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- Metastatic cancer
- Any diagnosis of end-stage organ failure (eg, congestive heart failure, chronic obstructive pulmonary disease, chronic renal failure) with increasing disability, frequent hospitalisation, and/or decreasing benefit from therapies
- Advanced degenerative neurological conditions.
A palliative approach should be considered for any patient when you would not be surprised if they died within the next twelve months, ie, the 'surprise' question.
The answer to this question should be an intuitive one, pulling together a range of clinical, co-morbidity, social and other factors that give a whole picture of deterioration. If you would not be surprised, then what measures might be taken to improve the patient’s quality of life now and in preparation for possible further decline?
https://www.caresearch.com.au/caresearch/tabid/1507/Default.aspxThe answer to this question should be an intuitive one, pulling together a range of clinical, co-morbidity, social and other factors that give a whole picture of deterioration. If you would not be surprised, then what measures might be taken to improve the patient’s quality of life now and in preparation for possible further decline?
Identification
Earlier identification of those individuals who may be in the last year of their life leads to earlier planning and better care. Appropriate supportive care measures can be introduced which enables earlier discussion of the person’s wishes, improves care which is aligned to their preferences and leads to fewer crises.
https://bit.ly/2ZayYfA
Research shows certain thingscan act as ‘triggers’ which
indicate that a palliative care
approach is appropriate,
such as when someone…
1. …has complex or persistent
problems with managing
symptoms such as pain or
breathlessness
2. …has high levels of
unplanned hospital use
3. …has more than one
condition to manage
4. …has changes in eating
habits and nourishment
5. …has new clinical
interventions introduced
6. …is diagnosed with a
particular condition
7. …has high levels of palliative
care needs as indicated by an
appropriate screening tool
https://www.mariecurie.org.uk/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4696032/The palliative care population as seriously ill patients and those with advanced disease (such as persons living with advanced cancer or intensive care unit patients at high risk of dying), who are unlikely to be cured, to recover, or to stabilize.
Uncoordinated or ineffective carehttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC4696032/
creates an undue burden on the already physically, mentally, and emotionally taxing experience of suffering with advanced and serious illness.
Pain at the end of life is something that many people worry about. Not everyone gets pain. And with the right treatment and support, pain can usually be managed. Tell the doctor or nurse about any pain. They’ll look at medicines or other ways to help manage the pain.
https://www.mariecurie.org.uk/
The general public has a better understanding of the value of ACP, including how to:
- * have conversations about preferences for care
- * access and complete relevant forms
- * make ACP available to health, community and aged care providers
- * advocate for appropriate care.
The meticulous and comprehensive assessment and management of pain and other physical symptoms, as well as social, spiritual, psychological, and cultural aspects of care, are critically important as the patient nears death.
https://www.ascopost.com/- 1.☛ Opioids are very good analgesics for acute pain and for pain at the end of life but there is little evidence that they are helpful for long term pain.
- 2.☛ A small proportion of people may obtain good pain relief with opioids in the long-term if the dose can be kept low and especially if their use is intermittent (however it is difficult to identify these people at the point of opioid initiation).
- 3.☛ The risk of harm increases substantially at doses above an oral morphine equivalent of 120mg/day, but there is no increased benefit: tapering or stopping high dose opioids needs careful planning and collaboration.
- 4.☛ If a patient has pain that remains severe despite opioid treatment it means they are not working and should be stopped, even if no other treatment is available.
- 5.☛ Chronic pain is very complex and if patients have refractory and disabling symptoms, particularly if they are on high opioid doses, a very detailed assessment of the many emotional influences on their pain experience is essential.
Opioid-induced constipation is costly for the healthcare system and decreases patients’ quality of life. Common barriers to diagnosing it include:
- ☛ Lack of clinician awareness;
- ☛ Lack of communication with patients;
- ☛ Patients not disclosing their symptoms because they feel ashamed;
- ☛ The absence of a universal diagnostic tool
Subcutaneous Drug Administration in Palliative care
https://bit.ly/SubcutaneousDrugPC
Intravenous (IV) injections should be avoided because they are invasive and no more effective than the subcutaneous route. Intramuscular injections should be avoided, as they are painful, particularly in patients who are cachectic.
Note: The SC route will not give better analgesia than the oral route unless there is a problem with absorption or administration.
Common indications for use are:
☛ dysphagia
☛ decreased level of consciousness
☛ intestinal obstruction
☛ severe nausea and vomiting
☛ agitated delirium
☛ poor absorption of oral medications
☛ severe oral lesions
http://cdhb.palliativecare.org.nz/Subcutaneous%20Bolus%20Administration.pdf
Inappropriate sites include:
- • lymphoedematous or ascitic areas
- • areas where there is broken skin
- • areas that have recently been irradiated
- • areas with infection
- • bony prominences
- • in close proximity to a joint
- • areas with tumours
- • skin folds
- • the anterior chest wall in cachetic patients
- • areas of inflammation
- • areas with extensive scarring
Palliative Care in New Zealand. Wellington: Ministry of Health).
