https://iha4health.org/wp-content/uploads/2017/06/PREPARE_Fillable_Advance-Directive_CA_EN.pdf
The Surprise Question (“Would I be surprised if this patient were to die within the next 12 months?”) is widely used to identify palliative patients, though with low predictive value. To improve timely identification of palliative care needs, we propose an additional Surprise Question (“Would I be surprised if this patient is still alive after 12 months?”) if the original Surprise Question is answered with “no.” The combination of the two questions is called the Double Surprise Question.
Answers on the original Surprise Question (yes/no). If “no,” answers on the additional Surprise Question (yes/no).
The Palliative care Outcome Scale (POS)
is a resource for palliative care practice, teaching and research. This
website has been established by a not-for-profit organisation to help
advance measurement in palliative care. Free resources and training are
available.
https://pos-pal.org/
An outcome is ‘the change in a patient’s current and future health status that can be attributed to preceding healthcare’.
Outcome
measurement involves the use of a valid and reliable measure to
establish a patient’s baseline health status and then evaluating changes
over time against that baseline. Outcome measurement is an important
step to measure the value of health care provided.
https://epub.ub.uni-muenchen.de/43641/1/EAPC_White_Paper.pdf
https://www.hse.ie/eng/services/publications/clinical-strategy-and-programmes/palliative-care-needs-assessment-guidance.pdf
- A team of doctors
- Nurses and nurse practitioners
- Physician assistants
- Registered dietitians
- Social workers
- Psychologists
- Massage therapists
- Chaplains
☛ Ensure your patient is aware of these goals
☛ Identity substitute decision maker (early in care)
☛ Educate decision makers/caregivers so they can make informed decisions on behalf of their loved one
☛ Understand what DNR (Do Not Resuscitate) means and how to get proper consent from your patient
☛ Ask open-ended questions
☛ Use the Symptom Management Tool to detect early signs
☛ Utilize the support of PSW’s (Personal Support Worker)
https://web.archive.org/web/20210123061817/http://www.thinkresearch.com/ca/wp-content/uploads/sites/6/2018/04/TRC_ThoughtPaper_EOL_2018.pdf
PALLIATIVE CARE FOR PATIENTS WITH HEART FAILURE
https://pharmacopallcare.blogspot.com/2020/09/palliative-care-for-patients-with-heart.html
HEART FAILURE AT THE END OF LIFE
Recognition of the dying phase can be difficult in HF patients because there can be an initial response to corrective treatment. Decisions should be lead by a senior clinician and involve the multi-disciplinary team. However the following features indicate that the patient is likely to be in the last phase of illness:
☛ Brittle fluid balance control with no identifiable reversible precipitant
☛ Diuretic resistance; failure to respond within 2 -3 days of appropriate change in treatment
☛ Sustained hypotension
☛ Unable to tolerate ACEI/ARBs or beta blockers,
☛ Worsening renal dysfunction
☛ Resistant hyponatraemia
☛ Hypoalbuminaemia.
Patients with HF requiring specialist palliative care referral usually have one of more of the following problems:
☛ Recurrent hospital admissions for de-compensated HF despite optimal medical treatment.
☛ Difficult communication issues (such as coping with uncertainty, prognosis, and preferred place of death).
☛ Difficulties in determining future care planning.
☛ Complex physical or psychological symptoms despite optimal tolerated therapy.
☛ Practical support needed to allow dying at home or hospice.
☛ Carers with high risk of bereavement difficulties.
People who are getting less well from one or more health problems often miss out on well planned care and support because they are not identified and offered the right help soon enough.
The SPICT is a simple tool designed to help health and care professionals find people who might benefit from better supportive and palliative care, including thinking ahead and planning future care.https://www.spict.org.uk/the-spict/spict-4all/
- How to palliate severe symptoms without the need for IV/SubQ medications,
- How to minimize the need for patient transfers by quickly treating patients in place,
- How to empower caregivers to care for patients at home, and how to enhance nursing efficiency amidst potential staff and resource shortages.
A multidisciplinary team can include a general practitioner,
- a surgeon,
- a medical oncologist,
- a radiation oncologist,
- a palliative care specialist,
- a nurse consultant,
- nurses,
- a dietician,
- a physiotherapist,
- an occupational therapist,
- a social worker,
- a psychologist,
- counsellor
- a pastoral care worker.
https://ww2.health.wa.gov.au/Reports-and-publications/WA-Cancer-Plan
https://ww2.health.wa.gov.au/~/media/Files/Corporate/Reports%20and%20publications/WA%20Cancer%20Plan/WA-Cancer-Plan.pdf
http://www.cheshire-epaige.nhs.uk/wp-content/uploads/2019/05/Syringe-Driver-Procedure-for-the-administrationof-medicationvia-a-subcutaneousroute-including-use-of-Mc-Kinley-T34-syringe-driver-ECT002989-1.pdf
Portable infusion pumps are used in palliative care to deliver a continuous subcutaneous infusion of medication over 24 hours. Mixing of medications in this manner is unlicensed but is supported by practice.
https://www.palliativecareguidelines.scot.nhs.uk/guidelines/end-of-life-care/syringe-pumps
When all reversible causes for the patient's deterioration have been considered, the multidisciplinary team agrees the patient is dying and change the goals of care. Reversible causes to consider include: dehydration, infection, opioid toxicity, renal impairment, hypercalcaemia or delirium.
https://handbook.ggcmedicines.org.uk/guidelines/pain-post-operative-nausea-and-vomiting-and-palliative-care-symptoms/palliative-care-last-days-of-life/
In the Australian context, symptoms that are encountered at the end of life are generally well controlled by the use of nine commonly used medications. These include:
- morphine sulphate/tartrate (an opioid);
- hydromorphone (Dilaudid, an opioid);
- haloperidol (Serenace, an antipsychotic/antiemetic);
- midazolam (Hypnovel, a short acting benzodiazepine);
- metoclopramide (Maxolon, an antiemetic);
- hyoscine hydrobromide (Hyoscine, an antimuscarinic /antiemetic);
- clonazepam (Rivotril, a benzodiazepine);
- hyoscine butylbromide (Buscopan, an antimuscarinic); and
- fentanyl (a narcotic).
