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PHTY3280 > L26: The critically ill or dying patient > Flashcards

L26: The critically ill or dying patient Flashcards

1
Q

What are the 8 presentations contents of a critically ill or dying patient?

A
  1. Progression through hospital admission
  2. Medical emergencies
  3. Palliative care
  4. Acute resuscitation plan (ARP)
  5. Issues specific to ICU
  6. Organ donation
  7. Issues specific to Oncology
  8. End of life essentials
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2
Q

What is the ideal progression of hospital admission?

A
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3
Q

What are the 2 progressions of of hospital admission?

A
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4
Q

What are the 7 characteristics of medical emergency/escalation in hospital admission?

A
  1. Increase observations
  2. Change in medication
  3. Increase in medication
  4. Assessment/treatment from different services (eg, chest physio)
  5. Different ventilation system (eg. airvo)
  6. May move patient closer to nursing station
  7. Change wards: eg. to respiratory ward
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5
Q

What are 2 characteristics of medical emergency- MERT?

A
  1. Know emergency procedures
    • Yearly basic life support
  2. Know your role
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6
Q

What are 5 characteristics of example at RBWH of medical emergency- MERT?

A
  1. Press emergency button in room
  2. A colleague phones 333
  3. State medical emergency, treating team, location, any variations (pregnant, paediatric)
  4. MERT team arrives
  5. Handover to MERT team
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7
Q

What are 3 occurences of MERT?

A
  1. Patient may remain on hospital ward with change in medical management
    1. Medication
    2. Change in oxygen system (e.g. airvo)
    3. Chest physiotherapy
  2. Patient may be transferred to ICU for more intensive treatment, 1:1 nursing, ventilation, cardiac support
  3. Transfer to surgery
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8
Q

What are 3 characteristics of Post-MERT (if still on ward)?

A
  1. Increase in frequency of obs (if still abnormal obs) / altered criteria
  2. Post MERT r/v
  3. Labelled as ‘patient of concern’ for the ward
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9
Q

What are 4 physiotherapy treatments of critically ill or dying patients?

A
  1. Challenge patients physically
  2. High risk activities
    1. Walking
    2. balance exercises
    3. Suctioning
  3. Patients can be medically unwell – Events can occur even when we complete all safety checks
  4. Documentation is crucial
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10
Q

What is the medical plan for the medical emergency (MERT)?

A

Know the medical plan

Is the patient for CPR?

  • This plan can change throughout admission
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11
Q

What if the decision is made to palliate?

A

Or what if all medical / surgical options have been exhausted and the patient will not recover?

  • No more options
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12
Q

What are 5 questions that can arise if a patient is palliative?

A
  1. How do you know if someone is dying?
  2. What does it mean if someone is palliative?
  3. What if the chart says ‘for comfort cares’?
  4. When do we stop treating as Physiotherapists?
  5. What do I do if someone starts talking about dying?
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13
Q

Why do we find death a difficult topic?

A
  1. Consider your personal beliefs / feelings around death
    1. My feelings / beliefs / opinions have changed over time
    2. Impacted by experiences
  2. Your past experience with death
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14
Q

Is it the age of the patient (5)?

A
  1. Paediatric – Innocence of children
  2. May be same age as yourself
  3. May be younger than yourself
  4. A mother / father of young children
  5. Elderly
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15
Q

What are 4 traumatic causes of becoming palliative/death?

A
  1. Grief of family
  2. Confronting nature of patient situation
  3. Confronting nature of patient appearance
  4. Treatment for organ donation preparation
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16
Q

What are 3 known illness causes of becoming palliative/death?

A
  1. Any suffering?
  2. Patient acceptance / preparedness for death
  3. Burden of disease
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17
Q

What are 3 characteristics of family reactions?

A
  1. Distraught
  2. Needing extra support
  3. Understanding
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18
Q

What are 3 characteristics of staff reactions?

