PALLIATIVE SYMPTOM MANAGEMENT OPTIONS
- If a patient is unable to swallow, morphine controlled release tablets may be administered rectally.
- Some oral medications (but not slow/prolonged release formulations) may be crushed or capsules emptied into liquid and administered orally.
- If IV access is not available, medications may be administered subcutaneously (SC) through either a primed butterfly needle sited on the upper chest or back above the scapula and secured with a transparent dressing, or with a portable syringe driver (if available).
Many patients do not receive palliative care
• Palliative care is negatively associated with
a system of diminished care
which is seen as a ‘lesser’ treatment alternative,
diminished possibilities for hope
and achievement of goals previously centered upon cure
and diminished choices for the circumstances
of one’s care given all other options have expired.
• Barriers to palliative care include:
- Limited resources to refer to
- Limited awareness of available resources
- Ignorance about palliative care
- Reluctance to refer
- Reluctance of the patient and/or family for referral
- Restrictive palliative care program eligibility criteria
Effects on patient and family if diagnosis of dying is not made
- Patient and family are unaware that death is imminent
- Patient loses trust in doctor as his or her condition deteriorates without acknowledgment that this is happening
- Patient and relatives get conflicting messages from the multiprofessional team
- Patient dies with uncontrolled symptoms, leading to a distressing and undignified death
- Patient and family feel dissatisfied
- At death, cardiopulmonary resuscitation may be inappropriately initiated
- Cultural and spiritual needs not met
All the above can lead to complex bereavement problems and formal complaints about care
http://palcare.streamliners.co.nz/Care of the dying patient the last days or hours.pdf
Applying a family-centred approach
to assessment and intervention
with efforts to focus on shared interests
increases the likelihood
of successful resolution
of family strain and optimal care
for the patient and all involved.
https://www.tandfonline.com/doi/abs/10.1179/096992608X296914
Prescribing in Palliative Care
https://library.nshealth.ca/PalliativeCare
Palliative and End of Life Care Toolkit
https://sites.google.com/view/pc-eolcare-toolkit/home
Palliative and care at end of life resources
https://www.health.qld.gov.au/clinical-practice/guidelines-procedures/patient-safety/end-of-life/resources/palliative-and-care-at-end-of-life-resources
Morphine has been proven to reduce dyspnoea - the mechanism is not clear.
Usually lower doses are required than those for pain, e.g. 2.5 - 10 mg of elixir 4 hourly or PRN. The dose can be gradually titrated as for pain, but comfort rather than resolution of dyspnoea is generally the desired end point.
http://cdhb.palliativecare.org.nz/index.htm
B.C. INTER-PROFESSIONAL PALLIATIVE SYMPTOM MANAGEMENT GUIDELINES
http://www.mhpcn.net/palliative-care-toolbox
Everyone’s needs are different at the end of their life and people should be provided with care that is consistent with their preferences and values.
https://www2.health.vic.gov.au/hospitals-and-health-services/patient-care/end-of-life-care
TREATMENT AND CARE TOWARDS THE END OF LIFE
What is the Liverpool Care Pathway?
https://www.nhs.uk/news/medical-practice/news-analysis-what-is-the-liverpool-care-pathway/
- Physical. Common physical symptoms include pain, fatigue, loss of appetite, nausea, vomiting, shortness of breath, and insomnia.
- Emotional and coping. Palliative care specialists can provide resources to help patients and families deal with the emotions that come with a cancer diagnosis and cancer treatment. Depression, anxiety, and fear are only a few of the concerns that can be addressed through palliative care.
- Spiritual. With a cancer diagnosis, patients and families often look more deeply for meaning in their lives. Some find the disease brings them closer to their faith or spiritual beliefs, whereas others struggle to understand why cancer happened to them. An expert in palliative care can help people explore their beliefs and values so that they can find a sense of peace or reach a point of acceptance that is appropriate for their situation.
http://www.wmcares.org.uk/wmpcp/guide/
For about four decades, pastoral care for spiritual and existential beliefs of patients in a palliative phase has been of paramount importance. Cicely Saunders’ so-called ‘‘total pain concept’’ explicitly recognizes the spiritual and existential dimension of pain along with the somatic, psychological and social aspects. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2785892/pdf/11017_2009_Article_9121.pdf
An all-island gateway to palliative care information
The website is aimed at health and social care professionals, academics,
researchers and educationalists in the palliative care field on the
island of Ireland. http://www.professionalpalliativehub.com/homepage
ELDAC has produced factsheets that provide a general introduction about ELDAC and the different ways that ELDAC can help you as an individual, service, or facility.
https://www.eldac.com.au/tabid/5092/Default.aspx#LM
GP practices have a unique role in coordinating and giving good quality end of life care.
