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Palliative care in stroke

Palliative care in stroke. Overview. Stroke demographics Palliative care Definition Role Palliative care in stroke Case studies. FACT. Stroke Education Ltd (NZ) 2006. World effects.

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Palliative care in stroke

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  1. Palliative care in stroke

  2. Overview • Stroke demographics • Palliative care • Definition • Role • Palliative care in stroke • Case studies

  3. FACT Stroke Education Ltd (NZ) 2006

  4. World effects • Stroke is the 2nd major cause of death worldwide and the leading cause of long-term disability in adults. (Donnan GA 2008) • According to the WHO, 15 million people worldwide have a stroke ever year, 5 million of whom die and 5 million are permanently disabled . • In the US alone, there are about 5.5 million stroke survivors and every 45 seconds someone has a stroke. Every 3 minutes someone in the USA dies from a stroke, and about half of stroke survivors are left disabled. • In Europe, approximately 650,000 people die of stroke.

  5. UK effects • 150,000 people have a stroke in the UK each year. • There are over 67,000 deaths due to stroke each year in the UK. Office of National Statistics Health Statistics Quarterly

  6. Men vs Women • Men are 25% more likely to suffer strokes than women. • 60% of deaths from stroke occur in women. • Women live longer • they are older on average when they have strokes • thus more often killed (NIMH 2002)

  7. Out of 10! • About 2 out of 10 people who have a stroke die within the first month. • 3 out of 10 die within the first year. • 5 out of 10 die within the first 5 years. • The more time that passes after a stroke, the less is the risk of dying from it.

  8. What is Palliative Care?

  9. World 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.

  10. Palliative Care Affirms life and regards dying as a normal process Uses a team approach to address the needs of patients and their families, including bereavement counselling. World health organisation 2010

  11. Palliative Care • Palliative care • Specialist palliative care • Terminal Care

  12. Who is involved in Palliative care? Multi–disciplinary team Doctors through to the kind word from a domestic

  13. Goals of palliative Care • Best quality of life. • Support system to promote patients’ & families’ self worth. • Poor care prior to death makes bereavement difficult and has long term repercussions on the health of family and friends.Parkes CM (1998) • Provide relief from suffering. • Symptom control.

  14. What is good palliative care • Humanity • Dignity • Respect • Good communication • Clear information • Best possible symptom control • Psychological support when needed • Continuity of care

  15. Nurses role in palliative care • All nurses should be able to: • Undertake basic symptom assessment and management. • Understand the experience of the dying patient and their families. • Engage in communication regarding individual needs and experiences. • Consult the specialist palliative care practitioners if the needs of patients are out of the nurses experience. Aranda S (2003)

  16. Symptoms stroke patients experience • Pain • Fatigue • Weakness • Lack of energy • Weight loss • Difficulty swallowing • Anorexia • Early Satiety • Restlessness & agitation • Dry mouth • Constipation • Respiratory secretions • Dyspnoea • Anxiety

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

  18. Case 1 • 71, male, independent. • Found in bed unconscious, doubly incontinent, dehydrated. • Right lateral gaze, L-sided weakness, extensive R-sided pneumonia, sore in his L leg, swelling in R-side head/face. • CT head: large L-sided intracerebral haemorrhage. • DNR, decided against feeding, withdraw Abx- died 24hrs later.

  19. Terminal care Case 1 • Communication amongst health care professionals. • Symptom assessment & control: • Pain, agitation, restlessness, breathing • Dignity: • pressure sore management, mouth care • Liverpool Care Pathway. • All of the above can be managed by the MDT • Specialist input can be sought as a one of measure if adequate symptom control is not achieved.

  20. Case 2 • 84, female, wheelchair-bound, house-bound, previous CVA. • Unconscious, L-sided weakness, pyrexia. • CT head: intracerebral haemorrhage. • Husband: ‘no life-prolonging measures’. • DNR, artificial feeding commenced, Abx given, prognosis: likely soon death. • Still alive on day 15 - Abx stopped. • Still alive on day 25 - NG feed stopped. • Died on day 31 of admission.

  21. Palliative careCase 2 • Communication • Husband-medical team? • “No life prolonging measures” - Abx?, Feeding?, Hydration? • Ethical issues? Right / wrong? • Prolonging suffering? • Quality of life? • Would Specialist Palliative Care input help? • “the key to good palliative care is that the dying process is actively managed rather than drifted into when all else fails” (Jarrett, 1997)

  22. Case 3 • 39, female, business owner. • Decreased conscious level, quadriplegia. • MRI: bilateral ventral pontine infarction with patent basilar artery- ‘Locked-in syndrome’. • 5/52 ITU, then ASU-MDT care. • 7/52 post-CVA: reliable voluntary movement in upper limb & jaw, goal-directed PT possible. • Depressed, contractures, pain, functional gain. • 3/12 post-CVA: rehab unit. • D/C 10/12 post-CVA with maximal community support.

  23. Stroke survivorsCase 3 • A case for Specialist Palliative care? • Chronic disease management • Continuity of care: • Community support • Psychological support / counselling • 1 in 5 stroke pt’s have suicidal thoughts • Symptom management • Lack of palliative specialist / information in stroke management: partnerships are therefore required to ensure a holistic approach to stroke management.

  24. Best Practice Tools • Liverpool care pathway (LCP) (Ellershaw & Wilkinson 2003) • Gold standard framework (GSF) (Thomas 2003) • Preferred Place of care Tool (PPC) (Storey et al 2003)

  25. Points to remember • Palliative care can be implemented by the generic medical team. • Limitations to practise • Ethical • Implementation of specialist palliative care early on in acute management of patients. • More research is required to see if Specialist Palliation is require for stroke survivors which may in fact improve rehabilitation outcome.

  26. Communication and compassion

  27. 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". Lancet349 (9061): 1269–76. doi:10.1016/S0140-6736(96)07493-4. PMID9142060. • Donnan GA, Fisher M, Macleod M, Davis SM (May 2008). "Stroke". Lancet371 (9624): 1612–23. doi:10.1016/S0140-6736(08)60694-7. PMID18468545. • 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 FoundationRoyal College of Physicians, (2001), • http://www.omnimedicalsearch.com/conditions-diseases/stroke-introduction.html

  28. References / Bibliography • WHO guidelines: cancer pain relief 2nd ed. Geneva: World health organisation: 1996

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