"If we are not aware of death,
we are not mindful of our living",
Dr. Virginia Seno
Educator in end of life communication
https://web.archive.org/web/20200824155042/https://www.crossroadshospice.com/media/1356/palliative-hospice-power-point.pdf
Why Do Advance Care Planning
☛ A study of families who faced end of life decisions on hospitalized loved ones conducted by the University of Oregon Health Sciences Center and NIH found that:
☛ In the absence of advance directives from the patient, families found this the most stressful of life events
☛ In the absence of advance directives families were more likely to insist on futile treatment, even when the patient was suffering
☛ When an advance directive was present, the family was more able to focus on the patient’s quality of life and to allow a switch to comfort care strategies
Suggested Strategies for Improving Quality of Life
☛ Identify sources of meaning, both positive and negative, before and during illness; identify current meanings of the illness for the person and for the family; explore creation of a life narrative (Written? Tape recorded? Favorite music?). Explore possible legacies for loved ones.
☛ Explore source of existential anguish before and during illness; attend to dreams as clues to sources of existential distress.
☛ Identify sources of healing connections for this person before and during illness.
☛ Minimize uncertainty: for example, introduce caregivers by name and occupation; discuss hospital routines, assessment, treatment options, related plans, possible side effects, and anticipated timing of interventions.
☛ Identify and support expression of fears (‘‘What is the worst part of all this?, ‘‘What has helped you most?’’).
☛ Identify ego defense mechanisms that increase distancing, denial, closure to others, blocks in opening to the hard reality at hand.
☛ Promote a calming, pleasant atmosphere characterized by efficiency, accompaniment, and caring, thus promoting a sense of security.
☛ Promote strategies that may bring the person into the present moment: meditation, music, discussion of their cherished interests (‘‘What have you always been passionate about?’’), domains of creativity; consider art and music therapy.
https://web.archive.org/web/20200906063756/https://www.mcgill.ca/wholepersoncare/files/wholepersoncare/Healing_Connections.pdf
- ☛ being treated as an individual, with dignity and respect
- ☛ being without pain and other symptoms
- ☛ being in familiar surroundings
- ☛ being in the company of close family and/or friends.
- ☛ identify patients with a year or less to live
- ☛ initiate conversations about end of life care
- ☛ put end of life care plans in place.
The best sites to use for subcutaneous infusion of fluids are the lateral aspects of the upper arms and thighs, the anterior chest below the clavicle and occasionally, the back or abdomen (Graham 2006).
Areas which should not be used are:-
- • Lymphoedematous limbs, e.g. avoid arms on the same side as previous breast/axillary surgery. A cannula breaches skin integrity, thus increasing the risk of infection in a limb which is already susceptible
- • The abdomen when distended by ascites or abdominal disease
- • Sites over bony prominences. The amount of subcutaneous tissue will be diminished, impairing the rate of absorption
- • Previously irradiated skin area. Radiotherapy can cause sclerosis of small blood vessels, thus reducing skin perfusion
- • Sites near a joint; excessive movement may cause cannula displacement and patient discomfort
Sites should be rotated and giving sets changed every 5 days or before if any signs of site reaction to minimise tissue damage (see monitoring section).
https://www.harrogateandruraldistrictccg.nhs.uk/clinicalguidance/palliative-care/Fatigue or “asthenia” is a subjective symptom, ranging from tiredness to exhaustion, that is out of proportion to recent activity. It occurs as a result of disease, emotional state and/or treatment, and may be acute or chronic.
Major features include:
- easy tiring and reduced capacity for activity;
- generalized weakness; and
- impaired concentration, with memory loss and emotional lability.
Fatigue usually has multiple causes and may be related to underlying disease, treatments, or a variety of reversible and non-reversible factors.
Symptom problems, psychosocial factors and mood disturbances, such as depression and anxiety, may all disrupt sleep and/or contribute to fatigue.
Monitor closely for drug interactions and adverse effects.Dose varies with indication.
Short term use of dexamethasone. Most commonly used at 2-4mg/d.
Methylprednisolone, 16 mg twice daily for one week;
although very rarely used also significantly improved fatigue.
