Recognising Dying can be Difficult
Patients are considered to be “approaching the end of life” when they are likely to die within the next 12 months. This group of patients encompasses those:
- 1. Where death is imminent
- 2. Who have advanced, progressive, incurable conditions
- 3. Who have general frailty and multi-morbidity
- 4. Suffering an acute crisis in a longer term condition
- 5. With life threatening acute conditions
“End of life care” focuses in particular on patients at the end of life, but the delivery of good end of life care relies heavily on the recognition that a patient is approaching the end of life. Without this recognition, it is less likely that all the necessary elements of communication and care will take place in the patient’s final days or weeks to make their death as comfortable as possible.
https://www.ouh.nhs.uk/about/trust-board/2016/july/documents/TB2016.69-end-of-life-strategy.pdf
If people think that palliative care and
hospice are synonymous, they may be reluctant to pursue palliative care if they intend to receive curative treatment for a serious illness.
Internet-based palliative care information pages
have the opportunity to provide
the public with important information
about palliative care.
https://journals.sagepub.com/doi/full/10.1177/1049909115615566
Understanding the Different Between Palliative Care and Hospice
Multiple Choice Questions
Click on a link below to access the MCQ(s) for that chapter. Select one option to the question and click 'Submit answer' to check your answer.
http://www.ataglanceseries.com/nursing/palliativecare/mcqs.asp
Self-assessment Cases
Select a case from the list below. Each case includes questions for self-test.
http://www.ataglanceseries.com/nursing/palliativecare/case.asp
It is important to coordinate this effort through regional and national associations, to reduce duplication and unnecessary work. IAHPC is also working with Age Platform Europe.
The Seven Guiding Questions, and help in finding answers
https://eapcnet.wordpress.com/
If people think that palliative care and
hospice are synonymous, they may be reluctant to pursue palliative care if they intend to receive curative treatment for a serious illness.
Internet-based palliative care information pages
have the opportunity to provide
the public with important information
about palliative care.
https://journals.sagepub.com/doi/full/10.1177/1049909115615566
Understanding the Different Between Palliative Care and Hospice
Multiple Choice Questions
Click on a link below to access the MCQ(s) for that chapter. Select one option to the question and click 'Submit answer' to check your answer.
http://www.ataglanceseries.com/nursing/palliativecare/mcqs.asp
Self-assessment Cases
Select a case from the list below. Each case includes questions for self-test.
http://www.ataglanceseries.com/nursing/palliativecare/case.asp
It is important to coordinate this effort through regional and national associations, to reduce duplication and unnecessary work. IAHPC is also working with Age Platform Europe.
The Seven Guiding Questions, and help in finding answers
https://eapcnet.wordpress.com/
Dermatological Symptoms in Palliative Care
https://pharmacopallcare.blogspot.com/2020/09/dermatological-symptoms-in-palliative.html
PALLIATIVE CARE SCREENING TOOL
Check each criteria that applies to the patient
https://web.archive.org/web/20200621190513if_/https://dev.carecompassnetwork.org/wp-content/uploads/sites/4/2017/03/CGC-CG-09-Clinical-Triggers-for-PCMH-Referral-to-Palliative-Care_UPDATE.pdf
Creutzfeldt has suggested the use of a “Palliative care needs checklist”—considering:
Check each criteria that applies to the patient
- ☐ New diagnosis of life limiting illness for symptom control, patient/family support
- ☐ Patient has progressive metastatic cancer
- ☐ Patient has advancing dementia including; difficulty swallowing, multiple infections, and decreasing intake
- ☐ Team/patient/family needs coordination of care
- ☐ Patient has progressive declining ability to complete activities of daily living without reasonable expectation for improvement
- ☐ Patient has weight loss/failure to thrive
- ☐ High Utilizer admission from a long-term care facility
- ☐ Patient has four or more hospitalizations for illness within twelve months
- ☐ Patient has difficult to control physical symptoms
- ☐ Patient/family/physician faces uncertainty regarding prognosis
- ☐ Patient/family/ physician faces uncertainty regarding pros and cons of treatment options
- ☐ Patient or family requests for treatment with low probability for success
- ☐ Patient/family/care team needs help with advance care planning (e.g., DNR conflicts)
- ☐ Patient/family/care team needs help with conflicts regarding the use of non-oral feeding/hydration in cognitively impaired, seriously ill, or dying patients
- ☐ Patient/family/physician request information regarding hospice appropriateness
- ☐ Patient or family has uncontrolled psychological, emotional, or spiritual distress
- ☐ Patient admitted due to side effects of chemotherapy
https://web.archive.org/web/20200621190513if_/https://dev.carecompassnetwork.org/wp-content/uploads/sites/4/2017/03/CGC-CG-09-Clinical-Triggers-for-PCMH-Referral-to-Palliative-Care_UPDATE.pdf
Creutzfeldt has suggested the use of a “Palliative care needs checklist”—considering:
☛ Does this patient have pain or distressing symptoms?
☛ Do the patient and/or family need social support or help with coping?
