Palliative Care and the Operating Department

1. Palliative Care and the Operating Department Phil Warren Head of Education Earl Mountbatten Hospice Isle of Wight

2. Perioperative Care • Embedded within evidence-based practice, the Perioperative care framework embodies theoretical knowledge, organisational skills, cognitive judgement and interpersonal integrity which is applied to the holistic care of the surgical patient. This must encompass the physiological and psychological support to patients who require care at all levels of dependency within all aspects of Pre Operative, Intra Operative and the Post Operative phases of patient care".

3. Perioperative Care • Some would argue that the Perioperative process encompasses all care from Pre-hospital, Diagnosis, Preoperative, Intraoperative, Postoperative, Discharge and follow-up. This is the true Perioperative picture!

4. Definition • “Palliative care is the active holistic care of patients with advanced progressive illness. Management of pain and other symptoms and provision of psychological, social and spiritual support is paramount. The goal of palliative care is achievement of the best quality of life for patients and their families. Many aspects of palliative care are also applicable earlier in the course of the illness in conjunction with other treatments". (NICE)

5. Supportive Care “Supportive care helps the patient and their family to cope with their condition and treatment, to cure, to continuing illness or death and into bereavement. It helps the patient to maximise the benefits of treatment and to live as well as possible with the effects of the disease. It is given equal priority alongside diagnosis and treatment”. (NCPC, NICE)

6. Who has palliative care needs? • The dying? • Those with incurable illness? • Those with life-threatening illness? • Those with chronic illness? • Those with any illness??

7. Causes of Death

8. Illness Trajectories Organ failure Cancer Dementia and decline Sudden death

9. Choice & Access • Perioperative care- surgeon, place, timing etc. accessed by all? • Palliative care – place of care, place of death. accessed by some? • Differing criteria affect admission and acceptance of dying status

10. Place of Death Place: home hospital hospice care home …………………………………………………………… Preference 56% 11% 24% 4% Actual 18.3% 56.9% 4.3% 20.5% Higginson I (2003) Priority for end of life care in England, Wales and Scotland, NCPC

11. Place of occurrence of death by underlying cause

12. In context • An example • Upper GI surgery 5 year survival • Oesophagus = 5% male, 8% female • Stomach = 9% male, 11% female • Pancreas = 2% male, 2% female

13. Palliative Care for All • Seeing similarities between cancer, heart failure and others • Shift to longer term palliative care requirements as cancer becomes more chronic and other chronic conditions adopt palliative needs • Palliative care becoming more complex as co-morbidity increases • Palliative care needs of older people differ from those of younger people

14. Palliative Care for All • NCPC – needs assessment shows geographical distribution of need in other conditions differs from cancer • Future in educating and empowering other specialists and usual carers – not large scale expansion of specialist palliative care delivery.

15. End of Life Care programme (EoLC) • Aims: • To extend the boundaries of palliative care provision…..for all patients regardless of diagnosis • By enabling more patients to live and die in the place of their choice • Gold Standards Framework • Liverpool Care Pathway

16. Gold Standards Framework • A programme for community palliative care • Aim - for the best for all • Processes – Identify, Assess, Plan • Goals – symptom free, place of care, security & support, carers, staff • Key tasks – “the 7 C’s” , communication, co-ordination, control of symptoms, continuity including out of hours, continued learning, carer support, care in the dying phase

17. Liverpool Care Pathway • Devised for use in hospitals, but can be used in primary/community/care home settings. • Empowers generalists to care for the dying, not just for cancer patients • IOW ICP Last Days of Life

18. Last Days of Life ICP (IOW) • Criteria for use – decreased level of consciousness & shortened life prognosis, “valid not for CPR”, MDT agree that the patient is dying • Patient assessment and care record, nursing, comfort, religious needs, psychological insight etc • Pain and symptom control algorithms

19. Issues to consider • Professionals not eliciting their problems and concerns • Service not available • Patients and carers being unaware of the services available that might help them • Professionals unaware of benefits of existing services and not offering access or referral • Poor communication and co-ordination amongst professionals

20. Palliative Care Provision IOW

21. The patient journey • From diagnosis to surgery and beyond • At any point palliative care needs may be required • In theatre? Patient needs & our needs

22. What can we do? • Broader understanding, long term implications of our care • Communication! • Education, access local provision • Do not work in isolation • Share experiences • User involvement

23. References • Isle of Wight Healthcare NHS Trust (2005) Integrated Care Pathway – Last Days of Life • NHS (2005) End of Life Care Programme • NHS (2005) The Gold Standards Framework • Tebbit. P. (2005) Where the results of Needs Assessment are taking us. NCPC • Young. E. (2005) National Council for Palliative Care

24. Useful Links • www.ncpc.org.uk • www.endoflifecare.nhs.uk • www.helpthehospices.org.uk • phil.warren@iwhospice.org