Palliative care in oncology Ondrej Slama Jiri Sedo MOÚ 2019 Cure rate in oncology 2019 • Cure (=longlasting complete remission) … 65% • death due to cancer progression or related complications 35% (5%- 90% - depending on cancer type) Majority of new „targeted therapies“ are noncurative (palliative) • prolong survival (by weeks - months –years) • improving the quality of life (impact on symptoms) • adverse effects What Is Palliative Care? Palliative Care is an approach to care which focuses on quality of life for those affected by life-limiting/life-threatening illness. …palliative care Its goal is more than comfort in dying; palliative care is about living, through control of pain and other symptoms, supporting emotional, spiritual, and cultural needs, and maximizing functional status. The spectrum of investigations and interventions consistent with a palliative approach is guided by the goals of patient and family. When does palliative care start? Quality of life in advanced disease? 1.ILLNESS MANAGEMENT 2. PHYSICAL 3. PSYCHOLOGICAL 8. LOSS, BEREAVEMENT 7. CARE AT THE END OF LIFE / DEATH MANEGEMENT 4. SOCIAL 5.SPIRITUAL6. PRACTICAL PATIENT & FAMILY 1. ILLNESS MANAGEMENT •Primary diagnosis, prognosis, tests •Secondary diagnosis (for example, dementia, psychiatric diagnosis, use of drugs, trauma) •Co-morbid (delirium, attacks, organs failure) •Adverse episodes (collateral effects, toxicity) 2. PHYSICAL •Pain & other symptoms •Conscience level, cognition •Function, safety, materials: •Motor (mobility, shallowness, excretion) •Senses (hearing, sight, smell, taste, touch) •Physiologic (breathing, circulation) •Sexual •Fluids, nutrition, wounds •Habits (alcohol, smoking) 3. PSYCHOLOGICAL •Personality, strengths, behavior, motivation •Depression, anxiety •Emotions (anger, distress, hope, loneliness) •Fears (abandonment, burdens, death) •Control, dignity, independence •Conflict, guilt, stress, assuming answers •Self-image, self-esteem 8. LOSS, BEREAVEMENT •Loss •Pain (for example, chronic acute, anticipatory) •Bereavement planning •Mourning 7. CARE AT THE END OF LIFE/DEATH MANAGEMENT •End of life (businesses ending, relationships closing, to say goodbye) •Delivery of gifts (objects, money, organs, thoughts) •Creation of legacy •Preparation for the awaited death •Anticipation changes in agony •Rituals •Certification •Care of agony •Funerals 4. SOCIAL •Values, cultural, beliefs, practices •Relations, roles with the family, friends, community •Isolation, abandonment, reconciliation •Safe, comforting environment •Privacy, intimacy •Routines, rituals, leisure, vocations •Financial resources, expenses •Legal (powers of attorney for businesses, health attention, advanced directives, last desire/testament beneficiaries) 5.SPIRITUAL •Significance, value •Existential, transcendental •Values, beliefs, practices, affinities •Spiritual advisors, rituals •Symbols, icons 6. PRACTICAL •Everyday activities (personal care, home work) •Dependents, pets •Access to telephone, transport •Care PATIENT & FAMILY Characteristics Demographic (age, sex, race, contact information) Culture (ethnic, language, nurture) Personal values, beliefs, practices, strengths Development status, education, alphabetization Disabilities PC interventions • Management of physical and psychical symptoms • Psychological support (communication, counceling) • Social support • Spiritual support Physical symptoms in advanced cancer Basic principles of symptom management • Assessment (in context) • „Causal“ management if possible and appropriate • „Symptomatic“ management • Pain • Dyspnoea • Fatigue • Anorexia • Nausea „Technical“ palliative interventions • Surgery (therapeutic, prophylactic) • Radiotherapy • Stents, drains, catethers Biliary obstruction 15 Stenting -ERCP Stenting -PTD Stenting via ERCP 16 Bronchial obstruction Uretheral obstruction Pleural drain Bone metastases Anxiety and depression • Supportive psychotherapy • Pharmacotherapy Palliative care plan • Clarifying goals of care • Individual risk/benefit assessment • Prefereneces/wishes • Advance care planning • Framework for decision making Communication about prognosis in PC • important (but difficult) • necessery for care planning • cultural factors Patient in palliative care 24 64 year old male, NSCLC, mets in lung, bone, liver. After 2 lines of chemotherapy, radiotherapy of primary tumor Patient´s „problems“ • Fatigue • Anorexia • Cachexia –weight loss • Pain • Dyspnea • Anxiety • Depression …„problems“ • loss of social roles (father, breadwinner, sexual partner..) • loss of self –esteem • What is the meaning of life with so many limitations? • What is the perspective? Hope for future? Palliative care plan • Place of care (pt´s preferrence, family support, available services) Symptoms • Pain: Fentanyl TTS + diclofenac + morphin SR p.r.n. Radiotherapy of painfull mts • Dyspnea: pleural drain, syntophyllin, ipratropin spay, oxygen concentrator • Anorexia: megestrolacetate Oxygen concentrator …palliative care plan • Anxiety, depresion: Mirtazapin nocte, alprazoplam p.r.n. • Regular contact with hospice team (psychosocial, spiritual..) • Family support • DNR, no intubation (patient´s wish) • Peaceful death at home after 4 months • no ER,ICU events