NUR3500 Chap.5 Palliative Care in End Stage Organ Disease
Palliative Care in End Stage Organ Disease
What the three failures share
Heart, lung and kidney failure sit on the organ failure trajectory: long term limitation punctuated by acute episodes, each of which could be the last, with a baseline that never quite returns. That shared shape is why they are taught together and why one assessment structure works for all three.
Assessment covers physical symptoms, emotional and psychosocial concerns, social and cultural context and spiritual distress, and then adds the person's own quality of life, what they understand about their illness, and their personhood.
The management principles are equally shared: focus on the symptom that troubles the patient most, treat reversible causes, identify interventions appropriate to this stage, share decisions and coordinate the team, and use non-pharmacological approaches alongside drugs.
Each of those rules something out, and the most commonly broken is the second: escalating a comfort drug before looking for infection, anaemia or constipation.
Heart failure
Heart failure is a long term condition in which the heart muscle can no longer move blood quickly enough to supply the oxygen the rest of the body is asking for, and it carries a real risk of sudden death.
It is graded by what activity provokes symptoms, from no limitation through to symptoms at rest. Fatigue and breathlessness lead the symptom cluster, usually with disturbed sleep and oedema, and pain is common and often missed because it is attributed to age. Low mood and poor appetite complete the picture.
An implanted defibrillator raises its own planning question as death approaches.
Lung disease
End stage lung disease is reached when the lungs can no longer clear carbon dioxide and supply enough oxygen, most often from chronic obstructive pulmonary disease or interstitial lung disease, and severity is staged by airflow on spirometry.
Breathlessness dominates and is amplified by fear: the sensation provokes panic, panic produces rapid shallow breathing, the person avoids movement and deconditions, and becomes breathless sooner.
Treatment therefore has four arms: drugs including carefully titrated opioids, breathing and positioning work, psychological support, and reconditioning.
Kidney disease
In advanced chronic kidney disease the person needs renal replacement therapy, and the point to hold onto is that dialysis sustains life rather than curing the disease.
Stopping established dialysis and never starting it are different situations with very different timescales, described in the course material as roughly a week or so in the first case and months to a year or two in the second, varying with comorbidity and residual urine output.
Fatigue, itch, constipation, poor appetite, pain, nausea, insomnia and breathlessness make up the usual cluster, and uraemic itch is the symptom most often under-treated.
What this chapter covers
- 01
The shared organ failure trajectory
- 02
Assessment structure and management principles
- 03
Advanced heart failure and functional grading
- 04
Breathlessness in advanced lung disease
- 05
Dialysis decisions and uraemic itch
Choosing what to treat first in kidney failure
- 2Justify assessing across all four domains before changing a drug.
- 2Give the reversible and mechanical measures.
- 3Give the pharmacological review and the third target.
Key terms
- Organ failure trajectory
- Long term limitation with acute exacerbations and a baseline that falls further after each episode.
- Functional classification
- Grading of heart failure by the level of activity that provokes symptoms, from none to symptoms at rest.
- Airflow staging
- Grading of obstructive lung disease severity by the proportion of predicted airflow achieved in the first second of a forced breath.
- Breathlessness cycle
- The self-reinforcing loop in which the sensation provokes fear, fear worsens breathing efficiency, and avoidance produces deconditioning.
- Renal replacement therapy
- Dialysis or transplantation, undertaken to sustain life in advanced kidney disease rather than to cure it.
- Uraemic itch
- Persistent itching in advanced kidney disease with multiple contributing causes, often responding poorly to antihistamines.
Palliative Care in End Stage Organ Disease FAQ
Are opioids safe for breathlessness in advanced lung disease?
Yes, when carefully titrated, and they are used for exactly that indication. The safeguard is the titration: small doses reviewed against the effect on the sensation rather than on a saturation reading. Ruling them out for fear of respiratory depression is a common and costly error.
When is oxygen the right answer for breathlessness?
Where there is hypoxia. Oxygen treats a low blood oxygen level rather than the sensation itself, so a normally saturated patient is more likely to be helped by cool moving air from a fan, by positioning and pacing, and by addressing the fear driving the cycle.
Why does stopping dialysis change the timescale so sharply?
Because withdrawal removes the only remaining mechanism clearing waste from someone with no residual function, so decline follows within days. A person who never started still has some residual kidney function, which is why survival in that situation is described in months to a year or two.
Exam move
Make a three column sheet headed heart, lung and kidney, and fill in the staging tool, the dominant symptom and the one decision that defines each. Then write the five management principles and, beside each, the shortcut it is designed to stop.
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