THE 1% RULE
About 1% of your patients will die each year
or, put another way,
1% of them are in their last year of life.
Outcome(s):
1) Patient outcomes including
physical health
(e.g., pain, fatigue, dyspnea),
mental health
(e.g., depression, distress),
and satisfaction;
2) Caregiver outcomes including
grief, quality of life, mental health,
physical health, and satisfaction;
3) Process outcomes including
communication,
cultural competence,
and continuity of care.
https://web.archive.org/web/20210127040947/https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/TND-0741-141211.pdf
The palliative care population as seriously ill patients and those with advanced disease (such as persons living with advanced cancer or intensive care unit patients at high risk of dying), who are unlikely to be cured, to recover, or to stabilize.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4696032/
Uncoordinated or ineffective care creates an undue burden on the already physically, mentally, and emotionally taxing experience of suffering with advanced and serious illness.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4696032/
Palliative care is care for patients with serious illness, like yourself.
- 1. Symptoms. Patients with serious illness often have symptoms like pain, shortness of breath, nausea, constipation, lack of energy, depression, anxiety, nausea, or difficulty sleeping. We are experts in the treatment of those symptoms. (patients usually say, "I've had some of those!").
- 2. Communication. The hospital is a busy place. Patients with serious ilness often have many doctors from different teams coming in and out of the picture. We help with communication to make sure that the treatments you receive match your goals. (slowly, with emphasis - patients and family usually nod)
- 3. Finding the right services outside the hospital (for patients who might leave the hospital). We help make sure that you have a smooth transition once you leave the hospital. We make sure you are set up with the right services - one service we often refer to is hospice. Another is our outpatient palliative care clinic.
What is palliative care, really?
An “extra layer of support” for those facing serious illness, appropriate at any time in the care of a serious illness
Three essential processes:
1. Pain and symptom management
2. Goals of care alignment
3. Care coordination
Three essential models:
1. Consultation
2. Co-management
3. Comprehensive care coordination
Glossary – Palliative care definition
Palliative care is the active holistic care of individuals across all ages with serious health-related suffering due to severe illness, and especially of those near the end of life. It aims to improve the quality of life of patients, their families and their caregivers.
Primary palliative care
Secondary palliative care
Tertiary palliative care
Systems-based approach
Potentially life-limiting or life-threatening condition
Goals of care
https://web.archive.org/
- Analgesia of cancer pain: This addresses the choice of analgesic medicine when initiating pain relief and the choice of opioid for maintenance of pain relief, including optimization of rescue medication, route of administration, and opioid rotation and cessation.
- Adjuvant medicines for cancer pain: This includes the use of steroids, antidepressants and anticonvulsants as adjuvant medicines.
- Management of pain related to bone metastases: This incorporates the use of bisphosphonates and radiotherapy to manage bone metastases.
MEDICATIONS SHOULD GENERALLY START AT LOWER DOSAGES
Medications should generally start at lower dosages before titrating to the desired effect. The dosing should initially be as needed and then transitioned to a standing dosage or long-acting medication for symptom management. When possible, proactive regimens that prevent symptoms should be used, because it is generally easier to prevent than to treat an acute symptom.
Because disrupted swallowing function and changes in the level of wakefulness can affect patients’ ability to swallow pills, medications must be provided in formulations that are safe and feasible for administration. Concentrated sublingual medications, dissolvable tablets, transdermal patches, creams or gels, and rectal suppositories can be given to patients with impaired swallowing and decreased responsiveness. Less common formulations may be obtained at local compounding pharmacies and hospice pharmacies. If sublingual tablets are used, mucous membranes must remain moist through careful oral care to allow for optimal absorption.
https://web.archive.org/web/20200920110133/https://www.aafp.org/afp/2017/0315/afp20170315p356.pdf
HYPODERMOCLYSIS
Historical and Current Practice
Hypodermoclysis was a widely accepted route
for parenteral hydration in the 1940s and 1950s
before falling out of favor after several reports of adverse reactions,
likely related to the use of hypertonic and electrolyte-free solutions.
Due to its ease of use,
and subsequent research demonstrating
its safety and efficacy,
HDC has become more widely used.
In the US,
HDC is mostly used
in geriatric and palliative care settings,
although it is used more widely elsewhere in the world.
Hypodermoclysis is a simple, safe and effective technique for subcutaneously administering fluids to a patient who requires hydration.
It avoids the need for venous access in patients who, at the end of life, often have very poor veins.
In the home/ hospice/residential care facility settings, it can be carried out without the need for fully IV credentialed nursing staff.
The fluids used are commonly
normal saline (0.9%),
normal saline/dextrose (2/3-1/3)
and Ringer’s Lactate.
Dextrose cannot be used as a hypodermoclysis solution.
The infusion rate can be up to 75 ml/hr. Solutions are infused by gravity, i.e., a pump is usually not necessary.
