Presented by Leigh Snyman April 2017 Overview Definition of - - PowerPoint PPT Presentation

Presented by Leigh Snyman April 2017

• Definition of Palliative Care
• Case based discussion
• Take home messages

Overview

WHO Definition of Palliative Care: Palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life- threatening illness Methods:

• Prevention and relief of suffering
• Assessment and treatment of pain and other

problems, physical, psychosocial and spiritual

WHO 2010

What is Palliative Care?

Palliative Care in Phases

Diagnosis Clinical Management Terminal Phase Curative/ life prolonging therapy Palliative management

Palliative Care in Phases

Diagnosis Clinical Management Terminal Phase

Curative/ life prolonging therapy Palliative management

• Relieve patient from

suffering

• Manage symptoms
• Protect patient

autonomy

• Patient centered care
• Good treatment

journey whatever the

• utcome
• Cure disease
• Manage adverse

events/ side effect

• Complete treatment

and achieve treatment success

Case study: Patient X

• 27 year old man
• HIV negative (confirmed)
• Unemployed, lives alone
• No child contacts
• Previous DS-TB in 2011 – cured
• March 2015 – presented with new TB symptoms
• GXP pos RR-TB, on sputum
• Culture pos, res to RIF and INH, inhA only, sus to Ofx and Ami –

MDR

• April 2015 – clinically stable and ambulant
• Commenced standard MDR treatment

Case study

• July 2015 (month 3)

– Monthly sputum cultures contaminated – Interrupted treatment for 6 weeks

• August 2015

– Returned to care – stable and weight increased, but coughing and night sweats back again – August sputum culture negative – Resumed MDR treatment (with Kana) at end Aug

• Dec 2015 (month 8)

– Culture positive again since Oct, losing weight – Abscess at injection site – Kana withdrawn – Considered MDR treatment failure – offered strengthened regimen with BDQ, LZD and CFZ

Case Study

• Jan 2016 (month 1 new regimen)

– Sputum culture pos, res to RIF, INH and Ami – pre-XDR – Continued regimen:

• PZA / BDQ / CFZ / LZD / LFX / TRD / hdINH
• June 2016 (month 6 new regimen, [mth 14 total])

– No culture conversion (lots of contaminated samples), still culture positive in June – No weight gain, bilateral extensive disease – Adherence reasonable – attending clinic in the week – BDQ withdrawn (6 months completed, Tx failing) – Considered pre-XDR treatment failure

Case example

• Aug 2016 (month 15 total)

– Still on PZA / CFZ / LZD / LFX / TRD / hdINH – Not eligible for surgery, or for NIX trial – Case presented to NCAC and Provincial M/XDR Review Committee – all agreed to withdraw treatment and manage palliatively – But patient refused and begged to continue! – Commenced palliative pathway… (Leigh)

• Nov 2016 (month 18 total)

– Still on treatment, much improved on morphine and with access to oxygen in sub-acute facility – Discovered Aug sputum culture negative…

Case example

• Jan 2017 (month 20 total)

– Still on PZA / CFZ / LZD / LFX / TRD / hdINH – Still on morphine but no longer on oxygen – Four monthly sputum cultures negative, but slow clinical improvement – Patient wanted info about other available options… – Sputum submitted to Pretoria for extended DST – Application submitted to add DLM and Meropenem to regimen, and restart BDQ, along with current regimen

• Mar 2017 (month 22 total)

– Admitted to BCH for monitoring, IV port inserted, now

• n salvage regimen, and hopeful!

Case study: Patient X

• Treatment failing?
• Hope failing?
• Body failing?
• Friends/ family failing?
• The Health care system

failing?

Relieving suffering

• Continued TB medication on pt.

request

• Encourage Hope while ensuring

patient had insight into situation

• Assess and treat the Body
• Educate Friends/ family
• Support the Health care system

– Access to medication, sputum test, respite care, emergency admissions and isolation

Ethical Issues to Note

• Patient Autonomy versus

Patient Review Board decision

• Public harm: infection control

implication of patients staying in the community

• Patient Harm- limited access to

care

• Justice- Equal access to life

saving treatment, care and support

Conclusions

• Cases confirm:

– Living with a life threatening disease is challenging – Relieving suffering is possible at community level – Sufficient care provision at community level often does not happen from MSF’s experience with various cases – Palliative care provision is not a reflex response

Recommendations

• Prioritization of RR-TB Palliative Care Guidelines drafted by

South Africa for implementation in 2016

• Palliative care training for HCWs need to be prioritized at

national and provincial level

• Partnerships between district health services and district

Palliative Care services are key to implement services at community level

• New Drugs + Trained HCW + Resources = Hope for the

future