Module 1: Palliative Care Flashcards
leading causes of death today?
- heart disease
- cancer
- stroke/cvd
- chronic lung disease
- trauma
- alzheimer’s
- diabetes
- influenza/pneumona
- kidney disease
- speticemia
11.
examples of steady decline?
20% of population
major cancer
age 60’s
hospice was developed for this group < 6 months to live
information on hospice
only medicare program tailored to EOL
requires prognosis < 6 months
15% of community dwelling die w/ hospice services
>50% cancer patients get hospice
average length of stay: 26 days
health care system issues w/ steady decline patients
hospice isn’t for everyone
very fragmented health care system that lacks continuity - everyone is just treating their organ/speciality leading to multiple specialists and no one feels responsible
great innacuracy with prognosis, & it limits ability to make best use of limited time
examples of slow decline with crises
25% of population
declining function w/ interspersed exacerbations, then unexpected death
progressive organ failure
age in 70s
health care system issues w/ slow decline
system is set up for crises by not slow decline
prognosis is unclear so hospice is not offered
continuity of care is interrupted by fragmented system & multiple hospitalizations
examples of prolonged dwindling?
- dementia & frailty
- >75 y/o
- afflicted w/ physical & mental disabilities
- interfere w/ ability to independently perform ADLs
- increase risk for further decline
- age 80s
aggressive care is associated with?
lower QOL & increased complications
barriers to quality care at EOL
poorly managed symptoms
lack of training for professionals
delayed access to hospice/palliatve care
poorly informed patients & families
lacke of appropriately prepared providers
palliative care information
can have palliative care while in ICU
based on need: for people with serious and complex illness, regardless of prognosis
can be provided together w/ approrpiate restorative or life sustaining treatment includig intensive care therapy
no limitation on CPR status/life support required.
provided by ICU team and/or palliative care consultant to primary team
hospice care information
based on prognosis for people expected to live < 6 months
strongly encourages the patient to forego restorative treatment and have concurrent care limitations such as DNR and no transfer to ICU
hospice team assumes primrary care responsibility
barriers to better integration of palliative care and critical care
unrealistic expectations for intensive care therapies on the part of patients/families/clinicians
misperception of palliative care and critical care as mutually exclusive/sequential rathr than complementary and concurrent approaches
conflation of palliative care w/ EOL or hospice care
concern tht incorporation of palliative care will hasten death, studies show it prolongs life & QOL
insufficient training of clinicians in communication and other necessary skills to provide high-quality palliative care
other barriers to better integration of palliative care and critical care
competing demands on ICU clinial effort w/o adequate reward for palliative care excellence
failure to apply effective approaches for system/culuture change to improve palliative care
consultative model vs. integrative model of palliative care
- expert palliative care through a palliative care consultation service - this is available at majority of US hospitals
- palliative care principles and process are incorporated as part of routine practice in ICU - less common
studies have shown that success can be reached in each model
principles of palliative care
interdisciplinary team
patient & family = unit of care: education & support, across illnesses & settings, berveavement support
attention to physical, social, psychological, spiritual
symptoms addressed in palliative care
pain
constipation
nausea & vomiting
diarrhea
bowel obstruction
anorexia & cachexia
delirium
depression
dyspnea
cough
loud respiration
hospice?
emphasis on QOL
need 6 months or less prognosis
have to forego additional curative care
physical factors affecting quality of life
functional ability
strength/fatigue
sleep & rest
nausea
appetite
constipation
pain
psychological factors for quality of life
anxiety
depression
enjoyment/leisure
pain distress
happiness
fear
cognition/attention
social factors for quality of life
financial burden
caregiver burder
roles and relationships
affection/sexual function
appearance
spiritual factors for quality of life
hope
suffering
meaning of pain
religiosity
transcendence
what does hospice include?
nursing care
PT/OT/SLP
medical social services
home health aid
homemaker services
medical supplies & appliance
MD services
short term inpatient care (respite, procedures)
counseling to patient and family
hospice criteria?
hospice criteria?
2 MDs estimate prognosis of < 6 months
recertify every 90 days x 2, then every 60 days
NP can be ‘attending’
end stage criteria?
decline in functional status
decrease tolerance physical activity
decrease cognitive ability
palliative performance scale < 50
dependent in 3 of 6 ADLs
symptoms at rest that significantly interfere w/ QOL
Physical ADLS?
DEATH
dress
eat
ambulate/transfer
toileting/continenece
hygiene - bathing/grooming
how do you measure progressive decline in palliative patients?
PPS - palliative performance scale
it’s a valid reliable funcitonal assessment tool that is based on the Karnofsky Performance Scale
how is the PPS physical performance measured?
