Geriatric palliative care Flashcards
Palliative care definition
- 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.
Trajectory of palliative care
- The focus of care shifts from treatment to cure to control to disease
- Hospice or palliative car comes to play at end-of-life
The approach to palliative care
- 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!
The geriatric context to palliative care
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.
Advanced care planning (ACP)
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
Establishing goals of care
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
POA
Power of Attorney
- the authority to act for another person in specified or all legal or financial matters
SDM
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
DNR
Do Not Resuscitate
EDITH
Expected Death in the Home
CMO
Comfort Measures Only
SMK
Symptom Management Kit
FTC
Failure to Cope
AND
Allow Natural Death
- A proposed alternative to a DNR order
Diagnosis and prognosis
- 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)
Functional assessment (Palliative Performance Scale [PPSv2] version 2)
50%
- Is spending 50% of time in bed or sitting
30%
- when people become bed bound
10%
- is when death is imminant
Gold standard framework
- 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.)
Illness trajectory
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
Language around palliative care
- “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
The importance of dignity
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
Basics of symptom assessment
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
Factoids about symptoms management
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
Preparing for end-of-life
- 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
Transitions in care
- 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.)
