Palliative care in strokePalliative care in stroke

OverviewOverview

Stroke demographicsStroke demographicsPalliative carePalliative care

DefinitionDefinitionRoleRole

Palliative care in strokePalliative care in strokeCase studiesCase studies

FACTFACT

Stroke Education Ltd (NZ) 2006 Stroke Education Ltd (NZ) 2006

World effectsWorld effects Stroke is the 2nd major cause of death worldwide and the leading cause of Stroke is the 2nd major cause of death worldwide and the leading cause of

long-term disability in adults. long-term disability in adults. (Donnan GA 2008) (Donnan GA 2008)

According to the WHO, 15 million people worldwide have a stroke ever year, According to the WHO, 15 million people worldwide have a stroke ever year, 5 million of whom die5 million of whom die and and 5 million are permanently 5 million are permanently disabled disabled ..

In the US alone, there are about 5.5 million stroke survivors and every 45 In the US alone, there are about 5.5 million stroke survivors and every 45 seconds someone has a stroke. Every seconds someone has a stroke. Every 3 minutes someone in the 3 minutes someone in the USA diesUSA dies from a stroke, and about from a stroke, and about half of stroke survivors are half of stroke survivors are left disabledleft disabled. .

In Europe, approximately In Europe, approximately 650,000 people die of stroke. 650,000 people die of stroke.

UK effectsUK effects

150,000 people have a stroke in the UK each 150,000 people have a stroke in the UK each year. year.

There are over 67,000 deaths due to stroke There are over 67,000 deaths due to stroke each year in the UK. each year in the UK.

Office of National Statistics Health Statistics QuarterlyOffice of National Statistics Health Statistics Quarterly

Men vs WomenMen vs Women

Men are 25% more likely to suffer strokes Men are 25% more likely to suffer strokes than women.than women.

60% of deaths from stroke occur in women. 60% of deaths from stroke occur in women. Women live longerWomen live longer they are older on average when they have they are older on average when they have

strokes strokes thus more often killedthus more often killed(NIMH 2002)(NIMH 2002)

Out of 10! Out of 10! About 2 out of 10 people who have a stroke die About 2 out of 10 people who have a stroke die

within the first month.within the first month.

3 out of 10 die within the first year.3 out of 10 die within the first year.

5 out of 10 die within the first 5 years.5 out of 10 die within the first 5 years.

The more time that passes after a stroke, the The more time that passes after a stroke, the less is the risk of dying from it. less is the risk of dying from it.

What is Palliative Care?What is Palliative Care?

World Health OrganisationWorld Health Organisation ‘Palliative care is an approach that improves

the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering’ by:

early identification.impeccable assessment.treatment of pain. physical, psychosocial and spiritual.

Palliative CarePalliative Care

Affirms life and regards dying as a Affirms life and regards dying as a normal processnormal process

Uses a team approach to address the needs Uses a team approach to address the needs of patients and their families, including of patients and their families, including bereavement counselling. bereavement counselling.

World health organisation 2010World health organisation 2010

Palliative CarePalliative Care

Palliative care Palliative care Specialist palliative care Specialist palliative care Terminal CareTerminal Care

Who is involved in Palliative care?Who is involved in Palliative care?

Multi–disciplinary team

Doctors through to the kind word from a domestic

Goals of palliative CareGoals of palliative Care

Best quality of life. Best quality of life. Support system to promote patients’ & Support system to promote patients’ &

families’ self worth.families’ self worth.Poor care prior to death makes bereavement difficult Poor care prior to death makes bereavement difficult

and has long term repercussions on the health of and has long term repercussions on the health of family and friends.family and friends.

Parkes CM (1998Parkes CM (1998))

Provide relief from suffering. Provide relief from suffering. Symptom control. Symptom control.

