Palliative care is both a philosophy of care
and a highly organized system
for delivering care.
Goal is to assure that each person experiences
the best quality of life
throughout the illness trajectory.
Palliative Care Outcomes Collaboration (PCOC)
Every patient has the right to effective treatment and management for pain and symptoms. In addition to palliative outcomes and profile programs, PCOC uses five clinical assessment tools to help identify and manage these common symptoms.
https://www.uow.edu.au/ahsri/pcoc/palliative-care/assessment-forms/
The Specialist Palliative Care teams consist
of healthcare professionals with experience
in this area of care.
These can include:
• Doctors
• Nurses
• Social Workers
• Benefits Advisors
• Physiotherapists
• Occupational Therapists
• Secretaries
• Pharmacists
• Psychologists
• Chaplaincy Team
• Complementary Therapists
• Ethnic Liaison Workers for South Asian patients
Improving Care at the End of Life:
Creating Hospice in Place
https://doi.org/10.4037/ccn2017228
Pain
Paracetamol (PR dose) or diclofenac (as SC) for pain or high temperature.
If prescribed regular oral opioids and the oral route is no longer reliable, convert the total 24 hour oral morphine or oxycodone dose to a 24 hour SC infusion, for example:
- oral morphine 30mg ≈ SC morphine 15mg ≈ SC diamorphine 10mg
- oral oxycodone 15mg ≈ SC oxycodone 7mg–8mg
FORMULARY AND GUIDELINES FOR MANAGEMENT
https://www.thurrockccg.nhs.uk/about-us/document-library/medicines-management/end-of-life-formulary/1558-end-of-life-formulary/file
The Dying Process
https://palliativecare.org.au/resources/the-dying-process
https://palliativecare.org.au/wp-content/uploads/dlm_uploads/2018/10/PCA_The-Dying-Process.pdf
http://www.grpcc.com.au/wp-content/uploads/2018/11/Medication-Guidelines-Algorithm-Final-3.9.18.pdf
New Ontario Palliative Care Network
https://www.ontariopalliativecarenetwork.ca/en
Palliative care enhances the quality of life of people with a life-limiting illness.
It may include:
- Help with decisions about treatments
- Expert medical care to help with pain and other symptoms at home or in hospital
- End-of-life care
- Social, psychological, emotional and spiritual support
- Support for family, friends and caregivers
- Information about financial, legal and other services
- Bereavement support
http://rcnendoflife.org.uk/symptom-management/
Palliative Care Knowledge Zone
https://www.mariecurie.org.uk/professionals/palliative-care-knowledge-zone
Palliative Care Care for Adults With a Progressive, Life-Limiting Illness
https://www.hqontario.ca/evidence-to-improve-care/quality-standards/view-all-quality-standards/palliative-care
Palliative Cancer Care Guidelines
https://emedicine.medscape.com/article/2500043-overview#showall
End-Of-Life Care - Guidelines
Palliative Sedation of Terminally ill Patients
- Drugs may be administered by intravenous, subcutaneous, oral (until the patient loses consciousness), enteral, sublingual, and rectal routs, depending on the route that has been used.
- The initial dose of sedatives may be small, with the patient able to communicate regularly. Dose of medication should be increased gradually as needed.
- Midazolam: 0.5-0.7 mg/kg, followed by infusion of 0.5-2 mg/h IV or 10 mg followed by 1-6 mg/h subcutaneously.
Everyone’s experience of dying is different, and some people will die suddenly or unexpectedly. But in most cases, there are some signs that can help you to recognise when someone is entering the terminal phase. These include:
- getting worse day by day or hour by hour
- reduced mobility, or becoming bed-bound
- extreme tiredness and weakness
- needing assistance with all personal care
- little interest in getting out of bed little
- interest in food or drink
- difficulty swallowing oral medication
- being less able to communicate
- not wanting to socialise
- sleepiness and drowsiness
- reduced urine output
- new incontinence
- increased restlessness, confusion, and agitation
- changes in their normal breathing pattern
- noisy chest secretions
- mottled skin and feeling cold to the touch
- the person may tell you that they feel as if they are dying
A person in their last days of life may not have
all of these signs but they might have a few at once. Just having one or
two of these signs makes it less likely that they are approaching their
last days.
https://www.mariecurie.org.uk/professionals/palliative-care-knowledge-zone/final-days/recognising-deterioration-dying-phase
NICE - End of life care
https://sites.google.com/view/endoflifecareforadults/nice-end-of-life-care
https://www.helpguide.org/articles/end-of-life/late-stage-and-end-of-life-care.htm
http://palcare.streamliners.co.nz/
End of Life Issues
https://medlineplus.gov/endoflifeissues.html
https://web.archive.org/web/20191223004409/https://www.chpca.net/media/319547/norms-of-practice-eng-web.pdf
ANOREXIA/CACHEXIA SYNDROME (ACS)
- loss of body weight,
- decrease of appetite,
- reduction in the level of energy,
- fatigue,
- weakness,
- chronic nausea,
- early satiety,
- change in body image,
- psychological distress.