Limit duration of treatment for fatigue.No benefit shown beyond 7 to 15 days.
Adverse effects increase with longer treatment and higher doses.
Give earlier in day to reduce insomnia.
Physicians believe to be effective, but evidence is inconsistent.
https://www.fraserhealth.ca/-/media/Project/FraserHealth/FraserHealth/Health-Professionals/Professionals-Resources/Hospice-palliative-care/Sections-PDFs-for-FH-Aug31/9524-18-FH---Sym_Guide-Fatigue.pdf
MEDICATIONS COMMONLY USED IN PALLIATIVE CARE
https://pharmacopallcare.blogspot.com/2020/09/medications-commonly-used-in-palliative.html
- Palliative care is attending to the physical, emotional and spiritual suffering of patients and families who are dealing with a serious illness. Hospice is a type of palliative care that we provide in the last six months of life. And I would say hospice is even distinct from end-of-life care, which is really the care of patients in the last days and hours of their lives.
- In our country, hospice is overwhelmingly provided in a patient's home or in a nursing home, whereas palliative care is available at any stage of an illness. And so we can see people in the hospital; we can see people in clinics when they come to see their oncologist or their cardiologist. With palliative care, you can have us on your team just right alongside care like chemotherapy or dialysis — we're meant to attend to your quality of life. And in an ideal circumstance, we will be there when you decide to transition to hospice.
- Recognising dying can be challenging for health and care professionals. There is often uncertainty about how long a person has left to live and the signs that suggest that someone is dying are complex and subtle.
- Some health and care professionals are uncomfortable discussing how long someone has left to live, and sometimes do not have the skills and confidence to give difficult news or talk about the dying process. Adequate training and continued support is important to help health and care professionals to communicate sensitively and effectively.
- Effective shared decision-making can help to ensure that people get the right care in the last days of their life. Health and care professionals can help to achieve this if they have the right communication skills, and have a good rapport with the dying person and those important to them.
For a patient who has an advanced life-threatening illness and who is dying, artificial hydration and nutrition may not provide many benefits. Artificial hydration and nutrition in these patients may make the patient live a little longer, but not always.https://familydoctor.org/artificial-hydration-and-nutrition/
- The Liverpool Care Pathway was developed in 1997 as a pathway to provide a template to non-Palliative Medicine specialty providers of evidence-based, multidisciplinary care of patients at the end-of-life and included support for caregivers and families with the intent to provide Palliative Care across the entire United Kingdom health system.
- The data from the program showed that it improved knowledge of when and how to stop futile therapies and how to communicate with patients and families about death and dying. This pathway also provided evidence that improving communication between medical staff and between the medical staff and patients and their families had positive outcomes for patients.
- The program was abruptly discontinued in 2014 due to various criticisms from national reviews. The discontinuation of the Liverpool Care Pathway, which was the most used end-of-life care pathway ever, raised the question of whether end-of-life care pathways for the treatment of the dying were effective.
• Opioids are the mainstay of pain management in patients with cancer
• Morphine is considered first choice opioid:
– familiarity
– low cost
– available formulations
– proven effectiveness
• Reasons for opioid switching include:
– intolerable adverse effects limiting dose escalation
– inadequate response, despite escalation of current opioid
– renal/hepatic impairment
– development of analgesic tolerance
– patient factors
• Historically, 10 mg of parenteral morphine has been considered to be the standard comparator
• Equianalgesia, or equipotency, can be achieved by accounting for these factors
– dose corrections
– alternate route of administration
• Equianalgesic dose:
– The dose at which two opioids (at steady state) provide approximately the same pain relief
– Two opioids can be made equipotent , resulting in equianalgesia
https://guildfordadvancedcourses.co.uk/wp-content/uploads/2019/10/2-Equianalgesia.pdf
EFFECTIVE COMMUNICATION IN PALLIATIVE CARE
https://pharmacopallcare.blogspot.com/2020/09/effective-communication-in-palliative.html
The Core Curriculum contains the most important Fast Facts within a particular palliative care domain or speciality area. These can be used to supplement a Generalists Palliative Care training initiative, for on-boarding new palliative care specialists, for health professional trainees working in hospice and palliative medicine or for “just in time” education to meet a clinical problem.
https://www.mypcnow.org/fast-facts/core-curriculum/The clinical priorities of terminal care are:
- talking to the person, the family and carers
- managing symptoms
- ensuring medicines are available for symptom management
- withdrawing non-essential medicines
- advising other health professionals involved in the person’s care.
