Is Palliative Approach Indicated?
Would I be surprised if this patient died in the next 6-12 months?
General indicators >1
- A poor or deteriorating status (limited self-care, in bed or chair over 50% of the day).
- A history of multiple hospitalizations in the last 6 months.
- A need for more care at home (or is already in a hospital facility).
- Multiple comorbidities causing symptoms or functional decline.
- Patient requests palliative approach.
Disease-specific indicators >2
- increasing age
- serum calcium >2.8mmol/l
- DVT or PE
- brainmets or CNS involvement in hematological malignancies
- spinal cord compression
- malignant pericardial effusions
- serum albumin <35 mmol/l
- body mass index <21
- severe airway obstruction (FEV1<30%) or restrictive deficit (vital capacity <60%)
- persistent breathlessness at rest or on minimal exertion despite optimal tolerated therapy (exclusive of exacerbation)
- six-minute walk distance of <100 meters
- comorbidities of symptomatic heart failure or obstructive sleep apnea
- depression, anxiety, living alone
- increased emergency admissions for infective exacerbations and/or respiratory failure
- increasing age
- male gender
- recurrent lung aspiration
- pressure ulcers
- low oral intake/weight loss/BMI <18.5
- age >75
- serum albumin <35
- unable to do self-care (ADL) without assistance
- malnutrition (weight loss >10%)
- heart failure
- creatinine >265 mmol/l
- NYHA class III/IV heart failure due to valve disease or coronary artery disease not amenable to surgery/angioplasty
- persistent symptoms (breathlessness/chest pain) despite optimal tolerated therapy
- renal impairment (eGFR <30 ml/min)
- cardiac cachexia: progressive loss of lean body mass, reduced muscle strength, anorexia, fatigue
- markers of chronic inflammation/cachexia anemia: hemoglobin <115, uric acid >565, albumin <32
- two or more episodes needing intravenous (furosemide and/or inotropes) therapy in last 6 months
- age >65 years
- CNS lymphoma
- viral load on HAART (highly active antiretroviral therapy) >10,000
- poor performance status
- other life-limiting co-morbidities
- age >50
- serum bilirubin >237 that does not respond well to therapy
- eGFR <40ml/min
- ascites present
- encephalopathy present
Renal failure on hemodialysis
- age >80
- albumin <35
- peripheral vascular disease
- other comorbidities such as heart or liver disease, stroke, diabetes with end-stage organ damage
Renal failure not on dialysis
- eGFR (estimated Glomerular Filtration Rate) <15ml/min
- age > 75
- albumin < 35
- other comorbidities such as heart disease, stroke, diabetes with end-stage organ damage
- Large volume of brain affected
- Increasing age
- Function prior to stroke
- Degree of disability
- Dysphagia causing aspiration
Other neurodegenerative diseases
- Age > 75
- Low FVC – respiratory muscle weakness
- Swallowing difficulties &/or poor nutritional status
- Medical complications e.g. aspiration pneumonia or sepsis
- Cognitive impairment
- Rapid spread from onset region toanother region — ALS
- Medications less effective — Parkinson’s
If not surprised and patient has general and disease-specific criteria – patient benefits from palliative approach
Talk tip: “We can’t cure your disease, but our goal is to help you live as well as you can for as long as you can.”
Talk tip: “Although we do not have any further treatments to reverse the disease there is always something we can do to help you feel better.”
Common symptoms of advanced disease
Using the scale, evaluate each of following symptoms: (0=none, 10=worst possible)
- Shortness of breath/dyspnea
- Lack of appetite/anorexia
Note about pain assessment:
- identify site(s), causes, severity, and impact on function, mood and quality of life.
- pain is a physical and emotional experience and can be influenced by multiple other factors.
Note about shortness of breath/dyspnea assessment: it CANNOT be assessed by the respiratory rate or the oxygen saturation. Like pain – it is subjective. Ask patient if they feel short of breath.
Talk tip: if the patient has many symptoms, ask which symptom is bothering them the most, and manage that symptom as the top priority.
CAM tool for Delirium Assessment
The Confusion Assessment Method (CAM) enables you to determine if your patient has delirium. A diagnosis of delirium requires:
- acute onset and fluctuation
- disorganized thinking or altered consciousness
Acute onset and fluctuation
Is there evidence of an acute change in mental status from baseline?
Does the abnormal behaviour:
- come and go
- fluctuate during the day
- increase/decrease in severity
Does the patient:
- have difficulty focusing attention?
- become easily distracted?
- has difficulty keeping track of what is said?
Is the patient’s thinking disorganized or incoherent, i.e. does the patient have:
- rambling speech or irrelevant conversation?
- unpredictable switching of subjects?
- unclear or illogical flow of ideas?
Overall, what is the patient’s level of consciousness:
- alert (normal)
- vigilant (hyperalert)
- lethargic (drowsy but easily roused)
- stuporous (difficult to rouse)
- comatose (unrousable)
Don’t forget hypercalcemia
- 10% of cancer patients (50% of multiple myeloma, 25% breast, 25% lung, renal)
- Due to osteoclast destruction of bone secondary to bone metastases
- Paraneoplastic production of PTH in non-solid tumors – leukemia, lymphoma
- Common cause of hypoactive delirium
- Sign of advanced disease, BUT treatment can improve quality and length of life
- Symptoms: polyuria, polydipsia → dehydration, nausea, constipation, confusion, drowsiness, weakness,
- Signs: hyporeflexia, ileus, bradycardia, Q-T interval reduced <0.36 sec, T wave abrupt upslope
- Diagnosis: serum calcium (corrected for albumin) > 2.8mmol/L or > 11mg/dl (Corrected Ca+2 = Measured Ca+2 + (40 – serum albumin) X 0.02)