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NUR360 LS2 > Geriatric palliative care > Flashcards

Geriatric palliative care Flashcards

1
Q

Palliative care definition

A
  • An approach to care that aims to relieve suffering and improve the quality of living and dying in those patients diagnosed with life threatening and life limiting illness.
  • Good palliative care does not intentionally hasten death.
  • Avoiding inappropriate treatments, suffering, and prolongation of dying.
  • Applicable to all ages.
  • Not just for the terminal phases of life or the last few weeks or days.
  • Can be provided by primary care providers, specialist providers, or can be its own specialty.
  • Primary, secondary, and tertiary levels.
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2
Q

Trajectory of palliative care

A
  • The focus of care shifts from treatment to cure to control to disease
  • Hospice or palliative car comes to play at end-of-life
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3
Q

The approach to palliative care

A
  • Quality of life – defined by the individual
  • Preserving dignity
  • Symptom management
  • Advanced care planning and treatment decisions
  • Exploring wishes, values, personhood
  • Discussing and preparing for end-of-life
  • Ethical and moral problem solving
  • Assessing and managing grief
  • Care for the caregiver!
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4
Q

The geriatric context to palliative care

A

Geriatric palliative care integrates the complementary specialties of geriatrics and palliative care to provide comprehensive care for older patients entering the later stage of their lives, and their families.

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5
Q

Advanced care planning (ACP)

A

Involves:

  • Reflecting on and communicating about one’s values and wishes for future health and personal care.
  • Identifying a person or persons who can make decisions regarding one’s health if one lacks the capacity to make decisions oneself.

ACP is not:

  • A single conversation
  • Synonymous with a “code” discussion
  • Set in stone

It is: “Hoping for the best, preparing for the worst.”

  • Dynamic: can change over time for different reasons
  • About how you approach it
  • Analogies helpful for introducing the topic
  • A “just in case” and a safety plan
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6
Q

Establishing goals of care

A

Questions to ask:

  • “What would be important to you if you had an advanced incurable illness?”
  • “What goals do you have for the time you have left?”
  • Comfort versus life prolongation; setting priorities
  • Goals of care discussions are ongoing and should occur when individuals are well enough to articulate their wishes
  • Think about it as a continuum
  • What’s important to them and what do they want that time to look like
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7
Q

POA

A

Power of Attorney

- the authority to act for another person in specified or all legal or financial matters

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8
Q

SDM

A

Substitute Decision Maker

  • is the person(s) who is entitled by law to make health decisions on behalf of an incapable person
  • What the person would of wanted
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9
Q

DNR

A

Do Not Resuscitate

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10
Q

EDITH

A

Expected Death in the Home

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11
Q

CMO

A

Comfort Measures Only

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12
Q

SMK

A

Symptom Management Kit

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13
Q

FTC

A

Failure to Cope

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14
Q

AND

A

Allow Natural Death

- A proposed alternative to a DNR order

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15
Q

Diagnosis and prognosis

A
  • Prognosis will depend on the diagnosis and existing comorbidities
  • Some clients will present with more than one life-limiting illness
  • Prognostication is not an exact science
  • Time frames are given in ranges of time (e.g. 3-6 months)
  • Cancer is generally more predictable
  • Based largely on functional status (PPSv2, Frailty Scale)
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16
Q

Functional assessment (Palliative Performance Scale [PPSv2] version 2)

A

50%
- Is spending 50% of time in bed or sitting

30%
- when people become bed bound

10%
- is when death is imminant

17
Q

Gold standard framework

A
  • Originated in the UK; Adapted by various institutions
  • Assists in the early identification of patients who would benefit from a palliative
    approach to care
  • Provides guidance on prognostication
  • Surprise question; would you be surprised if the patient were to die in a year?
  • General indicators of decline: deterioration, advanced disease, decreased response to treatment, choice for no further disease modifying treatment.
  • Specific clinical indicators related to certain conditions (COPD, CHF, frailty, dementia, etc.)
18
Q