The Leadership Alliance for the Care of Dying People, which included CQC, agreed five priorities for the care of the dying person:
- The possibility that a person may die within the coming days or hours is recognised and communicated clearly, decisions about care are made in accordance with the person’s needs and wishes, and these are reviewed and revised regularly.
- Sensitive communication takes place between staff and the person who is dying and those important to them. Training in communication, person centred approach and symptom control and services available is needed to improve care for all.
- The dying person, and those identified as important to them, are involved in decisions about treatment and care. GPs should support people to make choices about their preferred place of death.
- The people important to the dying person are listened to and their needs are respected.
- Care is tailored to the individual and delivered with compassion – with an individual care plan in place. GPs should coordinate making and following an individualised care plan. Care plans should ideally be owned by the patient but recognised in all settings.
http://www.palliativecarebridge.com.au/resources/end-of-life-resource-booklet
Spiritual support is a highly skilful activity. It requires education and experience in spiritual support. Sufficient information is provided in this section to guide readers on spiritual support. It is imperative that the caring team observes the following during healthcare interventions:
If a member of the caring team feels incapable to respond to a particular situation of spiritual need, he or she should enlist the services of an appropriate individual.
- Do not impose personal beliefs (or lack of them) on patient or families.
- Respond to patient's expression of need with a correct understanding of their background.
- Be sensitive to patient's signal for spiritual and psychological support.
http://www.jpalliativecare.com/article.asp?issn=0973-1075;year=2007;volume=13;issue=2;spage=32;epage=41;aulast=Narayanasamy#Spiritual%20Needs
As a patient nears the end of life,
a holistic approach is recommended.
This approach involves
early identification
of those likely to be
in the last few months of life,
discussion of end of life issues
with patients and those close to them
and provision of high quality care.
The process continues after death
with support for those left behind
as well as reflective practice
and audit for the practice team.
a holistic approach is recommended.
This approach involves
early identification
of those likely to be
in the last few months of life,
discussion of end of life issues
with patients and those close to them
and provision of high quality care.
The process continues after death
with support for those left behind
as well as reflective practice
and audit for the practice team.
https://www.rcgp.org.uk/clinical-and-research/resources/toolkits/palliative-and-end-of-life-care-toolkit.aspx
Patient Management
Assessment and management of physical symptoms is a major focus of palliative care,
as poorly controlled pain or nausea can seriously affect a patient's
quality of life. It can also reduce their ability to maintain physical
functioning which then affects all aspects of their daily life.
https://www.caresearch.com.au/caresearch/tabid/132/Default.aspx
CPCRE - End of Life Pathways
Links
https://www.health.qld.gov.au/cpcre/eol_pthwys_lnks
A
carer is someone who is supporting a relative, friend or neighbour who
cannot manage without help due to illness or disability.
http://www.calderdale-carers.co.uk/
Resources Most modules include information about helpful website resources. Here is a full list for your convenience.
https://www.caresearch.com.au/tel/tabid/4658/Default.aspx
The National Guidelines for Spiritual Care in Aged Care project
https://meaningfulageing.org.au/national-guidelines-for-spiritual-care-in-aged-care-documents/
National Palliative Care Strategy
https://www.safetyandquality.gov.au/publications-and-resources/resource-library/national-palliative-care-strategy
https://web.archive.org/web/20210130122755/https://journals.viamedica.pl/advances_in_palliative_medicine/article/download/35095/25518
CPCRE - End of Life Pathways
Links
- Liverpool Care Pathway https://web.archive.org/web/20121106014748/http://www.mcpcil.org.uk/mcpcil/liverpool-care-pathway/
- Palliative Care Australia http://www.pallcare.org.au
https://www.health.qld.gov.au/cpcre/eol_pthwys_lnks
http://www.calderdale-carers.co.uk/
Resources Most modules include information about helpful website resources. Here is a full list for your convenience.
https://www.caresearch.com.au/tel/tabid/4658/Default.aspx
The National Guidelines for Spiritual Care in Aged Care project
https://meaningfulageing.org.au/national-guidelines-for-spiritual-care-in-aged-care-documents/
https://www.safetyandquality.gov.au/publications-and-resources/resource-library/national-palliative-care-strategy
Depo corticosteroids
like triamcinolone acetonide
or methylprednisolone acetate
may be useful in the treatment
of some conditions in palliative care.