10% incremental levels from fully ambulatory 100% to death 0%
how is PPS differentiated further?
degree of ambulation
ability to do activities/extent of disease
ability to do self care
food/fluid intake
level of consciousness
additional end stage criteria?
frequent >2 ER visits or hospital admissions
issues with nutrition
loss >10% body weight over 4-6 months = poor prognostic sign
terminal diagnosis (prognosis < 6 months)
diagnosis specific criteria (by system)
what are some hospice diagnoses?
terminal illnesses
cancer, dementia, ESLD, COPD, ESRD, HIV/AIDS, CVA/coma, chronic neurodegenerative disease, failure to thrive, heart disease,
who gets hospice?
10% non white - african americans have stronger preference to continue treatment
51% women
71% with cancer
diagnoses of those in hospice
43% cancer
57%: dementia, esrd, chf, copd, als
who is most likely to refer for hospice?
medical generalist, geritrician & family practitioner
hospice outcomes?
longer survival: CHF, lung cancer, pancreatic cancer
lower costs without shorter life
lower use of acute care at EOL
late enrollment is associated with poor patient QOL, depression/mortality in bereaved.
r
barriers to hospice
late referrals
culture/racial preferences
low income & educational level
distrust of system
need for primary care provider to agree to prognosis
opportunities in ICU for palliative care
untreated pain and symptoms
failure to address other needs
poor communication - comprised decision making –> worse experience
gap between patient preferences & treatment, delayed start of appropriate care plans
use of therapies with burdens greater than benefits.
what are some simple communication interventions?
“get to know me” poster
identification of surrogate decision maker
advanced directive status
give printed materials for family infomation
breavement brochure
impact of family meetings & printed materials?
element: proactive, protocalized family meetings with distribution of printed informational materials
90 day follow up showed lower prevalence & severity of PTSD related symptoms
prevalence & severity of anxity & depression
what does proactive communication give you?
greater family satisfaction & comprehension
earlier implementaiton of appropriate care plans
reduced use non-beneficial treatments (ICU, LOS & conflict re care goals)
efficiences & other benefits w/o increased ICU mortality
what beneftis are there with increased family satisfaction w/ clinical statements?
- assure patient will not be abandoned before death
- assure patient will be comfortable and will not suffer
- support for family decisions about end of life care, including decision to withdraw or continue life support
what are issues with professional burnout/moral distress
- 40% critical care nurses feel they’ve acted against their conscience caring for dying patients
- assocaited with increased prevalence of PTSD symptoms in critical care nurses
- high level of burnout in intensivitis, prevalance & associated factors
key points of palliative care?
- communication is key
- palliative care is a continuum
- provide patients & family opportunities for informed autonomous decision making
- death today is preceded by 2 years of disability and a prolonged process in the hospital.
- a progressive deterioration with crises
- mean hospice LOS is only 26 days
- authority to send to hospice?
- MD must certify for hospice and incapacity
- NP may be attending for Hospice and do MOLST
points for code status and goals of care discussion
establish setting - ensure comfort and privacy - introduce the subject
what does the patient understand
what does the patient expect?
listen carefully to the patient’s response
discuss a DNR order - never say do you want use to do ‘everything’ it’s unclear
respond to emotions
establish a plan
ask them what they know about CPR
palliative care methods for pain & conspitaion?
pain: assess, multimodal approach, nonpharmacologic, pharmacologic (opioid, NSAID, neuromodulators), anticipate & manage side effects
Constipation: causes: opioids, immobility, poor fluid intake, prophylax, stool softner and laxative, stimulants (senna, bisocodyl) osmotic agents )sorbitol, lactulose, after 4 days enema or disimpaction
paliative care methods for nausea & vomiting
D/t drugs & toxins: chemoreceptor trigger zone: vomiting center; teatments; dopamine antagonist (haloperidol - used a lot post op); prokinetic agent (metoclopromide); serotonergic antagonists (ondansetron, granisetron)
the gut: treatments, motility agents (metoclopromide); serotonin antagonists (ondansetron, granisetron); antihistamines (promethazine, hydroxyzine, meclizine, dimenhydrinate)
anorexa & cachexia
almost universal issue
treat dry mouth w/ saliva substitues
liberalize diet
appetite stimulants (Megesterol acetate)
how to deal with dyspnea
self report
treatment
O2 if sat is <90%
open window/fan
opioid to control respiratory drive
benzodiazepine to control anxiety
look for other causes
how to help w/ cough
excess fluid production, irritation of airway receptors
look for cause
nebulized local anesthetic
opioid - codeine, hydrocodone, methadone for longer duration of action
dextromethorphan help w/ loud respirations
death rattle
family education
scopolamine, hyoscyamine
how to deal with diarrhea
rare 7-10%
rule out excessive laxative use
check for fecal impaction
how to deal with bowel obstruction
50% patients w/ ovarian or GI cancer
median survival 3 months
high symptom burden (N/V/colic, abdominal pain)
treatment
endoscopic stent if focal
combination therapy
opioid, antispasmodics, antiemetics, antisecretory agents, corticosteroids
how to deal with delirium
distressing to patient and family
search for cause
non-sedating vs sedating antipsychotic
avoid benzodiazepines
how to deal with depression
underrecognized and treated
insomnia, anorexia, loss of interest, anhedonia, suicidal ideation
treatment
antidepressats, address other symptoms, talk therapy, PMH consult
nausea & vomiting
in 40-70% of patients w/ advanced cancer
causes: disease vs treatment
drugs (opioids)/toxins
gut: gastric irritation or distention, liver capsule stretch, stasis of bowel
biliary
GU, tumor, peritoneal irritation
other sites: vestibular apparatus, cerebral cortex)
treatment: scopolamine, meclizine, hydrobromide
in the cerebral cortex - increased ICP treatment is dexamethasone
example of motility agent
metoclopromide
example of serotonin antagonist
odansetron, granisetron
example of antihistamines
promethazine, hydroxyzine, meclizine, dimenhydrinate
causes and treatments of vestibular apparatus nausea & vomiting
causes: drugs (opioids), labryinthitis, acoutic & other tumors
treatments: scopolamine, meclizine, hydrobromide
cerebral cortex causes & treatments for N/V
causes: increased ICP, CNS malignancy
treatment: Dexamethasone, 8 mg PO/IV/SubQ
type & order for surrogate?
