Palliative care in stroke

Transcription

1 Palliative care in stroke

2 Overview Stroke demographics Palliative care Definition Role Palliative care in stroke Case studies

3 FACT Stroke Education Ltd (NZ) 2006

4 World effects Stroke is the 2nd major cause of death worldwide and the leading cause of long-term disability in adults. (Donnan GA 2008) According to the WHO, 15 million people worldwide have a stroke ever year, 5 million of whom die and 5 million are permanently disabled. In the US alone, there are about 5.5 million stroke survivors and every 45 seconds someone has a stroke. Every 3 minutes someone in the USA dies from a stroke, and about half of stroke survivors are left disabled. In Europe, approximately 650,000 people die of stroke.

5 UK effects 150,000 people have a stroke in the UK each year. There are over 67,000 deaths due to stroke each year in the UK. Office of National Statistics Health Statistics Quarterly

6 Men vs Women Men are 25% more likely to suffer strokes than women. 60% of deaths from stroke occur in women. Women live longer they are older on average when they have strokes thus more often killed (NIMH 2002)

7 Out of 10! About 2 out of 10 people who have a stroke die within the first month. 3 out of 10 die within the first year. 5 out of 10 die within the first 5 years. The more time that passes after a stroke, the less is the risk of dying from it.

8 What is Palliative Care?

9 World Health Organisation Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with lifethreatening illness, through the prevention and relief of suffering by: early identification. impeccable assessment. treatment of pain. physical, psychosocial and spiritual.

10 Palliative Care Affirms life and regards dying as a normal process Uses a team approach to address the needs of patients and their families, including bereavement counselling. World health organisation 2010

11 Palliative Care Palliative care Specialist palliative care Terminal Care

12 Who is involved in Palliative care? Multi disciplinary team Doctors through to the kind word from a domestic

13 Goals of palliative Care Best quality of life. Support system to promote patients & families self worth. Poor care prior to death makes bereavement difficult and has long term repercussions on the health of family and friends. Parkes CM (1998) Provide relief from suffering. Symptom control.

14 What is good palliative care Humanity Dignity Respect Good communication Clear information Best possible symptom control Psychological support when needed Continuity of care

15 Aranda S (2003) Nurses role in palliative care All nurses should be able to: Undertake basic symptom assessment and management. Understand the experience of the dying patient and their families. Engage in communication regarding individual needs and experiences. Consult the specialist palliative care practitioners if the needs of patients are out of the nurses experience.

16 Symptoms stroke patients experience Pain Fatigue Weakness Lack of energy Weight loss Difficulty swallowing Anorexia Early Satiety Restlessness & agitation Dry mouth Constipation Respiratory secretions Dyspnoea Anxiety

17 Stages in palliative care. Is their a role in stroke?

18 Case 1 71, male, independent. Found in bed unconscious, doubly incontinent, dehydrated. Right lateral gaze, L-sided weakness, extensive R-sided pneumonia, sore in his L leg, swelling in R-side head/face. CT head: large L-sided intracerebral haemorrhage. DNR, decided against feeding, withdraw Abx- died 24hrs later.

19 Terminal care Case 1 Communication amongst health care professionals. Symptom assessment & control: Pain, agitation, restlessness, breathing Dignity: pressure sore management, mouth care Liverpool Care Pathway. All of the above can be managed by the MDT Specialist input can be sought as a one of measure if adequate symptom control is not achieved.

20 Case 2 84, female, wheelchair-bound, house-bound, previous CVA. Unconscious, L-sided weakness, pyrexia. CT head: intracerebral haemorrhage. Husband: no life-prolonging measures. DNR, artificial feeding commenced, Abx given, prognosis: likely soon death. Still alive on day 15 - Abx stopped. Still alive on day 25 - NG feed stopped. Died on day 31 of admission.

21 Communication Palliative care Case 2 Husband-medical team? No life prolonging measures - Abx?, Feeding?, Hydration? Ethical issues? Right / wrong? Prolonging suffering? Quality of life? Would Specialist Palliative Care input help? the key to good palliative care is that the dying process is actively managed rather than drifted into when all else fails (Jarrett, 1997)

22 Case 3 39, female, business owner. Decreased conscious level, quadriplegia. MRI: bilateral ventral pontine infarction with patent basilar artery- Locked-in syndrome. 5/52 ITU, then ASU-MDT care. 7/52 post-cva: reliable voluntary movement in upper limb & jaw, goal-directed PT possible. Depressed, contractures, pain, functional gain. 3/12 post-cva: rehab unit. D/C 10/12 post-cva with maximal community support.

23 Stroke survivors Case 3 A case for Specialist Palliative care? Chronic disease management Continuity of care: Community support Psychological support / counselling 1 in 5 stroke pt s have suicidal thoughts Symptom management Lack of palliative specialist / information in stroke management: partnerships are therefore required to ensure a holistic approach to stroke management.

24 Best Practice Tools Liverpool care pathway (LCP) (Ellershaw & Wilkinson 2003) Gold standard framework (GSF) (Thomas 2003) Preferred Place of care Tool (PPC) (Storey et al 2003)

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26 Points to remember Palliative care can be implemented by the generic medical team. Limitations to practise Ethical Implementation of specialist palliative care early on in acute management of patients. More research is required to see if Specialist Palliation is require for stroke survivors which may in fact improve rehabilitation outcome.

27 Communication and compassion

28 References / Bibliography National Institute of Neurological Disorders and Stroke (NINDS) (1999). "Stroke: Hope Through Research". National Institutes of Health. Villarosa, Linda, Ed., Singleton, LaFayette, MD, Johnson, Kirk A. (1993). Black Health Library Guide to Stroke. Henry Holt and Company, New York. Murray CJ, Lopez AD (1997). "Mortality by cause for eight regions of the world: Global Burden of Disease Study". Lancet 349 (9061): doi: /s (96) PMID Donnan GA, Fisher M, Macleod M, Davis SM (May 2008). "Stroke". Lancet 371 (9624): doi: /s (08) PMID The World health report Annex Table 2: Deaths by cause, sex and mortality stratum in WHO regions, estimates for Geneva: World Health Organization Office of National Statistics Health Statistics Quarterly 2005 Coronary Heart Disease Statistics. British Heart Foundation Royal College of Physicians, (2001),

29 References / Bibliography WHO guidelines: cancer pain relief 2 nd ed. Geneva: World health organisation: 1996