(Ika - 2021)
SHIFT TO FOCUS ON COMFORT CARE:
General considerations
Discontinue unnecessary prescriptions, monitoring activities, and procedures. Consider stopping anything that doesn’t focus on comfort and alleviating symptoms/distress unless there is a good reason to continue it. Common areas that require review include:
☛ I/V fluids, antibiotics, s/c heparin, insulin, enteral nutrition & TPN.
☛ O2 masks and nasal prongs unless clear symptom benefit.
☛ Stop blood and radiological tests.
☛ Stop monitoring vital signs including oxygen saturation, fluid balance etc.
☛ Deactivate ICDs and remove cardiac monitors.
☛ Ensure DNACPR order signed / EWS stopped.
ENVIRONMENT:
General Physical environment:
☛ Where possible a quiet, peaceful environment is preferable.
☛ Minimise loud noises and bright lights (delirium is not uncommon in last days/hours of life).
Bedside environment:
☛ Calm, reassuring bedside presence.
☛ Inform patient (even if unresponsive) who you are and what you are doing or about to do.
PSYCHOLOGICAL / SPIRITUAL CARE:
Insight:
☛ Where appropriate, patient insight should be assessed and fears / wishes explored.
☛ Consider if formal pastoral care support needed / rituals which are important to patient & family.
PHYSICAL CARE:
Respiratory Secretions:
☛ Explain to family & reassure that it may not represent discomfort.
☛ Re-positioning patient on side may help.
☛ Assess need for pharmacological intervention.
☛ Suctioning is rarely useful or indicated in last hours/days of life and has all the associated infection risks of an aerosol-generating procedure (AGP). It should be avoided where possible.
☛ For AGP and PPE guidance refer to https://www.hpsc.ie
Bowel care:
☛ Invasive procedures for bowel care rarely needed when imminently dying.
Urinary care:
☛ Catheterise if in urinary retention or incontinence likely to cause loss of skin integrity or aids the general comfort level of patient.
Mouth care:
☛ Ensure mouth and lips are clean and moist.
☛ Regularly moisten oral cavity with sips of water /water-based gel when able to swallow or with moist mouth sponge when unable.
Food and fluid:
☛ Continue to offer variety of soft foods / sips of water through teaspoon / straw while conscious, able to sit up, and as appropriate.
☛ Accept when patient unable/declines to take as this is natural part of dying. Never force.
General comfort:
☛ Repositioning, regular turning 2 – 4 hourly to prevent pressure sores.
☛ Regular skin and eye care.
SOCIAL / FAMILY CARE
*Physical presence will depend on infection control protocols
☛ Explain to family that death is approaching in sensitive yet clear way.
☛ Explain focus of care is on comfort and dignity.
☛ Explain the expected changes in physical and cognitive function as this will relieve distress for family.
☛ Check previous experiences and understanding of dying as it may allow you to correct misunderstandings.
QUESTIONS FAMILY MEMBERS OFTEN ASK
☛ How long has (s) he got?
“We can’t be certain, but it’s likely to be within a few hours or days at most. What would you like for her?”
☛ Can (s)he still hear?
“We don’t know for sure but if you would like to say something, now is the time “
☛ How will you know if (s)he has pain?
“We will watch carefully for signs of distress. We will give whatever medication is needed to keep him/her pain free and comfortable”
☛ Is (s)he dying of dehydration or starvation?
“At this time, all of the vital organs including his heart and kidneys are shutting down. His/her body cannot cope with food or fluid right now.”
Version 6. 14.4.20
Refer to https://hse.drsteevenslibrary.ie for most up to date information.
This guidance document was developed by the National Palliative Care Clinical Programme in accordance with HPSC guidance, https://www.hpsc.ie
Source:
SPECIALIST PALLIATIVE CARE MULTIDISCIPLINARY TEAM MEETINGS
When you have been referred
to a specialist care team,
your care may be discussed
at a weekly multidisciplinary team meeting
known generally as an MDT.
The aim of the meeting
is for all of the different people
who are looking after you
to discuss your diagnosis,
treatment
and care
and to plan
a way forward for you
and your family.
The MDT consists
of people who are experts
in different areas
of palliative medicine
and care.
You may not have
direct contact with all members
of the team
but they will be involved
in planning your care.
The team will ensure
that you are given
the most appropriate care
and treatment
at all stages
of your illness
and will keep you
informed of decisions made
about your care.
A typical team may include:
- ☛ A doctor who is a specialist in palliative medicine
- ☛ Team administrator or secretary
- ☛ Palliative care clinical nurse specialist
- ☛ Palliative care social worker
- ☛ A member of the psychology services
- ☛ A physiotherapist or occupational therapist
- ☛ A member of a spiritual support team
GP surgeries hold MDTs
on a monthly basis
and work with primary
and specialist palliative care teams
to ensure
your care is monitored
where appropriate.