Source: Oxford Textbook of Palliative Medicine, 3rd Edition
Opioid dose conversion guide - Approximate Equivalence Tables
https://book.pallcare.info/index.php?tid=125&searchstring=opioid%20potency
Neuropathic pain responds poorly to opiates and NSAIDs; current NICE guidelines for the management of neuropathic pain advocate the use of duloxetine, amitriptyline (or nortriptyline), or gabapentoids as fi rst-line treatment.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4952837/pdf/416.pdf
- examples include
- daily dose of oxycodone < 10 mg, or equivalent, over previous 14 days
- total opioid use ≤ 7 days over previous 60 days
- not filling opioid prescription for ≥ 6 months
- not filling opioid prescription for ≥ 12 months
https://book.pallcare.info/index.php?tid=23&dg=9
Intersection of Palliative Care and Spiritual Care
https://palliativecarenetwork.com/resources/?cat=intersection-of-palliative-care-and-spiritual-care
WHAT IS SPIRITUALITY?
Here are some common themes to help us better understand concept of spirituality:
1. Relationship to God, a spiritual being, a Higher Power or reality greater than self
2. Not of the self
3. Transcendence or connectedness unrelated to a belief in a higher being
4. Existential, not of the material world
5. Meaning and purpose in life
6. Life force of the person, integrating aspect of the person
7. Summative definitions that combines multiple themes
The essence of spirituality in a sample of terminally ill as 4 major themes:
1. Communion with self (self-identity, wholeness, inner peace)
2. Communion with others (love, reconciliation)
3. Communion with nature (inspiration, creativity)
4. Communion with a higher being (faithfulness, hope, gratitude)
It is powerful to consider this aspect of your patient, as these qualities constitute who this person is.
As primary doctors we aim to learn about our patient as a whole and how they interpret, interact, and deal with the world.
This will affect how they deal with and interact with you as their doctor and with their health care decision making.
https://pubmed.ncbi.nlm.nih.gov/31375189/
Gold Standards Framework (GSF) in primary care was developed originally back in 1998, to enable GPs and Primary Care Teams to provide top quality care for all people in their final year of life, with any condition, in any setting, at any time.
http://www.goldstandardsframework.org.uk/primary-care-training-programme
Syringe drivers are often required to provide medicines for symptom management in patients who are terminally ill. They provide continuous subcutaneous administration of medicines to enable effective symptom control when medicines given by other routes are inappropriate or no longer effective.
End-Stage Indicators
https://www.montgomeryhospice.org/health-professionals/end-stage-indicators/end-stage-indicators
http://www.palliativecare.bradford.nhs.uk/Pages/WhatIsPalliativeCare.aspx
https://www.sueryder.org/how-we-can-help/sue-ryder-manorlands-hospice
https://www.bradfordhospitals.nhs.uk/palliative-care/
https://www.bdct.nhs.uk/services/palliative-care/
http://www.palliativecare.bradford.nhs.uk/Pages/UsefulLinks.aspx
http://www.bowelcanceruk.org.uk/
http://www.breastcancercare.org.uk/
http://www.breastcancerhaven.org.uk/
http://www.bristolcancerhelp.org/
http://www.brit-thoracic.org.uk/
http://www.dyingmatters.org/
http://www.hda.org.uk/
http://www.helpthehospices.org.uk/
http://www.hospiceinformation.co.uk/
http://www.macmillan.org.uk/
http://www.mariecurie.org.uk/
http://www.meriyaadain.co.uk/
http://www.mndassociation.org.uk/
http://www.mssociety.org.uk/
http://www.ncpc.org.uk/
http://www.nhs.uk/Planners/end-of-life-care/Pages/what-is-end-of-life-care.aspx
http://www.nwyhelearning.nhs.uk/elearning/yorksandhumber/shared/DNACPR/DNACPR_260515_sm_720p.mp4
http://www.orchid-cancer.org.uk/
http://www.palliativecare.bradford.nhs.uk/http://www.prostate-cancer.org.uk/
http://www.roycastle.org/
http://www.suerydercare.org/
http://www.togetherforshortlives.org.uk/
http://www.yorkshire-cancer-net.org.uk/
Patients are considered frail
if they have three or more of the following five criteria:
• Reduced activity
• Slowing of mobility
• Weight loss
• Diminished handgrip strength
• Exhaustion
The principles of end-of-life care are
applicable to frail individuals
with progressive conditions
from the time of diagnosis throughout
the course of decline.
As the population ages,
more people suffer and die
from progressive chronic conditions
such as cerebrovascular disease,
respiratory disease, and dementia.
An interdisciplinary team approach can
ensure all components of palliation are
effectively delivered,
such as easing symptoms,
providing psychosocial
and spiritual support,
and improving quality of life.
https://www.ccjm.org/content/80/3/168
Advance care planning is defined as discussing and planning for care in the future when the person may no longer have decision-making capacity.
https://training.caresearch.com.au/learner/assessment/view/id,10221/p,submit/qid,submit
Okay kan, Bro!
IKA SYAMSUL HUDA MZ
