Increasing pain associated with rapidly escalating opioid doses.
Characterisedby change in pattern of pain, becoming more diffuse and associated with hyperalgesia, allodynia and myoclonus.
When severe may progress to delirium, fits, coma and death.
- Seek Specialist Palliative Care advice
- Will require a reduction in background opioid.
- May need ketamine and/or a switch to methadone or buprenorphine
- The Australian Commission on Safety and Quality in Health Care defines dying as 'the terminal phase of life, where death is imminent and likely to occur within hours or days, or occasionally weeks.'
- This term is interchangeable with ‘terminal phase’ or ‘actively dying’.
- The Palliative Care Outcomes Collaboration (PCOC) uses the term terminal phase and defines this as 'death is likely within days'.
“Palliative sedation” is defined as the use of sedative medications to relieve refractory symptoms by a reduction in consciousness. Depending on the level of consciousness, three levels of sedation may be distinguished: mild, intermediate and deep. Depending on the duration, sedation is often described as intermittent or continuous.
http://www.cmq.org/publications-pdf/p-1-2016-08-29-en-sedation-palliative-fin-de-vie.pdf- Because most dying people are more comfortable without eating or drinking near the end of life, forcing food or liquids is usually not beneficial, especially if restraints, IVs, or hospitalization would be required. Not forcing someone to eat or drink is not letting him "starve to death."
- The truth is, for those who are dying, the times come when it might be more compassionate, caring, even natural, to allow a natural dehydration to occur. Forcing tube feedings and IVs on dying patients can make the last days of their lives more uncomfortable.
The foundation of medical ethics is supported by four pillars, namely;
- Autonomy - patient has the right to choose or refuse the treatment
- Beneficence - a doctor should act in the best interest of the patient
- Non-maleficence - first, do no harm
- Justice - it concerns the distribution of health resources equitably.
- Dignity - the patient and the persons treating the patient have the right to dignity
- Truthfulness and honesty - the concept of informed consent and truth telling
It’s about conversations.
It’s about wishes.
It’s how we care for each other.
Advance Care Planning is a process of reflection and communication. It is a time for you to reflect on your values and wishes, and to let people know what kind of health and personal care you would want in the future if you were unable to speak for yourself.
https://www.advancecareplanning.ca/what-is-advance-care-planning/- Over-the-counter Tylenol (generic acetaminophen) is often the best choice for people with high blood pressure, heart failure, or kidney problems.
- If Tylenol or generic acetaminophen do not work, ask your doctor about using a stronger prescription painkiller, such as Ultram (generic tramadol) for a short time.
- Do not use tramadol if you have epilepsy or if you take Paxil (generic paroxetine), Prozac (generic fluoxotine), or Zoloft (generic sertraline). Taking tramadol with these drugs can increase your risk of seizures.
How well does cardiopulmonary resuscitation (CPR) work?
- Very few people of all ages survive CPR in hospital.
- CPR can cause injuries, such as broken ribs or bruised lungs.
- People who survive CPR often need a ventilator afterwards.
- About half of the people who survive CPR are left with brain damage and ongoing serious health issues.
Advance Care Planning helps you plan for your future health-care and gives you control over your care.
https://bc-cpc.ca/cpc/all-resources/individuals/advance-care-planning/
The following is a selection of tools for assessing pain and assessing and tracking the level of symptoms (some are patient reported).
http://www.npcrc.org/content/25/Measurement-and-Evaluation-Tools.aspx
"Any triage system that does not integrate palliative care principles is unethical. Patients who are not expected to survive should not be abandoned but must receive palliative care as a human right,"
https://www.eurekalert.org/pub_releases/
- 01 Medical Care of People with Serious Illness in Palliative Care
- 02 Psychiatric, Psychological, and Spiritual Care in Palliative Care
- 03 Pain Assessment and Management in Palliative Care
- 04 Nonpain Symptom Management in Palliative Care
- 05 Communication and Teamwork in Palliative Care
- 06 Ethical and Legal Practice in Palliative Care
- 07 Pediatric Palliative Care and Hospice in Palliative Care
- 08 COPD, Heart Failure, and Renal Disease in Palliative Care
- 09 HIV, Dementia, and Neurological Conditions in Palliative Care
Over 80% of patients receiving palliative care do not have severe symptoms at the time of death. Only a small proportion experience severe symptoms and evidence shows these symptoms either become absent or mild as death approaches. When patients are referred to palliative care 9% experience severe pain but this reduces to approximately 2% prior to death. Patients in their final days and hours receiving palliative care experience less pain, symptoms and problems than earlier in their illness.
https://ahsri.uow.edu.au/
Individualised care of people who are dying encompasses physical symptoms (such as pain, increasing fatigue and breathlessness), psychological symptoms (such as anxiety and depression), social and spiritual needs. Good communication and advance planning is necessary to ensure that people are appropriately involved in the decision-making process about the care they or their loved ones receive and that patients and families are treated with respect to maintain their dignity.
