, have to be carefullyconsidered. Support programmes need to beevaluated, with the outcome of interventionsproperly assessed. Shatin Hospital andBradbury Hospice had implemented a palliativecare at old age home project with promisingresults. The programme provided training as perthe needs of old age home staff; andinterventions were offered to clients requiringintensive support. Anticipatory grief workshopswere held for elderly with psychosocial needs,and a randomised controlled trial was used toevaluate an initiative in early and betterpreparation for residents facing end of life.Experience and results of the programme werefurther discussed in the presentation.6 th Hong Kong Palliative Care Symposium - ABSTRACTSHKSPM Newsletter 2009 Sep Issue 2 P12
Newsletter of Hong Kong Society of Palliative MedicineCrisis in Palliative CareDr Lam Po Tin,Department of Medicine & Geriatrics,United Christian Hospital.Correspondence: lampt@ha.org.hk(Presented in 6 th Hong Kong Palliative CareSymposium)Definition of Crisis in Palliative CareCrisis means a time of great danger,difficulty or uncertainty when problems must besolved or important decisions must be made. 1 Toindividuals, it is the subjective reaction to astressful life experience that compromises theindividual’s stability and ability to cope orfunction 2 .Palliative care aims to improve quality of lifeby early identification, impeccable assessmentand treatment of symptoms while meeting theneeds of patients with advanced andprogressive diseases. It comprises diseasespecificand symptom-guided interventions, withemphasis on preparing patients and theirfamilies for foreseeable, distressing clinicalproblems. 3 Hence, any unexpected change nearthe end-of-life may be considered as crisis to thepalliative care patient, family and even staff untilmore information about the change can beobtained.Crisis in palliative care is not exactlyequivalent to medical or oncologicalemergencies which are defined by diseasespecificprocesses, such as spinal cordcompression, pathological bone fractures,superior vena caval obstruction, septicneutropenia, hypercalcemia, hyponatraemia. Inthese situations, we focus on “what can be doneto save life?” with diagnostic or therapeuticalgorithms, and aggressive treatment cansometimes enhance overall survival. However,towards the end-of-life when death is anexpected and accepted outcome; we questionthe emergency nature of these situations, wequestion the mechanisms and algorithms usedin standard emergency treatment to be used forcrisis in palliative care. The priorities of palliativecare gradually shift towards the end-of-life.Insteadad, we focus on “what is the appropriatetreatment for this patient in this particularsituation?” 3Precipitating events and AssessmentWhen a crisis occurs near the end-of-life, theclinician should carry out an impeccableassessment including (1) identification of theprecipitating events; (2) prompt understandingof the underlying disease-specific or pathophysiologicalprocesses; (3) determination onwhether active/life sustaining treatment couldprolong life or maintain quality of life; (4)prognostication – both tumour and co-morbidityrelated; (5) patient’s wish; (6) extent of clinicaldecline or course of expected illness; (7) attitudeof family ; and finally (8) overall care. All thesemight have a more decisive role than disease -specific features and the complexity of atherapeutic decision during crisis near the end oflife usually requires the expertise of amulti-professional palliative care team. Theprecipitating events can be (i) physical-related,e.g. acute dyspnoea, acute delirium, acute painor massive haemorrhage; (ii) psychologicalrelatede.g. suicidal attempt; (iii) social-relatede.g. acute decompensating family or caregiversuch as caregiver fatigue / caregiver illness; and(iv) spiritual-related, e.g. existential distress.Clinician and the palliative care team should befamiliar with the clinical approach in managingthese precipitating events.Decision making and its factorsAt the time of crisis in palliative care, eithercategory of decisions should be made, namelythe decision to use potentially life-sustainingtreatments or decisionsto use treatmentmodalities that emphasize quality of life &comfort care. 4 However, such discussions onmedical decisions can be facilitated prior to theoccurrence of crisis. The optimal timing for thisdiscussion is during a routine outpatient visit,during which the patient should have anopportunity to learn from the physician theanticipated disease course, the potentialtreatment options, and together with thephysician, define the goals of care in case acutecrisis arises. Needless to say, the physician hasto balance the anxiety of alerting and preparingthe patient and the family for such an eventCrisis in Palliative CareHKSPM Newsletter 2009 Sep Issue 2 P13
Page 8 and 9: Newsletter of Hong Kong Society of

Please click here (1.5MB) - Hong Kong Society of Palliative Medicine

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?