- The subcutaneous infusion of fluids, or hypodermoclysis, can be a useful method for correcting mild to moderate dehydration, particularly in the elderly and in palliative care.
- Subcutaneous fluids are most commonly used to maintain hydration in patients who are unable to take adequate fluids orally, to correct mild to moderate dehydration, and in situations where it is difficult or impractical to insert an intravenous line.
• Low cost
• Patient comfort/acceptability
• Simple insertion
• More suitable for community/home care setting
• Reduced complications (e.g. fluid overload, infection).
- To reduce the risk of irritation and other adverse effects, potassium should be sufficiently diluted. , The recommended concentrations of potassium chloride used are variable and range from 10mmol/litre to 40mmol/litre. Concentrations above 40mmol/litre are not recommended for subcutaneous infusion.
- The subcutaneous route is not appropriate for the administration of large amounts of potassium or for treating severe dehydration or severe hypokalaemia.
How to facilitate the family meeting Finally,
it is important to decide who will lead the family meeting, taking into
account who the patient/family may have the strongest therapeutic
relationship with, and to name key roles in the meeting as relevant
(e.g., the surgical consultant will be sharing the news that the
patient is no longer a surgical candidate, or the oncologist will be
reviewing chemotherapy options and outcomes). Often the leader is a
physician or an advanced practice nurse, especially if biomedical facts
are being shared, but this depends on institutional culture and the
purpose of the family meeting.
https://www.mypcnow.org/wp-content/uploads/2019/03/Core-Specialty-Palliative-Care-Teams.pdf
Specialist palliative care (SPC) has expanded since it’s origins and
not only supports patients where required at end of life but also
supports symptom control in potentially life-limiting conditions. The
emphasis of the speciality has always been on holistic care of the
patients. Patients may be referred with any life-limiting condition, be
that a form of cancer or non-cancer.
https://www.gloshospitals.nhs.uk/our-services/services-we-offer/end-life-palliative-care/Figures and tables from each chapter are available to view or download below. https://bit.ly/3fS8g19
Top 10 Things Palliative Care Clinicians Wished Everyone Knew About Palliative Care
- 1. Palliative care can help address the multifaceted aspects of care for patients facing a serious illness
2. Palliative care is appropriate at any stage of serious illness
3. Early integration of palliative care is becoming the new standard of care for patients with advanced cancer
4. Moving beyond cancer: palliative care can be beneficial for many chronic diseases
5. Palliative care teams manage total pain
6. Patients with a serious illness have many symptoms that palliative care teams can help address
7. Palliative care can help address the emotional impact of serious illness on patients and their families
8. Palliative care teams assist in complex communication interactions
9. Addressing the barriers to palliative care involvement: patients’ hopes and values equate to more than a cure
10. Palliative care enhances health care value
The symptoms listed below are common symptoms we see in our DIPG patient population that increase from the time of progression to the end of life affecting their quality of life. Listed below are explanations and suggestions for intervention.
https://dipgregistry.org/physicians/symptom-management-and-palliative-care/https://www.nice.org.uk/guidance/ng31/chapter/Recommendations#recognising-when-a-person-may-be-in-the-last-days-of-life
- Assess what medicines the person might need to manage symptoms likely to occur during their last days of life (such as agitation, anxiety, breathlessness, nausea and vomiting, noisy respiratory secretions and pain). Discuss any prescribing needs with the dying person, those important to them and the multiprofessional team.
- Ensure that suitable anticipatory medicines and routes are prescribed as early as possible. Review these medicines as the dying person's needs change.
The message of palliative care is that whatever the disease, however advanced it is, whatever treatments have already been given, there is always something which can be done to improve the quality of the life remaining to the patient.
SIDE EFFECTS OF OPIATES
Side effects of opiates are many and the most notable is constipation, which has an occurrence rate of nearly100%. The nurse should educate patients and caregivers about this side effect. Constipation can be managed by the routine administration of stool softeners. Other common side effects such as nausea and sedation will subside within 3 to 7 days as the patient begins to tolerate the medication. It is important for the nurse to educate the patient and family that these are not allergic reactions to the medications and that true allergies to opiates are not common occurrences.
https://web.archive.org/web/20201002131206/http://www.rn.org/courses/coursematerial-152.pdf
These guidelines
are one of many resources available to health care professionals in
Fraser Health to improve health care outcomes in hospice
palliative/end-of-life care.
https://www.fraserhealth.ca/employees/clinical-resources/hospice-palliative-care#.XgUbqRsxW00
Ooookay kan, Bro!