What is good palliative careWhat is good palliative care

Humanity Humanity Dignity Dignity Respect Respect Good communication Good communication Clear information Clear information Best possible symptom controlBest possible symptom controlPsychological support when needed Psychological support when needed Continuity of care Continuity of care

Nurses role in palliative careNurses role in palliative care

All nurses should be able to:All nurses should be able to:Undertake basic symptom assessment and Undertake basic symptom assessment and

management.management.Understand the experience of the dying patient and Understand the experience of the dying patient and

their families.their families.Engage in communication regarding individual Engage in communication regarding individual

needs and experiences. needs and experiences. Consult the specialist palliative care practitioners if Consult the specialist palliative care practitioners if

the needs of patients are out of the nurses the needs of patients are out of the nurses experience. experience.

Aranda S (2003)Aranda S (2003)

Symptoms stroke patients experienceSymptoms stroke patients experience

Pain Pain FatigueFatigue

WeaknessWeakness Lack of energy Lack of energy Weight loss Weight loss Difficulty swallowingDifficulty swallowing Anorexia Anorexia Early SatietyEarly Satiety

Restlessness & Restlessness & agitationagitation

Dry mouth Dry mouth Constipation Constipation Respiratory secretionsRespiratory secretions Dyspnoea Dyspnoea AnxietyAnxiety

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

Case 1Case 1 71, male, independent.71, male, independent. Found in bed unconscious, doubly incontinent, Found in bed unconscious, doubly incontinent,

dehydrated.dehydrated. Right lateral gaze, L-sided weakness, extensive Right lateral gaze, L-sided weakness, extensive

R-sided pneumonia, sore in his L leg, swelling in R-sided pneumonia, sore in his L leg, swelling in R-side head/face.R-side head/face.

CT head: large L-sided intracerebral CT head: large L-sided intracerebral haemorrhage.haemorrhage.

DNR, decided against feeding, withdraw Abx- DNR, decided against feeding, withdraw Abx- died 24hrs later.died 24hrs later.

Terminal care Terminal care Case 1Case 1

Communication amongst health care Communication amongst health care professionals. professionals.

Symptom assessment & control:Symptom assessment & control: Pain, agitation, restlessness, breathingPain, agitation, restlessness, breathing

Dignity:Dignity: pressure sore management, mouth carepressure sore management, mouth care

Liverpool Care Pathway.Liverpool Care Pathway. All of the above can be managed by the MDTAll of the above can be managed by the MDT Specialist input can be sought as a one of Specialist input can be sought as a one of

measure if adequate symptom control is not measure if adequate symptom control is not achieved.achieved.

Case 2Case 2 84, female, wheelchair-bound, house-bound, 84, female, wheelchair-bound, house-bound,

previous CVA.previous CVA. Unconscious, L-sided weakness, pyrexia.Unconscious, L-sided weakness, pyrexia. CT head: intracerebral haemorrhage.CT head: intracerebral haemorrhage. Husband: ‘no life-prolonging measures’.Husband: ‘no life-prolonging measures’. DNR, artificial feeding commenced, Abx given, DNR, artificial feeding commenced, Abx given,

prognosis: likely soon death.prognosis: likely soon death. Still alive on day 15 - Abx stopped.Still alive on day 15 - Abx stopped. Still alive on day 25 - NG feed stopped.Still alive on day 25 - NG feed stopped. Died on day 31 of admission.Died on day 31 of admission.

Palliative carePalliative careCase 2Case 2

CommunicationCommunication Husband-medical team? Husband-medical team? ““No life prolonging measures” - Abx?, Feeding?, Hydration?No life prolonging measures” - Abx?, Feeding?, Hydration? Ethical issues? Right / wrong?Ethical issues? Right / wrong?

Prolonging suffering? Prolonging suffering? Quality of life?Quality of life? Would Specialist Palliative Care input help? Would Specialist Palliative Care input help?