Management of Subcutaneous Infusions in Palliative Care
Based on a literature review, an initial list of the 21 most common symptoms in palliative care was developed by the Working Group:.
21 Most common symptoms in palliative care
Pain
Mild to moderate
Moderate to severe
Bone*
Neuropathic
Visceral
Dyspnoea
Terminal respiratory congestion
Dry mouth*
Hiccups*
Anorexia–cachexia
Constipation
Diarrhoea
Nausea
Vomiting
Fatigue*
Anxiety
Depression
Delirium
Insomnia
Terminal restlessness
Sweating*
* The expert group determined after the process was completed that there was not enough evidence to recommend any medications as both safe and effective for these five symptoms.
https://ejhp.bmj.com/content/19/1/34#T1
WE ARE ALL GOING TO DIE
Death can be a painful reality.
Even so it is the least understood body process
because of three important facts.
First,
there is an emotional response to death
on the part of the dying person
and their family and/or loved ones.
Second,
each person and their family have
a spiritual meaning attached to death
and the dying process.
Finally,
death is the ultimate unknown
and can only be entered alone.
The simplest
definition of death is a moment
in time at the end of physical life
which is preceded by a dying process.
https://web.archive.org/web/20200928064237/https://www.oatext.com/pdf/NPC-2-139.pdf
Both the Palliative Performance Scale (Wilner & Arnold, 2004) and the Mortality Risk Index (Tsai & Arnold, 2006) provide general indicators of decline:
- ❖❖ Decrease in ambulatory ability
- ❖❖ Decline in activity level
- ❖❖ Increased evidence of disease, such as the spread of a cancer
- ❖❖ Decreased ability to care for self
- ❖❖ Decreased intake; weight loss
- ❖❖ Decreased level of consciousness
- ❖❖ Increase in symptoms, such as shortness of breath
- ❖❖ Multiple hospitalizations
To comfort always: a nurse’s guide to end-of-life care / Linda Norlander. c2008.
Another paradigm for determining which children should be referred for palliative care based on prognosis and illness trajectory has been proposed by Together for Short Lives, a UK organization that supports children with life-threatening illness and their families.
Four illness trajectories are described:
Category 1: Life-threatening conditions for which treatment is available but may fail, such as cancer or irreversible kidney failure
Category 2: Conditions wherein premature death is inevitable but treatment may prolong life, such as cystic fibrosis or Duchenne muscular dystrophy
Category 3: Progressive conditions without curative treatment options, such as muccopolysaccharidoses and Batten disease
Category 4: Irreversible but nonprogressive conditions causing severe disability, health complications, and risk of premature death, such as severe cerebral palsy, some brain or spinal cord injuries.
https://pubmed.ncbi.nlm.nih.gov/25084721/
Inappropriate referrals include:
☛ 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 or who are unaware of their underlying disease
☛ Those whose problems are principally psychological and need specialist psychiatric referral, whether or not they have declined such help
However, team members may offer advice on a “one off” basis to the responsible team if there are particular problems and the appropriate specialist team is not available.
https://web.archive.org/web/20200901202635/https://www.palliativedrugs.com/download/SpecialistPalliativeCareReferralforPatients.pdf
Palliative care is required for a wide range of diseases. The majority of adults in need of palliative care have chronic diseases such as cardiovascular diseases (38.5%), cancer (34%), chronic respiratory diseases (10.3%), AIDS (5.7%) and diabetes (4.6%). Many other conditions may require palliative care, including kidney failure, chronic liver disease, multiple sclerosis, Parkinson’s disease, rheumatoid arthritis, neurological disease, dementia, congenital anomalies and drug-resistant tuberculosis.
FOR CONVERSATIONS ABOUT THE LAST DAYS OF LIFE
Spiritual can have a spectrum of meaning ranging from the explicitly religious to a less defined sense of ‘otherness’ or ‘connectedness’ or for some, a personal search for meaning. This is not to suggest that those requiring more formal religious care do not need or want to address the wider questions of meaning. Conversely, at such times many people who might not describe themselves as ‘religious’ might wish to return to a faith they were brought up with, finding in that hope and comfort. Alternatively they might express none of these and simply want the presence of someone who will be with them in the loneliness of their suffering. To care for the spirit is to attend to all of the above.
So from the devoutly religious to those searching for meaning or those with no expressed interest in religion or spirituality there is much a healthcare worker can do to help support a dying patient and make these moments as valuable as possible.
https://web.archive.org/web/20210605084234/http://www.liverpoolcatholic.org.uk/userfiles_rcaol/file/Auxiliary%20Bishops/09%20Consultation%20Draft%20%20-%20Guide%20to%20the%20Spiritual%20Care%20of%20the%20Dying%20Person.pdf
Okay kan, Bro!
IKA SYAMSUL HUDA MZ