https://www.ncbi.nlm.nih.gov/books/NBK356001/RESPIRATORY SYMPTOMS IN PALLIATIVE CARE
https://pharmacopallcare.blogspot.com/2020/09/respiratory-symptoms-in-palliative-care.html
The Tasmanian Palliative Care Formulary includes:
- Medications with specialised palliative care indications
- Routes and dosing, including via syringe drivers
- Variations on usual prescribing for this patient group
- Summaries that compare medications within a class, eg. NSAIDs, benzodiazepines
- Links to useful resources;
- symptom management guidelines
- syringe driver compatibilities, and
- opioid conversion tables
https://palliativecareformulary.tas.gov.au/SpecialtyFormulary/3
PALLIATIVE CARE CURRICULUM AND MODULE
https://pharmacopallcare.blogspot.com/2020/09/palliative-care-curriculum-and-module.html
Palliative Care treats the symptoms that occur during a life-threatening condition or a serious illness, including physical, emotional, and psychological symptoms, as well as side effects of primary treatment. Whereas primary treatment focuses on curing the illness or extending life, this type of care is about improving the quality of life during treatment.
https://integracare.on.ca/palliative-care/
- • health care, nutrition and hydration
- • where you would like to live and die
- • comfort measures and support services
Your personal directive needs to be written, dated, signed by you, and witnessed by an adult. You do not need a lawyer to write a personal directive.
Antipsychotics can reduce distressing symptoms and shorten duration of delirium for all types of delirium:
- Haloperidol : orally 1.5mg - 3mg 4hourly & 3- 5mg nocte.
- Levomepromazine.
- Atypical antipsychotics : Olanzapine, Quetiapine.
At the end of life reassess daily underlying cause may have resolved. Review medications to ensure symptoms remain controlled. Provide extra support for family/carers.
https://ecancer.org/en/elearning/module/86-symptom-management-confusion-and-delirium/learn
Spiritual needs can include:
- the need for meaning and purpose in our lives
- the need to love and feel loved
- the need to feel a sense of belonging
- the need to feel hope, peace and gratitude.
What’s most important to someone can change over their life time.
Caring for people with a terminal illness can be very demanding. It might prompt you to ask questions about your own mortality, your beliefs, and look for meaning and purpose in your life.
https://www.mariecurie.org.uk/professionals/palliative-care-knowledge-zone/individual-needs/spirituality-end-life
It is important for your family and doctor to know that you have prepared a personal directive. Let them know where you keep your personal directive.
A personal directive does not include financial decisions.
http://www.nshealth.ca/sites/nshealth.ca/files/preparing_for_death_and_dying_nsha.pdfPALLIATIVE CARE SPECIALIST OR PHYSICIAN
- 1. Prescribes or recommends treatment for pain, nausea, constipation, anxiety, depression, breathlessness or any other symptoms you may have
- 2. Usually provides care in a palliative care unit (hospice) or hospital (both for inpatients or people attending an outpatient clinic), but may also be able to visit you in your home or residential aged care facility
- 3. Communicates with and advises the cancer specialist and your gp so your treatment is well coordinated
- 4. May refer you and your family to a grief counsellor, psychologist or other support person
- 5. Assists with decisionmaking about care and treatment choices
LOSS, GRIEF AND BEREAVEMENT IN PALLIATIVE CARE
https://pharmacopallcare.blogspot.com/2020/09/loss-grief-and-bereavement-in.html
The
practice of hospice palliative care is relatively young. In Canada, it
began in the 1970s and has evolved rapidly. The term “hospice palliative
care” was coined to recognize the convergence of hospice and palliative
care into one movement that has the same principles and norms of
practice.
https://www.chpca.ca/resource/norms/Palliative care teams improve quality of care in a manner that leads to reduced hospital costs. They achieve this by combining:
- → Time to devote to intensive family meetings and patient/family counseling.
- → Skilled communication on what to expect in the future in order to ensure that care is matched to the goals and priorities of the patient and the family.
- → Expert symptom management of both physical and emotional distress.
- → Coordination and communication of care plans among all providers and across settings.
Clinician: “What are your most important goals if your health situation worsens?”
Patient: “Just
to spend time with the family. That’s about it. And be here as long as I
can. I’m not looking for a miracle. I’m just looking for a little
time.”
https://www.ariadnelabs.org/areas-of-work/serious-illness-care/
Palliative
care is the care of patients with active, progressive, faradvanced
disease, for whom the focus of care is the relief and prevention of
suffering and the quality of life.
The following should be noted
- active disease: this activity can be confirmed and measured objectively by clinical examination and investigations
- progressive disease: this too can be assessed clinically
- far-advanced disease: more difficult to define but examples are
- → extensive metastatic disease in cancer
- → refractory cardiac failure
- → total dependency in neurodegenerative conditions or Alzheimer’s disease
- focus on the quality of life is the key feature of the definition
- it is person-oriented, not disease-oriented
- it is not primarily concerned with life prolongation (nor with life shortening)
- it is not primarily concerned with producing long term disease remission
- it is holistic in approach and aims to address all the patient’s problems, both physical and psychosocial
- it uses a multidisciplinary or interprofessional approach involving doctors, nurses and allied health personnel to cover all aspects of care
- it is dedicated to the quality of whatever life remains for the patient
- palliative care is appropriate for all patients with active, progressive, faradvanced disease and not just patients with cancer
- palliative care is appropriate for patients receiving continuing therapy for their underlying disease
- palliative care should never be withheld until such time that all treatment alternatives for the underlying disease have been exhausted
Five Wishes lets your family and doctors know:
- → Who you want to make health care decisions for you when you can’t make them.
- → The kind of medical treatment you want or don’t want.
- → How comfortable you want to be.
- → How you want people to treat you.
- → What you want your loved ones to know.
Okay kan, Bro!
