Palliative care is not about healing,https://www.akademienunion.de/fileadmin/
but about providing comprehensive care and support to those with incurable, life-threatening diseases. The intention is for palliative care to envelop patients and their families like a cloak (lat. pallium = mantle). Finding a satisfactory means of achieving this is a major challenge facing society.
The work of palliative care can be sub-divided into:
(i) biological aspects: pain and symptom management;
(ii) psychological and spiritual support: for patients, families, friends, and carers, and after death for the bereaved; and
(iii) communication and decision-making: especially so-called ‘death-talk’.
https://web.archive.org/web/20210624060216/http://www.austlii.edu.au/au/journals/QUTLawRw/2016/2.pdf
BALANCING HOPE AND TRUTH
“There is nothing more we can do,
your disease is incurable,
so there is no point
in staying in hospital”….
Here doctor is totally destroying hope, hence incorrect.
Doctor should try to balance hope and truth as shown below:
“I am sorry
that there are no more treatments
available to cure your disease,
but we can start other medicines
to help you be more comfortable.
Then you can be at home with your family.
If you need any help in the future,
you must come to the clinic or contact me.”
Palliative:
☛ refers to an approach to care, as well as a philosophy of care.
☛ should not be used as a label for patients, nor as a category of patients. A person may have palliative care needs, or they may receive a palliative approach to care.
☛ is not a phase or stage in the illness trajectory, nor a diagnosis. A palliative approach to care is appropriate for any individual and/or family living with a life-limiting illness at any time.
CHALLENGE:
Patient surveys indicate that most of us
or our place of residence,
but in some parts of England and Wales,
fewer than 50% do
because the necessary services are not there
to support them.
Without expanding the resources
in all settings
– whether home, community, hospital, hospice or care home
– we will remain unable to meet
the choices of patients and their families.
https://web.archive.org/save/https://csiweb.pos-pal.co.uk/csi-content/uploads/2021/01/Cicely-Saunders-Manifesto-A4-multipage_Jan2021-2.pdf
Performance Status and Functional in Palliative Care
https://bit.ly/PerformanceStatusPC
Reluctance to refer among clinicians:
- Fear of upsetting patients who are comforted by the familiarity of their family doctor
- Not wanting to be perceived as giving up on or abandoning patients
- Seeing referral as an admission of failure in looking after a patient, and
- Low awareness of the potential benefits to patients and caregivers.
https://www.vitas.com/hospice-and-palliative-care-basics/about-palliative-care/hospice-vs-palliative-care-whats-the-difference/
This care can focus on:
- controlling symptoms
- independence
- emotional, spiritual and cultural wellbeing
- planning for the future
- caring for patient's family and carers.
Many people think that palliative care is only provided in the last weeks and months of life, when curative treatments are no longer available. A palliative approach to care can help people early in their illness. It can start at diagnosis, when treatments are taking place and there may still be many months and years left to live.
Palliative care 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
- Occupational therapy, physiotherapy and social work
- Music therapy
- Support for family, friends and caregivers
- Trained volunteers to visit with patients
- Information about financial, legal and other services
- Bereavement support
- Hampir 25% pasien yang segera akan meninggal dunia, dalam 30 hari terakhirnya masih menerima pengobatan terapi radiasi.
- Apakah terapi radiasi pada pasien penyakit terminal kanker seperti itu masih dibutuhkan?
- Untuk pasien dalam minggu-minggu terakhir kehidupan, efek samping dan gangguan radioterapi paliatif mungkin lebih besar daripada manfaatnya, dan perawatan paliatif holistik mungkin lebih tepat.
https://www.bmj.com/content/bmj/360/bmj.k821.full.pdf
IN PALLIATIVE CARE, THESE 10 FACTORS MATTER MOST
- Palliative care and hospice patients receive a comprehensive assessment (physical, psychological, social, spiritual and functional) soon after admission.
- Seriously ill palliative care and hospice patients are screened for pain, shortness of breath, nausea, and constipation during the admission visit.
- Seriously ill palliative care and hospice patients who screen positive for at least moderate pain receive treatment (medication or other) within 24 hours.
- Patients with advanced or life-threatening illness are screened for shortness of breath and, if positive to at least a moderate degree, have a plan to manage it.
- Seriously ill palliative care and hospice patients have a documented discussion regarding emotional needs.
- Hospice patients have a documented discussion of spiritual concerns or preference not to discuss them.
- Seriously ill palliative care and hospice patients have documentation of the surrogate decision-maker’s name (such as the person who has healthcare power of attorney) and contact information, or absence of a surrogate.
- Seriously ill palliative care and hospice patients have documentation of their preferences for life-sustaining treatments.
- Vulnerable elders with documented preferences to withhold or withdraw life-sustaining treatments have their preferences followed.
- Palliative care and hospice patients or their families are asked about their experience of care using a relevant survey.
Palliative Care Nursing: Looking Back, Looking Forward
- We will never understands every aspect of one another’s lives, faith, culture, professional requirements, but the most important thing to remember is to ask.