There are four main ways to provide Specialist Palliative Care:
- ☛ Inpatient hospice and specialist palliative care units
- ☛ Hospital – based services, where multi-disciplinary palliative teams work with patients in wards and clinics;
- ☛ Community teams, which provide specialist advice and work alongside a patient’s own GP practice teams enabling specialist care to be provided in the patient’s home or care home;
- ☛ Day care, which enables patients to continue living at home while having access to day facilities provided by a multi-disciplinary health and social care team.
https://web.archive.org/web/20200915123533/https://thepalliativehub.com/what-is-palliative-care/#
Specialist Palliative Care is largely inappropriate for:
- ☛ Patients with chronic stable disease or disability with a life expectancy of several years.
- ☛ Patients with chronic pain problems not associated with progressive terminal disease.
- ☛ Competent patients who decline referral
- ☛ Patients who are unaware of their underlying disease (unless this is a cultural preference in which case this needs to be sensitively addressed).
- ☛ Those patients whose problems are principally psychological and need specialist psychiatric referral, whether or not they have declined such help.
Like hospice, palliative care provides:
☛ Improved pain and symptom management
☛ Careful attention to quality of life
☛ Fresh look at medical goals and priorities
☛ Opportunity to consider life closure
☛ Multidisciplinary approach
☛ Focus on patient and family
Unlike hospice, palliative care does not require:
☛ Forgo active treatment of underling disease
☛ Forgo acute hospitalization
☛ Accept palliation as primary goal of treatment
☛ Accept a 6 month or less prognosis
When to discuss palliative care:
☛ Would you be surprised if patient died this hospitalization?
- Patient imminently dying
- Significant suffering and poor prognosis
☛ Would you be surprised if patient died in 6 months?
- Significant suffering regardless of prognosis
- Patients who fear future pain and suffering
- All patients with possibly life threatening illness
PALLIATIVE CARE EMERGENCIES
Palliative care emergencies are
sudden life-threatening
changes in a patient’s condition that,
without an adequate response,
will result in deterioration
in that person’s health
or quality of life.
Some patients can be identified
as higher risk
because of the nature of their disease,
and emergency situations
can be anticipated
and planned for.
In these circumstances
the patient’s wishes
can be ascertained
and the response required
to meet the patient’s wishes
can be discussed
and incorporated
into the Advance Care Plan.
It is important
to explore the benefits,
burdens
and limits
of acute treatments.
Palliative care emergencies include:
☛ hypercalcaemia
☛ malignant spinal cord compression
☛ superior vena cava obstruction
☛ terminal agitation
☛ raised intracranial pressure
☛ catastrophic bleeding
☛ seizures
☛ stridor
However,
it should be noted
that patients who
have advanced disease
can be more susceptible
to any type of medical emergency.
Their physiological reserve
is often poor
and special attention needs
to be given to their underlying disease.
Communication
with the patient
and their families
is key in these circumstances.
Things we do not want to miss!
The most common emergencies in palliative care are:
1. Hypercalcaemia
2. Spinal cord compression (SCC)
3. Superior vena cava obstruction (SVCO)
4. Dyspnoea
5. Seizures
6. Haemorrhage
7. Psychiatric emergencies
8. Acute anxiety and delirium
9. Hypoglycaemia
10. Increased intracranial pressure
11. Cardiac tamponade
12. Drug toxicity/side effects.
GLOBAL ATLAS OF PALLIATIVE CARE AT THE END-OF-LIFE
The Atlas addresses a number of key questions:
1. What is palliative care?
2. Why is palliative care a human rights issue?
3. What are the main diseases requiring palliative care?
4. What is the need for palliative care?
5. What are the barriers to palliative care?
6. Where is palliative care currently available?
7. What are the models of palliative care worldwide?
8. What resources are devoted to palliative care?
9. What is the way forward?
https://pubmed.ncbi.nlm.nih.gov/28797861/
https://www.who.int/nmh/Global_Atlas_of_Palliative_Care.pdf
http://www.thewhpca.org/resources/global-atlas-on-end-of-life-care
One-pager guideline for the duration of Covid-19
Adherence to guideline recommendations will not ensure a successful outcome in every case.
For more detailed guidance,
suggest https://www.palliativecareguidelines.scot.nhs.uk
AND/OR contact specialist palliative care team for advice.
It is the responsibility of all professionals to exercise clinical judgement in the management of individual patients.
In the event of a patient unexpectedly stabilising / improving, reconsider the diagnosis of ‘dying’.
This guideline is for all healthcare professionals.
Okay kan, Bro!
IKA SYAMSUL HUDA MZ
