Sharon Hancock RN,MN Clinical Nurse Specialist, Respiratory Service, MidCentral Health. 11/11/2015 MidCentral Health

Transcription

1 Sharon Hancock RN,MN Clinical Nurse Specialist, Respiratory Service, MidCentral Health 11/11/2015 MidCentral Health 1

2 Advanced Respiratory Disease Traditional model of palliative care is geared around cancer patients the trajectory of non-malignant disease is variable Unlike cancer, no beginning and no end Patients with COPD see themselves as living with, not dying of, COPD 11/11/2015 MidCentral Health 2

3 Cancer Illness Trajectory 11/11/2015 MidCentral Health 3

4 COPD Illness Trajectory 11/11/2015 MidCentral Health 4

5 COPD - Umbrella term Smoking related (COPD) Chronic persistent asthma (COPD) Chronic Bronchitis (COPD) Unrecognised Asthma (COPD) Bronchiectasis (COPD) Cystic Fibrosis (COPD) Airflow obstruction (COPD related to age) 11/11/2015 MidCentral Health 5

6 Smoking related COPD causes of death Other 10% Unknown 7% Respiratory 35% Cancer 21% Cardiac 27% 11/11/2015 MidCentral Health 6

7 Right Heart Failure -pulmonary hypertension -periodontal disease GORD OSA Cerebrovascular disease Metabolic -obesity -atherosclerosis -dyslipidaemia -hyperglycaemia -hypertension Less co-morbidity COPD Psychological -anxiety -depression -panic -myocardial infarction Cardiovascular -hypertension -atherosclerosis Cachectic -under weight -muscle wasting -osteoperosis -renal impairment 11/11/2015 MidCentral Health 7

8 Whose fault is it anyway? 11/11/2015 MidCentral Health 8

9 Symptoms Physical symptoms breathlessness more predominant in COPD than cancer; fatigue and malaise common Psychological symptoms anxiety, depression and panic, social isolation and loneliness more prevalent 11/11/2015 MidCentral Health 9

10 COPD Staging Lung Function Mild: FEV1 80% predicted Moderate: FEV1 50% < - < 80% predicted Severe: FEV1 30% < - < 50% predicted Very Severe: FEV 1 < 30% or FEV 1 < 50% and respiratory failure 11/11/2015 MidCentral Health 10

11 Reduced exercise tolerance 11/11/2015 MidCentral Health 11

12 Body mass index BODE Index Obstruction (airflow) Dyspnoea (shortness of breath) Exercise tolerance 11/11/2015 MidCentral Health 12

13 Exacerbations/ Comorbidities Major determinant of morbidity & mortality, leads to: Systemic inflammation Myostatin release Bone weakening Increase in symptoms Breathlessness 11/11/2015 MidCentral Health 13

14 Staff Perspective Difficulty in prognostic accuracy Unwillingness to discuss advanced care planning Time Uncertainty on what information to give Lack of confidence 11/11/2015 MidCentral Health 14

15 Patient Perspective It isn t a death sentence It isn t untreatable It isn t necessarily progressive It isn t necessarily crippling It isn t a single disease, so it never affects two patients in exactly the same way No one size fits all 11/11/2015 MidCentral Health 15

16 Carer Perspective Carer burden, limited respite Degree of breathlessness made caring difficult Uncertainty about prognosis Patients anxiety worse at night carer gets poor sleep 11/11/2015 MidCentral Health 16

17 After 12.5 hours with no break! Carers unmet needs 11/11/2015 MidCentral Health 17

18 When to refer to palliative care? FEV1? Exercise tolerance? Number of exacerbations in a year? Need for Bi level? Surprise question? 11/11/2015 MidCentral Health 18

19 Models of palliative care 11/11/2015 MidCentral Health 19

20 Opiods Palliative Treatment Anxiolytics Midazolam nasal spray Palliative Oxygen 11/11/2015 MidCentral Health 20

21 Discovery of Oxygen

22 The Pneumatic Institution

23 The 19 th Century

24 Early 20 th Century

25 The First World War

26 First nasal prongs 1920`s

27 Long term Oxygen Therapy: The evidence All trials were multi centre trials on patients with diagnosis of COPD who were hypoxaemic 1980 The NOTT trial - increased survival 1981 MRC Trial increased survival Petty combined the results of both trials: conclusive evidence of increased survival

28 Rationale for prescribing LTOT Chronic hypoxaemia (PaO2 < 55mmHg) LTOT is prescribed to prevent secondary complications of the heart & other organs When administered to those clinically indicated, LTOT improves longevity and quality of life Oxygen is not given for breathlessness, rationale is prolonged survival

29 Side effects of oxygen therapy Risk to COPD patient (hypercapnea) Atelectasis Oxygen toxicity (50% O2 or more) Hyperoxaemia associated with INCREASED mortality in survivors of cardiac arrest Oxygen therapy INCREASED mortality in non-hypoxic patients with mild-moderate stroke Lack of mobility as attached to equipment 11/11/2015 MidCentral Health 29

30 Definition of Breathlessness ATS Definition: Breathlessness is a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity. The experience derives from multiple physiological, psychological,social and environmental factors If breathlessness is unable to be relieved by treating an underlying cause it is called refractory 11/11/2015 MidCentral Health 30

31 New Zealand Ministry of Health Specifications for provision of domiciliary oxygen therapy - palliation o Palliation for terminally ill patients. o Management of dyspnoea that is inadequately controlled on narcotic/anxiolytics and with SpO2 < 90% on air at rest o Focus is on symptom control to decrease the sensation of breathlessness 11/11/2015 MidCentral Health 31

32 Palliative Oxygen therapy: The evidence May provide symptomatic relief for patients with intractable/refractory dyspnoea with significant hypoxaemia Oxygen alone does not benefit most patients with breathlessness (Bruera 1993,2003, Goodridge 2009) Relief of hypoxaemia may not relieve breathlessness (Mountain,1978, Stulbarg 1989, Kikuchi 2001) Oxygen does not reduce breathlessness in the non hypoxaemic patients (Air versus oxygen study: Abernethy et al 2010, Uronis 2008) 11/11/2015 MidCentral Health 32

33 Implications of palliative oxygen therapy Patients may be prescribed ineffective treatments as O2 therapy diverts focus O2 is not a benign intervention: consider quality of life, psychological distress, side effects, ability to manage equipment Consider patients and carers attitudes, beliefs, preference 11/11/2015 MidCentral Health 33

34 Advanced Care Planning ACP is a process of discussion and shared planning for future health It informs medical planning for potential future acute events / deterioration It informs palliative / end of life care Reduces hospital transfers, unscheduled GP/emergency visits 11/11/2015 MidCentral Health 34

35 Advanced Care Planning Hope for the best, plan for the worst Discussion with EPOA/family Opportunity to plan for future changes in health status with GP and others. Reduces family anxiety and complaints Website November 2014 MidCentral Health 35

36 In summary The rational for oxygen therapy varies depending on the patients requirements and medical/nursing assessment. Palliative oxygen has limited use - but may be helpful in some situations. It is part of the tool box we can use. Advanced planning and early referral to palliative care important 11/11/2015 MidCentral Health 36

37 Oxygen bars How far have we come in 200 years...oxygen bubbled through coloured water. Trending overseas and in Auckland!