☛ Do we need to readdress goals of care or adjust treatment according to patient-centred goals?
☛ What needs to be done today?
☛ Do the patient and/or family need social support or help with coping?
☛ Do we need to readdress goals of care or adjust treatment according to patient-centred goals?
☛ What needs to be done today?
Thus the recognition of palliative care needs is essential and most patients can be assessed and managed by the stroke team, with consultation with specialist services when the issues are more complex—often with more complex decision making at end of life.
The palliative doctor leads the team, working closely with your nurses, who will have regular contact with you. Most of the team members receive special training in palliative care.
Your team will
- prescribe treatments to control pain and other uncomfortable symptoms
- assist with difficult medical decisions, helping you weigh the pros and cons of various treatments
- coordinate care with your other doctors and help you navigate the often confusing healthcare system
- guide you in making a plan for living well, based on your needs, concerns, and goals for care
- provide you and your loved ones emotional and spiritual support and guidance.
Members of the hospice and palliative care team can include
- You
- Your loved ones
- Palliative doctor
- Your other doctors
- Nurse
- Social worker
- Pharmacist
- Chaplain
- Physical therapist
- Dietician
- Volunteers
- Some people find that music, humor or distraction, hot or cold packs, or exercise can really help relieve their pain or lessen their symptoms.
- Other complementary methods include massage therapy, biofeedback, therapeutic touch, chiropractic manipulation, pet therapy, acupuncture, hypnosis, guided imagery, and cognitive and behavior therapies.
Questions the palliative doctor and other team members may ask include
- How can we help you live well?
- What makes you happy?
- What activities or experiences would you like to do or continue doing so that you feel you are living well?
- Are there any special events or activities that you are looking forward to?
- What are your fears or worries about your illness or medical care?
- What needs or services would you like to discuss?
- What do you hope for your family and loved ones?
- What keeps you going when life’s challenges seem overwhelming?
- Do you have religious or spiritual needs that are important to you?
- In what way do you feel you could make this time especially meaningful to you?
- If you have to choose between living longer and living more comfortably or energetically, how would you approach this balance?
Pharmacological interventions
Optimal symptom control in the last few days of life requires considerable skill and may be challenging for even an experienced palliative care clinician. There may be a number of concurrent clinical problems as well as an underlying desire to get the care right for the dying person and those important to them. Poorly controlled symptoms can lead to considerable distress as they interfere with the ability to engage in other important activities including saying goodbye to those important to the dying person and putting financial affairs in order. Many of the medications used to manage these symptoms may cause a degree of sedation, or other side effects.
Pain Assessment in Hospice and Palliative Care
OPIOID SIDE EFFECTS
These include:
• Constipation (very common, always prescribe a laxative).
• Nausea and vomiting (always prescribe a p.r.n. antiemetic).
• Drowsiness (dose-related and often temporary).
• Confusion, hallucinations and delirium (may need a dose reduction, if pain free, or change in opioid).
• Respiratory depression (rarely a problem if titrated correctly). Both respiratory rate and oxygen saturations will be decreased if opioid-induced.
• Neither tolerance nor addiction are significant problems in patients at the end of life.
"People with serious illness have priorities besides simply prolonging their lives. Surveys find that their top concerns include avoiding suffering, strengthening relationships with family and friends, being mentally aware, not being a burden on others, and achieving a sense that their life is complete."
https://diigo.com/0hucb3
Emotional and Communication Support
Health professionals providing palliative care must be sensitive to the reality that depression, anxiety, and sleep disorders may be present and may cause physical or emotional symptoms. Furthermore, unique psychosocial issues accompany terminal illness.
Emotional responses such as denial, anger, sadness, acceptance, and hope may vary from day to day and may differ between the client and the various members of the family.
https://www.nursece.com/courses/113-palliative-care-essentials
The differences between palliative care and end-of-life care include:
The differences between palliative care and end-of-life care include:
- Palliative care is provided to seriously ill patients coping with pain, distressing symptoms, stress or other serious side effects of their illness or treatments meant to cure it.
- End-of-life care is provided to seriously ill patients who have a prognosis of six months or less, in their doctor’s best judgment, if the disease follows its normal course.
- Palliative care is for anyone living with a serious illness at any stage,
- while end-of-life care is for the last few weeks or months of life.
- Meaning palliative care is intended to help patients live more comfortably with their ongoing condition.
- Palliative care is for anyone seeking curative treatments,
- while end-of-life care is for someone who has decided to forgo curative treatments and seek comfort care in the last few months, weeks, or days of their life.
- Palliative care is provided during a consultation in an office setting or a visit in the hospital,
- while end-of-life care is provided in your home, nursing home or assisted living, or inpatient hospice facility.
- Palliative care is provided by a palliative-trained, board-certified physician or nurse practitioner.
- Hospice care is provided by a board-certified physician, nurse practitioner, nurse, social worker, spiritual support counselor, certified home health aide, and volunteer.