in Maryland..
written advanced directives (patient’s wishes or best interest)
guardian of the person
spouse or domestic partner
adult child
parent
adult brother or sister
friend or relative
what does molst do for us? (Medical Orders for Life Sustaining Treatment)
standardized medical order form
coveres options for CPR & other life sustaining treatments
portable & enduring
valid in all health care ettings & in the community
helps increase the likelihood that patient’s wishes regarding life sustaining treatments are honored
when must a MOLST form be completed?
a patient is admitted or transferred to
a nursing home
assisted living facility
home health agency
hospice
kidney dialysis center
hospital patients *not required for ER, observation, or short stay patients
NP who signs MOLST order form is responsible for ….
discussing with & have patient / surrogate informed consent
if patient denies either then they become a full code with full life sustaining treatment
section 1, CPR status must be completed for everyone
ensure orders are consistent with patient’s wishes
give copy to patient/surroagte within 48 hours
revise orders at request of patient/surrogate
a copy accompanies patient if they are transferred
when can a surrogate authority withhold life sustaining treatment
- must certify patient’s incapacity
- 2 MDs certify condition
- terminal: incurable, no recovery, imminent death
- end stage: advanced, irreversible, severe permanent deterioration
- persistent vegetative state: no awareness self/surroundings, reflex activity only
3.or 2 MDs certify that treatment is medically ineffective for this patient - meaning it will not prevent or reduce deterioration (generally neurologist, neurosurgeon, specialist in cognitive function)
when are MOLST orders reviewed
annually
patient transferred between health care facilities (receiving facility reviews)
patient is discharged
patient has substantial change in health status
patient loses capacity to make health care decisions
patient changes wishes
when might you withdrawal life support
patient is experiencing irreversible terminal illness / life support is postponing an unavoidable death
anticipated outcome from continued care is state of health inconsistent with patient’s wishes via medical record, family or surrogate decision maker
how do you go about withdrawal of life support?
discuss plan with multi D team, family and patient if they are consious and possess decision making capactiy
consider consulting palliative care, pastoral care and ethics if needed
prepare patient and family with what may occcur
comfort/sedation, help w/ respiratory effort,
discuss plan with all staff involved: respiratory therapy, nursing to make sure everyone is comfortable with the process
can you use neuromusclar blockade during withdrawal?
no…it’s prohibitied
should be stopped and appropriate reveral implemented prior to withdrawal
can you remove tubes/drains if there is going to be an autopsy?
no
what is definition of death
irreversible apnea & unconsciousness in absence of circulation
- heart stops beating
- breathing stops
- pupiles fixed & dilated
- pale and waxen color
- temperature drops
- muscles relax
- jaw falls open
- eyes remain open
- urine & stool released
conditions that can mimic death
hypothermia
prolonged immersion in cold water
alcohol or drugs - TCAs barbiturates, anesthetic agents
suddent cause of somatic death - airway obstruction, electric shock, lightening strike
coma - hypoglycemia/hyperosmolar state, myxedema, hepatic encephalopathy
how do you pronounce death
observe for a minimum of 5 mintes
cardiac function for > 1 minute - absent heart sounds & central pulse (can look at ECG, arterial line, echo)
respiratory function for > 1 minute - absence of breath sounds & visible chest movement
neurological function > 1 minute - absent pupillary responses to light, corneal reflexxes, motor response to supra orbital pressure
post mortem examination sequence?
inspection: dilated pupils, corneal reflex, corneal cloudines, fundi for segmentation of retinal blood colums, trunk for post mortem staining
palpation: major pules, muslce tone for rigor mortis (>3 hours after death), loss of eye tension, temperature < 35
ausculatate heart & lungs: x 1 minute & repeat at intervals