Principles of Palliative CareIf it is thought that a person may be entering the last days of life, gather and document information on:
Palliative care incorporates the whole spectrum of care — medical, nursing, psychological, social, cultural and spiritual. A holistic approach, incorporating these wider aspects of care, is good medical practice and in palliative care it is essential.The principles of palliative care might simply be regarded as those of good clinical practice, whatever the patient’s illness, wherever the patient is under care, whatever his / her social status, creed, culture or education.https://hospicecare.com/what-we-do/publications/getting-started/6-principles-of-palliative-care
- the person's physiological, psychological, social and spiritual needs
- current clinical signs and symptoms
- medical history and the clinical context, including underlying diagnoses
- the person's goals and wishes
- the views of those important to the person about future care.
This is called a holistic approach, because it deals with you as a "whole" person.
Palliative care isn’t just for the end of life. You may receive palliative care earlier in your illness while you are still receiving other therapies to treat your condition.
https://www.nidirect.gov.uk/SUBCUTANEOUS MEDICATIONS FOR PALLIATIVE CARE
https://pharmacopallcare.blogspot.com/2020/09/subcutaneous-medications-for-palliative.html
The end of life care provided may include listening and talking with you after news about the possibility of the end of your life, being empathetic to your concerns and needs, and referring you to more specialised support or care if required.
https://www.betterhealth.vic.gov.au/QUALITY PALLIATIVE CARE
Core components of quality palliative care:
- ☛ Frequent assessment of the patient’s physical, emotional, social, and spiritual well-being
- ☛ Management of emotional distress
- ☛ Offer referral to expert-level palliative care
- ☛ Offer referral to hospice if the patient has a prognosis of 6 months or less
- ☛ Management of care and direct contact with patient and family for complex situations by a specialist-level palliative care physician
- ☛ Round-the-clock access to coordinated care and services
- ☛ Management of pain and other symptoms
- ☛ Counseling of patient and family
- ☛ Family caregiver support
- ☛ Attention to the patient’s social context and social needs
- ☛ Attention to the patient’s spiritual and religious needs
- ☛ Regular personalized revision of the care
https://www.sciencedirect.com/science/article/abs/pii/S0025712520300018?via%3Dihub
Clinician–Patient Communication and Advance Care Planning
- ☛ Most people nearing the end of life are not physically, mentally, or cognitively able to make their own decisions about care.
- The majority of these patients will receive acute hospital care from physicians who do not know them. Therefore, advance care planning is essential to ensure that patients receive care reflecting their values, goals, and preferences.
- ☛ Of people who indicate end-of-life care preferences, most choose care focused on alleviating pain and suffering.
- However, because the default mode of hospital treatment is acute care,
- advance planning and medical orders are needed to ensure that these preferences are honored.
- ☛ Frequent clinician–patient conversationsabout end-of-life care values, goals, and preferences are necessary to avoid unwanted treatment.
- However, most people—particularly younger, poorer, minority, and less-educated individuals, do not have these conversations.
- Clinicians need to initiate conversations about end-of-life care choices
- and work to ensure that patient and family decision making is based on adequate information and understanding.
- ☛ Incentives, quality standards, and system support are needed to promote improved clinician communication skills and more frequent and productive clinician–patient conversations.
These 7 antibiotics can cover almost all infections caused by Gram-negative, Gram-positive, aerobic, anaerobic and extended-spectrum beta-lactamase (ESBL) microorganisms in palliative care patients. We can therefore conclude that palliative patients with infections can be treated with ceftriaxone, cefepime, ampicillin, amikacin, tobramycin, ertapenem and teicoplanin administered subcutaneously when appropriate off-label use authorisation has been obtained and a benefit assessment performed.
https://www.oatext.com/pdf/GDT-2-121.pdf
Okay kan, Bro!