A
  1. Long stay patient
  2. Patient well known to service
  3. Unexpected death
  4. Quick deterioration
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19
Q

What are 3 characteristics of debriefing?

A
  1. Discuss with colleagues
  2. Discuss with team leader / line manager
  3. Psychology / counselling through employee assistance program
  4. Morbidity and mortality meetings
20
Q

What are 3 characteristics of other considerations of debriefing?

A
  1. Rostering of staff
  2. Preferences for rosters
  3. Can choose to opt out of certain areas
21
Q

What is palliative care?

A
  • World Health organisation:
    • “Palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual”
  • Queensland Government:
    • “Palliative care is healthcare that focuses on improving the quality of life and quality of care for people with a life-limiting illness, as well as families”
22
Q

What is the palliative care team?

A
  1. Doctors, Nurses
  2. Allied health – Physiotherapy, Occupational therapy, Social work, Psychology
23
Q

What are 6 aims of RBWH palliative care service in the palliative care team?

A
  1. Resolution of complex symptoms
  2. Relief of pain and suffering
  3. Informed decision-making
  4. Work in partnership with other members of the patients care team
  5. Whole person approach
  6. Therapeutic relationship
24
Q

What are 5 characteristics of palliative care?

A
  1. Affects funding if choose to return home
  2. Affects equipment available – hoist, hospital bed
  3. Amount of nursing available in the house
  4. Services can be put in place quickly
  5. Medication management with plans for escalation
    1. ‘breakthrough pain relief’
    2. Nikki Pump
25
Q

What is the Advanced Health directive?

A
  1. Document where people can make choices about health care they do/do not want if they can no longer make decisions for themselves
  2. Names religious, spiritual or cultural beliefs
26
Q

What are 3 characteristics (3.4) of ARP?

A
  1. Discussion between Doctor, patient +/- patients family
  2. Decision regarding CPR – yes or no
  3. Decision regarding level of intervention
    1. IV antibiotics
    2. IV fluids
    3. MERTS
    4. Intensive care unit
27
Q

What are 5 characteristics of Clinical guidance for the dying patient (CgDp)?

A
  1. Assessed as being in the last hours of life
  2. Have an ARP that states not for CPR
  3. Supports clinical judgement does not replace it
  4. Daily review by treating team, if not more
  5. Support (Not replace)to treating team by palliative care team

Focus on comfort –> no obs done anymore

28
Q

What is the chart of comfort cares?

A
29
Q

What happens when a person dies on the ward (7)?

A
  1. Curtains closed + door closed
  2. Butterfly placed on door + sign asking people to see N/S prior to entering
  3. Medical team notified
  4. Death verified
  5. Family notified – if not already present
  6. Paperwork completed and documented in chart
  7. Cleaning and preparation of body
  8. Autopsy required?
  9. Involvement of Coroner?
  10. Organ donation? (ICU patients)
  11. Transfer of body to morgue – discreet
30
Q

How do you know if someone is dying?

A

Physiotherapy and end of life

  • Imagine the difference you can make at this time
31
Q
A
  1. Physiotherapy can still play an important role
  2. Improve quality of life in last few weeks/days
  3. Assess mobility
  4. Educate patient and family on mobility decline
    • (just for that specific point in time –> might deteriorate) –> let family know
  5. Teach family how to assist with mobility
    1. In/out of bed
    2. Bed mobility
  6. Teach family how to use mobility equipment, e.g. hoist; slide sheets
  7. Positioning
  8. ADVOCATE for palliative care referral if not yet completed!
32
Q

When do we cease physiotherapy?

A
  1. Goals of care
    1. Return home? Mobility
    2. Transfer to palliative care unit?
    3. Remain on hospital ward?
  2. Prognosis – days / weeks / months
    1. Just allow them to talk to family
    2. Get patient up (still allow them to do what they want)
  3. Patient wishes
  4. Family wishes
  5. Multidisciplinary team meetings
    1. Consider the impact of not visiting patient each day (from patient perspective
  7. Make sure still care once in palliative care
33
Q

What do I say if someone starts talking about dying/death (3)?