Some patients may only require 1 litre 3–4 times per week, rather than daily administration. A smaller volume (1 liter per day) is often adequate to maintain hydration in terminally ill patients requiring hydration for symptom control.
Potassium chloride up to 40 mEq per litre may be added to the solution. Do not mix hypodermoclysis solutions with other medications. If medications are being administered by the SC route, use separate site(s).
Change the solution bag every 24 hours. Change the tubing every 72 hours. Change the SC site if painful, red, hard or leaking.
Subcutaneous hypodermoclysis sites may last up to seven days.
Daily assessment of client condition and insertion site is necessary.
If the one site is used for multiple medications/concentration flush with a compatible solution after each medication.
The volume of the flush should be equal to the volume of the tubing.
If one site for multiple medications/concentration: All medications must be compatible. Do not fill extension tubing with medication. Tubing may be left empty or prefilled with NS. Flush (the volume of the tubing dead space) with normal saline or compatible solution between medications and after medication administration. Label site “multiple medications”.
Note: Haldol requires its own designated site as it is not compatible with sodium chloride 9%
Hypodermoclysis - Possible Benefits:
☛ Viewed by family as “doing something” to help—this may decrease anxiety level of family
☛ May decrease pre-renal azotemia symptoms which may increase comfort level
☛ Risk of delirium may decrease with hydration via HDC
☛ Less invasive than peripheral IV
☛ Safe, simple, practical, low-cost
☛ No risk of thrombosis at site
☛ Uses less nursing time than peripheral iv insertion
☛ Greater infusion site choices (posterior upper arms, upper chest, abdomen, thighs, flank, infraclavicular)
Principles of Consultation Etiquette
- 1 Determine the question
- (How can I help you in your care of patient?).
- 2 Triage urgency
- (emergent vs. urgent vs. elective).
- 3 Gather your own data
- (thorough history and focused physical examination).
- 4 Brevity
- (focus your consult notes on assessment/recommendations).
- 5 Specificity
- (goal-oriented recommendations).
- 6 Plan ahead
- (contingency plans for anticipated future problems).
- 7 Honor turf
- (be careful to address the problem for which you were called).
- 8 Teach-with tact
- (viewing every consultation as a teaching, and marketing, opportunity).
- 9 Personal contact
- (direct to the requesting physician).
- 10 Follow-up
- (including your ongoing role and knowing when to sign off).
These principles may also be called the ‘ten commandments for effective consultations.’
https://web.archive.org/web/20160401053325/http://jspm.ne.jp/jspm_eng/guidance.pdf
https://www.health.qld.gov.au/cpcre/subcutaneous/guidelines
Palliative care is the active holistic care of individuals across all ages with serious health-related suffering due to severe illness and especially of those near the end of life. It aims to improve the quality of life of patients, their families and their caregivers.
https://palliativecareindonesia.blogspot.com/p/blog-page_6.html
SPIRITUAL CARE
Sample Methods for Spiritual Care
➔ Assist with advance care planning
➔ Assist with spiritual/religious practices
➔ Bereavement support
➔ Encourage life review
➔ Encourage sharing of feelings
➔ Explore nature of God
➔ Offer emotional support
➔ Offer spiritual/religious support
Sample Interventions for Spiritual Care
➔ Perform a blessing
➔ Provide grief resources
➔ Share words of hope and inspiration
➔ Acknowledge response to difficult experience
➔ Reflective listening
SUPPORTING THE FAMILY:
Modify Stressor
Optimize symptom control
Maximize functional capacity
Clearly communicated drug regimen
Anticipatory, realistic discharge planning
Enhance resources & coping
Information
Skill training
Finance
Equipment, home modification
Other tangible support
Respite: physical or mental pause
Stress management
Emotional support
Psychological intervention
Transcendence
Spirituality
Cognitive process of meaning in illness
Means: legacy, narration
Cultural context
Religious context
The culture can influence
who is with the one at the time of death
and whether the patient wants to die
at home, in the hospital, or in a hospice facility.
Some cultures treat death
with the utmost reverence
while others prefer
to celebrate the life before it.
Other cultures fear death.
Communicating with the patient
and the family regarding their cultural beliefs
will help the palliative care team
to provide more efficient support.
in North America, Western Europe and Oceania,
great strides have been made in the treatment of cancer.
Public awareness has increased,
treatment modalities improved
and consequently the number of survivors is rapidly increasing.
Concomitantly,
advances in palliative care have also taken place,
albeit at a slightly lower pace.
Unfortunately,
that is not the case
in most of the low- and middle-income countries.
https://web.archive.org/web/20210622111733/http://www.academyforlife.va/content/dam/pav/documenti%20pdf/2018/Pallife2018_slides/11_Hassan_Palliative%20Care%20in%20Arabic%20Countries_Feb28th_Session2.pdf
https://t.co/sU8epWl0VZ pic.twitter.com/Zr4LOfRXz4
— Ika Syamsul Huda MZ, MD, MPH (@drikasyamsul) June 23, 2021
Ookay kan, Bro!