““the key to good palliative care is that the dying process is actively the key to good palliative care is that the dying process is actively managed rather than drifted into when all else fails” managed rather than drifted into when all else fails”

(Jarrett, 1997)(Jarrett, 1997)

Case 3Case 3 39, female, business owner.39, female, business owner. Decreased conscious level, quadriplegia.Decreased conscious level, quadriplegia. MRI: bilateral ventral pontine infarction with patent MRI: bilateral ventral pontine infarction with patent

basilar artery- ‘Locked-in syndrome’.basilar artery- ‘Locked-in syndrome’. 5/52 ITU, then ASU-MDT care.5/52 ITU, then ASU-MDT care. 7/52 post-CVA: reliable voluntary movement in upper 7/52 post-CVA: reliable voluntary movement in upper

limb & jaw, goal-directed PT possible.limb & jaw, goal-directed PT possible. Depressed, contractures, pain, functional gain.Depressed, contractures, pain, functional gain. 3/12 post-CVA: rehab unit.3/12 post-CVA: rehab unit. D/C 10/12 post-CVA with maximal community support. D/C 10/12 post-CVA with maximal community support.

Stroke survivorsStroke survivorsCase 3Case 3

A case for Specialist Palliative care? A case for Specialist Palliative care? Chronic disease managementChronic disease managementContinuity of care: Continuity of care:

Community support Community support Psychological support / counselling Psychological support / counselling 1 in 5 stroke pt’s have suicidal thoughts1 in 5 stroke pt’s have suicidal thoughts

Symptom management Symptom management Lack of palliative specialist / information in Lack of palliative specialist / information in

stroke management: partnerships are stroke management: partnerships are therefore required to ensure a holistic therefore required to ensure a holistic approach to stroke management.approach to stroke management.

Best Practice ToolsBest Practice Tools

Liverpool care pathway (LCP)Liverpool care pathway (LCP)(Ellershaw & Wilkinson 2003)(Ellershaw & Wilkinson 2003)

Gold standard framework (GSF)Gold standard framework (GSF)

(Thomas 2003)(Thomas 2003)

Preferred Place of care Tool (PPC) Preferred Place of care Tool (PPC) (Storey et al 2003)(Storey et al 2003)

Points to remember Points to remember

Palliative care can be implemented by the generic medical Palliative care can be implemented by the generic medical team.team.

Limitations to practiseLimitations to practiseEthical Ethical

Implementation of specialist palliative care early on in acute Implementation of specialist palliative care early on in acute management of patients. management of patients.

More research is required to see if Specialist Palliation is More research is required to see if Specialist Palliation is require for stroke survivors which may in fact improve require for stroke survivors which may in fact improve rehabilitation outcome. rehabilitation outcome.

Communication and Communication and compassion compassion

References / Bibliography References / Bibliography http://www.stroke-education.com/info/StrokeInfo.do

National Institute of Neurological Disorders and Stroke (NINDS) (1999). "Stroke: Hope Through Research".

National Institutes of Health. http://www.ninds.nih.gov/disorders/stroke/detail_stroke.htm. 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): 1269–76. doi:10.1016/S0140-6736(96)07493-4. PMID 9142060. Donnan GA, Fisher M, Macleod M, Davis SM (May 2008). "Stroke". Lancet 371 (9624): 1612–23. doi:10.1016/S0140-

6736(08)60694-7. PMID 18468545.

The World health report 2004. Annex Table 2: Deaths by cause, sex and mortality stratum in WHO regions, estimates for 2002.. Geneva: World Health Organization. 2004. http://www.who.int/entity/whr/2004/en/report04_en.pdf.

Office of National Statistics Health Statistics Quarterly 2005 Coronary Heart Disease Statistics. British Heart Foundation

Royal College of Physicians, (2001), http://www.omnimedicalsearch.com/conditions-diseases/stroke-introduction.html

References / BibliographyReferences / Bibliography

WHO guidelines: cancer pain relief 2WHO guidelines: cancer pain relief 2ndnd ed. ed. Geneva: World health organisation: 1996Geneva: World health organisation: 1996