- If we ask and see to understand the reasons why, then we can begin to respond with respect and compassion.
- • Refractory pain and other symptoms.
- • Complex depression, anxiety, grief, and existential or spiritual distress.
- • Conflicts among family and/or healthcare teams regarding treatment and goals of care, as well as difficulty with coping.
- • Questions related to home palliative care or hospice programs.
Health Care Proxy
I have discussed with my agent my wishes
about____________ and I want my agent
to make all decisions about these measures.
Examples of medical treatments about which
you may wish to give your agent special
instructions are listed below:
This is not a complete list: ⤸
• artificial respiration
• artificial nutrition and hydration (nourishment and water provided by feeding tube)
• cardiopulmonary resuscitation (CPR)
• antipsychotic medication
• electric shock therapy
• antibiotics
• surgical procedures
• dialysis
• transplantation
• blood transfusions
• abortion
• sterilization
https://web.archive.org/web/20210103103723/https://www.health.ny.gov/publications/1430.pdf
Four categories of drugs are expected to be related to the terminal illness and related conditions and should be paid for by the hospice.
- Analgesics
- Antiemetics
- Laxatives
- Anti-anxiety meds
“Palliative” Versus “Terminal” Sedation
ANTICIPATORY PRESCRIBING OF ‘JUST IN CASE’ MEDICATION FOR SYMPTOM CONTROL
The following medications are usually provided:
- Opioid: The appropriate drug and dose should be chosen for the individual. Morphine sulphate is the usual drug of choice for subcutaneous (SC) administration, unless the patient is already maintained on an alternative opioid or is in renal failure. Note the highest concentration of injectable morphine sulphate is 30mg/ml therefore a maximum PRN injection dose is 60mg (2mls). Diamorphine should be used for higher doses.
- Antiemetic: The appropriate drug should be chosen for the individual. Tailor the anti-emetic choice based on the likely cause. Haloperidol is the preferred first line anti-emetic unless there is a history of Parkinson’s disease or seizures
- Sedative: midazolam is the usual first line drug for restlessness/anxiety at the end of life. Haloperidol or levomepromazine should be used (instead of midazolam) for delirium/hallucinations.
- Anticholinergic for secretions: hyoscine butylbromide is the first line anti-cholinergic.
https://www.palliativecareguidelines.scot.nhs.uk/guidelines/pain/choosing-and-changing-opioids.aspx
Compound preparations of paracetamol and weak opioids may be useful. Only preparations with higher doses of opioids (codeine 30mg, dihydrocodeine 20-30mg) should be used, as the lower strength preparations produce opioid side effects with little analgesia.
Guideline for the use of symptom control
(West Midlands Palliative Care Physicians)
Version: 5th Edition, January 2012
SEARCH
https://www.ncbi.nlm.nih.gov/pubmed?cmd=search
Subcutaneous infusions are commonly used in palliative care, either in patients who are unable to take or tolerate oral medications, or during the terminal phase. If starting an infusion, consider which drugs are best included, as it can be a good way of reducing the tablet burden. http://cdhb.palliativecare.org.nz/index.htm?toc.htm?4151.htm
METRICS AND MEASUREMENT FOR PALLIATIVE CARE
Sample Structure Metrics
• Proportion of PC team members who have advanced training in palliative care
• The days of week and times of day the service is available to patients, families and referring providers
Sample Process Metrics
• Proportion of patients seen by the PC service who received a comprehensive assessment;
• Proportion of patients who had a documented discussion about hospice or PC within 2 months of death.
Sample Outcome Metrics
• Clinical / patient reported: pain score reported at initial encounter compared to pain score reported 30 days later
• Social: family satisfaction with care provided to a loved one
• Cost / utilization: cost of care in the final six months of life for patients seen by the PC service, compared to costs incurred by similar patients not seen by the service.
National Palliative Care Research Center - NPCRC
National Hospice and Palliative Care Organization - NHPCO
EORTC, the European Platform of Cancer Research - EORTC
Advancing Expert Care
https://advancingexpertcare.org/
Center to Advance Palliative Care - CAPC
Canadian Hospice Palliative Care Association - CHPCA
American Academy of Hospice and Palliative Medicine - AAHPM
What Happens at Your Initial Consultation?
You will be seen by a member
of the Macmillan Supportive and Palliative Care Team
who will review your medical history
and may arrange for further tests to be ordered
to help better understand your condition,
such as blood tests or scans.
The nurses involved in your healthcare want
to help you become involved
by giving you information about your treatment options
and want to understand what is important to you.
If you are asked to make a choice about your healthcare,
you may have lots of questions
that you wish to talk over with your family or friends.
It can help to write a list of questions
before our assessment.
https://web.archive.org/web/20210623193017/https://www.wrightingtonhospital.org.uk/media/downloads/sdm_information_leaflet.pdf
Ookay kan, Bro!
IKA SYAMSUL HUDA MZ