Illness trajectory

A

Rapid “cancer” trajectory, diagnosis to death

  • Onset of incurable cancer
  • Time; often a few years
  • Decline usually seems <2 months

Organ system failure trajectory

  • Begin to use hospital often, self-care becomes difficult
  • Time 2-3 years
  • Death usually seems “sudden”

Frailty/dementia trajectory

  • Onset could be deficits in ADL, speech, ambulation
  • Time is quite variable, up to 6-8 years
  • Slow decline into death
19
Q

Language around palliative care

A
  • “Is this patient now palliative?” - We still talk about treatment options
  • better to say that this person would benefit from a palliative care approach
  • What are the implications of labels?
  • What assumptions do we make when we hear this?

Labels versus clarification of approach to care.

  • Know the Goals!
  • Client goals versus clinician goals
20
Q

The importance of dignity

A

Undermining of dignity is strongly associated with:

  • Depression
  • Anxiety
  • Hopelessness
  • Loss of will to live
  • Desire for death
  • Feeling of being a burden to others
  • Lower quality of life

Bolstering the dignity of an individuals appears to mitigate suffering at the end of life

  • When we think about the medical and not the person they suffer
  • RNs are a key piece to providing a good death
21
Q

Basics of symptom assessment

A

Edmonton Symptom Assessment System; Revised (ESAS-r)

  • A crucial tool in palliative care assessments
  • Best done via self-report; can be used to follow efficacy of interventions/treatments

Assesses the following symptoms crucial to palliative care on a scale of 0 - 10:

  • Tiredness
  • Drowsiness
  • Nausea
  • Loss of Appetite
  • Depression
  • Anxiety
  • Dyspnea
  • Pain
  • Overall Wellbeing
  • Other
22
Q

Factoids about symptoms management

A

The same medications used to treat pain and anxiety are also used to effectively treat dyspnea
- Example: Hydromorphone is a safe and effective medication in small doses for management of CHF and COPD related dyspnea in the elderly.

Palliative care often involves the use of medications that are discouraged for use in the elderly.
- Example: Morphine, lorazepam, phenobarbital, scopolamine, midazolam, etc.

Non-pharmacological interventions can be quite helpful and should overlap
medications intended for symptom management.

Off-label use is common
- Example: Methylphenidate (Ritalin) use to counteract opioid related somnolence

23
Q

Preparing for end-of-life

A
  • What does the patient know about their illness?
  • Has a prognosis been communicated?
  • Preferred place of death
  • Resolving unfinished business
  • Evaluating legacy; Life review
  • Creation of legacy/memory projects
  • Integration of cultural and faith-based practices
  • Cultural competence is important
24
Q

Transitions in care

A
  • Critical juncture – balls are easily dropped
  • Continuity of care is essential

Consider the challenges of the following locations:

  • Home
  • Hospital
  • Emergency Room
  • Palliative care emergencies do happen.
  • Hospice
  • Shelter
  • Other (Street, tent, etc.)
25
Q

Important members fo the team in palliative care

A
  • The patient and their support system/family/friends (#1)
  • Primary care
  • Palliative care specialists
  • Physicians
  • Nurses
  • Nurse practitioners
  • Pharmacists
  • Occupational therapists
  • Volunteers
  • Physiotherapists
  • Personal support workers
  • Community care coordinators
  • Social workers
  • Spiritual care
  • Mental health supports
  • Alternative therapy practitioners and providers
  • Bereavement Counsellors
  • Aftercare services
26
Q

Key facts about palliative care

A
  • Palliative care applies to all people at some point in their lives
  • Palliative care is an approach and philosophy
  • Dignity and personhood are essential to this approach
  • People are more than their diagnosis and prognosis
  • Honest and open communication is key
  • Tools exist to map out symptoms and the effectiveness of treatments
  • Advanced care planning is a great start for all older patients
  • Palliative care opportunities are often missed at the outset of an illness
  • Exploring our feelings about palliative care help us to bring our best selves to patients and families with palliative care needs

NUR360 LS2 (11 decks)

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