Palliative care is the treatment, care and support for people from the point of diagnosis of a life-limiting (terminal) illness.https://www.mariecurie.org.uk/professionals/palliative-care-knowledge-zone/proving-good-quality-care/a-guide-to-end-of-life-services
End of life care involves treatment, care and support for people who are nearing the end of their life. It’s part of palliative care.
Neurological patients differ from oncological patients with respect to their symptoms, fluctuating disease course, varied prognoses, and difficulty in identifying end-of-life stage. Knowledge of different neurological conditions is important to practice neuropalliative care appropriately. Growth of neuropalliative care services must begin with the neurologist at the center of the multidisciplinary team. Neurologists need to be trained in communication skills and advance care planning, and must be aware of end-of-life care, do-not-resuscitate policies, and withdrawal of life support measures.
https://www.thieme-connect.com/products/ejournals/pdf/10.1055/s-0038-1675891.pdf
“In my last year of life, help me live well until I die.”
https://www.nextstageradicals.net/blog/
Final days
Following the phasing out of theLiverpool Care Pathway in 2014, the National Leadership Alliance for the Care of Dying People has published guidance that is summarised in the leaflet ‘Priorities of Care for the Dying Person’. The key recommendation was a move away from a ‘pathway’ approach, and a move towards developing individual care plans for dying people.
https://bit.ly/3cDYayS
Neurological Symptoms in Palliative Care
https://pharmacopallcare.blogspot.com/2020/09/neurological-symptoms-in-palliative.html
https://www.nextstageradicals.net/blog/
Final days
Following the phasing out of the
https://bit.ly/3cDYayS
THE “WORK” OF DYING
Many patients imagine that death comes suddenly, but for many, the knowledge that one's death is imminent comes first. Those with this awareness often must complete certain tasks to allow a peaceful death such as offering forgiveness, being forgiven, acknowledging regrets, finding closure in professional and community relationships, and saying goodbye to family and friends.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3241069/
However, the commonly held Muslim view of a good death is lacking. It almost entirely revolves around the unknowable relationship between the deceased and Allah, while neglecting more practical temporal aspects. For the purposes of this essay, I want to explore the practical side of a “good death” and show that this is actually part of a neglected Prophetic tradition that we can and should revive.
A good death is described as any passing in which an individual dies as peacefully as possible, in accordance with their wishes and according to their own ethical, cultural or religious standards. This includes dying free of pain, in a location of their preference (usually divided into one of the 3 H’s – home, hospital or hospice) and surrounded by their loved ones rather than medical and nursing staff.https://muslimmatters.org/2017/08/30/the-prophet-and-secrets-to-a-good-death/
Key risk factors for complicated grief
Background factors
- Close kinship to the dying person (especially loss of spouse or child).
- Female gender (especially mothers).
- Minority ethnic status.
- Insecure attachment style.
- High pre-loss marital dependence.
- Religion and spiritual beliefs and practices (for some, religious/spiritual belief results in lower levels of grief, and for others a stronger faith can lead to more severe experiences of grief).
Treatment-related factors
- Aggressive medical intervention (e.g., intensive care, ventilation, resuscitation).
- Ambivalence regarding treatment.
- Family conflict regarding treatment.
- Economic hardship created by treatment.
- Caregiver burden.
Death-related factors
- Bereavement overload (multiple losses in quick succession).
- Low acceptance of impending death.
- Violent death (suicide, homicide, accident).
- Finding or viewing the loved one’s body after a violent death.
- Death in the hospital (rather than at home).
- Dissatisfaction with death notification.
https://pumed.nci.nlm.nih.gov/28701233/
Clinical Practice Group (CPG) Guidelines
The following documents have been developed by the Gippsland Region Clinical Practice Group to assist health professionals and palliative care service providers develop their own policies and procedures around palliative care.
Please find below a list of our current available documents.
http://www.grpcc.com.au/health-professionals/resources/palliative-care-resources/
Steroids have many indications for use in palliative care.
Dexamethasone is the most commonly used corticosteroid
due to the smaller number of tablets at higher doses,
and the option for subcutaneous route if necessary.
Dose used and duration of treatment varies
depending on indication.
Although the short life expectancy
of some palliative patients means
they are unlikely to be affected
by more long-term side effects
such as muscle wasting, weakness and osteoporosis,
they can still experience diabetes
and the more distressing symptoms of insomnia, agitation and psychosis.
These Guidelines apply only
to those patients with a cancer diagnosis,
in whom steroids have been prescribed for symptom management.
NHSGGC : NHS Greater Glasgow and Clyde - Homepage of our official site
https://www.nhsggc.org.uk/
COVID-19: Effective communication for professionals (RED-MAP resources) – Effective Communication For Healthcare
https://www.ec4h.org.uk/covid-19-effective-communication-for-professionals/
Realistic Medicine – Shared decision making, reducing harm, waste and tackling unwarranted variation
https://www.realisticmedicine.scot/
ihub | Health and social care improvement in Scotland - Home
https://ihub.scot/
palliativecareggc.org.uk/
https://www.palliativecareggc.org.uk/
Ookay kan, Bro!
IKA SYAMSUL HUDA MZ