Although the drugs are injected locally
and exercise their effect locally,
their toxicity may be systemic.
Especially the first two weeks after injection
patients are prone to adrenal suppression
which may blunt hormonal stress response
during infection.
Other toxicities may be rare,
but significant in Palliative Care population.
Some patients may be more susceptible
for steroid toxicity
and they either should be warned about this
or the treatment should be postponed.
like triamcinolone acetonide
or methylprednisolone acetate
may be useful in the treatment
of some conditions in palliative care.
Although the drugs are injected locally
and exercise their effect locally,
their toxicity may be systemic.
Especially the first two weeks after injection
patients are prone to adrenal suppression
which may blunt hormonal stress response
during infection.
Other toxicities may be rare,
but significant in Palliative Care population.
Some patients may be more susceptible
for steroid toxicity
and they either should be warned about this
or the treatment should be postponed.
https://web.archive.org/web/20210130122755/https://journals.viamedica.pl/advances_in_palliative_medicine/article/download/35095/25518
Seven principles of the Palliative Care Program:
- People with a life-threatening illness and their carers and families have information about options for their future care and are actively involved in those decisions in the way that they wish
- Carers of people with a life-threatening illness are supported by health and community care providers
- People with a life-threatening illness and their carers and families have care that is underpinned by the palliative approach
- People with a life-threatening illness and their carers and families have access to specialist palliative care services when required
- People with a life-threatening illness and their carers and families have treatment and care that is coordinated and integrated across all settings
- People with a life-threatening illness and their carers and families have access to quality services and skilled staff to meet their needs
- People with a life-threatening illness and their carers and families are supported by their communities.
Stroke care strategy for Victoria
https://www2.health.vic.gov.au/Api/downloadmedia/%7B012C7C05-3760-49A2-A19D-391DA710D5A7%7D
Clinical Triggers for PCMH Referral to Palliative Care
- 1) Chronic or persistent pain or symptoms (e.g., dyspnea) requiring long-term management;
2) Cancer with metastasis or without any available curative or life-prolonging therapies;
3) Dementia causing inability to perform two or more ADLs;
4) Two or more hospitalizations and/or emergency visits for the same serious condition within six months;
5) Multiple serious illnesses or any single serious illness which remains symptomatic despite maximal treatment;
6) Despite medical treatment, continued oxygen dependency, shortness of breath or adverse cardiac symptoms brought on by exertion;
7) Unintentional and consistent weight loss over six to twelve months;
8) Serious illness necessitating significant and ongoing supervision or caregiving by others;
9) Patient, family or physician uncertainty regarding the appropriateness, usefulness or desirability of available treatment options;
10) In the absence of any of the foregoing and using holistic medical judgment, would the primary care physician be surprised if the patient died within eighteen months?
Saf-T-Intima 24 Gauge Subcutaneous Needle
A wise person once said,
“To care for a patient requires a whole person,
until you find one, use a team”.
Palliative Care is a team approach
to patient care that utilizes the services
of experts in symptoms,
physical as well as emotional and spiritual,
as they are needed for each individual
as well as their family,
or support system.
At the least the team includes
a physician, nurses, social workers and clergy.
A patient’s primary doctor may refer
a patient for Palliative Care,
not as default,
but to add to the existing medical team,
to improve the patient’s experience.
Patients and families also may
request referral to Palliative Care,
which is available in most health organizations,
either as an inpatient consult service
or an outpatient service.
There are many visiting nurse (VNA) programs
that also can provide ‘palliative care’
to homebound patients.
Once a patient is referred,
an initial assessment is often made
by a physician/advanced practice nurse,
and then a team is assembled
based on the specific needs
of that patient at that time.
As nothing in life is stagnant,
this team ‘walks with the patient and family’
and continues to readdress needs as they arise,
always focusing on how to make each day
the ‘best it can be, one day at a time’.
Ookay kan, Bro!
IKA SYAMSUL HUDA MZ