A
  1. Address patient’s fears
  2. Be open and honest
  3. Don’t give false open (with time, most patienst can deal with thenenews but incorrect information)
34
Q

What are 5 issues specific to ICU?

A
  1. Very visible bed spaces – poor privacy during very emotional times
  2. Death occurs in ICU more commonly than on wards due to very unwell and complex patients (not as often as you think)
  3. Tertiary centres (large hospitals) – very complex patients
  4. Not every one can be “fixed”
  5. Types of conditions:
    1. Attempted suicide –eg. Hanging
    2. Overdose
    3. Freak accidents
    4. Burns
    5. Trauma
    6. Serious infections
    7. Respiratory failure
35
Q

What are 7 types of conditions as issues specific to ICU?

A
  1. Attempted suicide –eg. Hanging
  2. Overdose
  3. Freak accidents
  4. Burns
  5. Trauma
  6. Serious infections (Physio quite involved)
  7. Respiratory failure (Physio quite involved)
36
Q

What are 2 characteristics of media for the critically ill or dying patient?

A
  1. Can be difficult to manage
  2. Can become involved due to issues relating to cause of illness/injury
37
Q

When to treat, when not to treat as IU related issues?

A
  1. How aggressive to be
  2. Brain death / organ donation
    1. Involves many people across many teams
    2. Difficult decisions
38
Q

What is the definition of death?

A
  1. Irreversible cessation of all function of the brain of the individual
    • Brain death
  2. Irreversible cessation of circulation of blood in the body of the individual
    • Circulatory or cardiac death
39
Q

What are 6 following tests (no response) that conform brain death?

A
  1. Response to painful stimuli
  2. Pupillary light reflex: response of the pupil to light
  3. Corneal reflex: blinking response when the eye is touched
  4. Caloric reflex: nystagmus response when ice cold water is put into the ear canal
  5. Cough reflex: cough or gag reaction when the back of the throat is touched
  6. Ability to breathe when the person is disconnected from the ventilator

Done by 2 both doctors (highly experienced) at 2 different times = same conclusion

40
Q

What is a circulatory death?

A

Donation after circulatory death is considered when the patient is expected to die within 90 minutes of withdrawal of mechanical ventilation. If the patient is still alive after 90 minutes, donation can not proceed

41
Q

What are 4 confirmations of circulatory death?

A
  1. Immobility
  2. Apnoea
  3. Absent skin perfusion
  4. Absence of circulation evidenced by absent arterial pulse for a minimum of 2 minutes
42
Q

What are 5 charcateristics of physiotherapy and organ donation?

A
  1. Significant role in lung function and viability to transplant
  2. Aiming to keep chest clear
  3. Aiming to minimise amount of oxygen needed to maintain PaO2
  4. Continue physiotherapy treatment until donation surgery occurs
    • Not a rule for how often - work off ABG results/CXR/secretion amount
  5. RESPECT the family of the patient
    1. Very difficult time
    2. Be respectful of their wishes
43
Q

What are 3 issues specific to oncology?

A
  1. Can be risk of terminal haemorrhage:
    1. Risk only present with certain tumours
    2. Due to location
    3. Due to low blood counts
  2. Can be large burden of disease
  3. May have been unwell for a long period of time
44
Q

What are 3 risks of terminal haemorrage as issues specific to oncology?

A
  1. Risk only present with certain tumours
  2. Due to location
  3. Due to low blood counts (Low platelets)
45
Q

What are 5 charcteristics of End of life ESSENTIALS- education for acute hospitals?

NOT EXAM QUESTION

A
  1. Aim of online modules as per EOL essentials website:
    • Improve quality and safety of end-of-life care in hospitals
  2. Available to doctors, nurses and allied health professionals
  3. Free
  4. Self-paced
  5. Videos with examples of difficult conversations / situations and ideas with how to respond

PHTY3280 (17 decks)

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