N304: Palliative

Question 1

How are the terms “hospice & palliative care” used in Canada?

Answer 1

In Canada, the terms “hospice” and “palliative care” are often used interchangeably to denote a philosophy of care. In fact the term “hospice palliative care” has been adopted by the Canadian HPC Association and utilized to indicate the integration of care throughout a variety of settings. In addition, the word “hospice” may refer to a place of care.

Question 2

Describe the term hospice

Answer 2

Primarily a ‘concept’ of care- not always a specific place of care, but often combined

i.e. a specific philosophy of and/or approach to care rather than merely a type of building or service, or both.

Question 3

Describe the term palliative care

Answer 3

Palliative care is an approach that improves the quality of life of patients and their families facing the problem 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.
-guided by the principles of Primary Health Care: accessible, participatory, interprofessional, health promoting, uses appropriate technology/skills

Question 4

What are the concepts of palliative care?

Answer 4

• affirms life/regards dying as normal process
• neither hastens nor postpones death (relieve suffering)
• provides relief from pain/other symptoms
• integrates psychological/spiritual aspects of care
• offers ongoing support systems to dying pts. and family members

Question 5

What is mean’t by “Palliative Care is a human right”

Answer 5

An ageing population, a growing incidence and prevalence of cancer, and a growing HIV/AIDS epidemic has brought increased attention to palliative care as a public health issue and a human right.

Question 6

What is the curative focus?

Answer 6

Diagnosis of disease & related symptoms
Curing of disease
Treatment of disease
Alleviation of symptoms

Question 7

What is the palliative focus?

Answer 7

Pt/family identify unique end-of-life goals
Assess how symptoms, issues are helping/ hindering reaching goals
Interventions to assist in reaching end-of-life goals
Quality of life closure

Question 8

What are the guiding principles of hospice and palliative care?

Answer 8

1. Person/family centered = basic ‘unit of care’
2. Ethical
3. High Quality
4. Team –based/Circle of Care
5. Safe and Effective
6. Accessible
7. Adequately Resourced /sufficient to support HPC activities
8. Collaborative
9. Advocacy-Based
10. Evidence-Informed/Knowledge-Based

Question 9

What are the goals of palliative care?

Answer 9

• Assure pt. receives excellent pain control/other symptom(nausea, dyspnea, secretions)/comfort measures
• Give pt. information needed to participate in care decisions
• offer ongoing emotional/spiritual support
• obtain expert help in planning care outside hospital i.e. Discharge Planning

Question 10

What is evidence based palliative care?

Answer 10

• Evidence-based practice is the conscious, explicit and judicious use of current evidence in making decisions about the care of individual patients.
• It is more difficult to measure quality of life and altered outcomes in patients and families whose illness or frailty make it difficult to collect data.
Outcome and quality of life measures need to be sensitive to the wider aspects of palliative care, not merely mortality, function, or absence of symptoms.
• Those working in palliative care must use existing research through appropriate systematic reviews to maximize the value of data yielded in caring for patients and families.

Question 11

Why do we need to use evidence based practice?

Answer 11

To provide the best care possible and…
To help:
• Inform health care providers, patients and families.
• Educate health care providers and the public.
• Include all members of the health care team.
• Improve clinical decision-making.
• Reduce variation in professional practice e.g. reduce preconceived notions such as “the pt. is drug seeking”
• Ensure equitable allocation of resources.
• Measure the quality of our care.
• Identify opportunities for improvement.
• Improve management of the health care system.
• Provide a foundation for the future.

Question 12

Describe quality of life

Answer 12

There are many models of quality of life, the important aspect is that they encompass all dimensions and focus on what is important for the patient and the ‘family’.

Question 13

What are the 4 domains of quality of life?

Answer 13

1. physical: functional ability, strength/fatigue, rest & sleep, nausea, appetite, constipation, pain.
2. psychological: anxiety, depression, enjoyment, leisure, pain, distress, happiness, fear, cognition, attention.
3. social: financial burden, caregiver burden, roles/relationships, affection/sexual function, appearance.
4. spiritual: hope, suffering, meaning of pain, religiosity, transcendence.

Question 14

What is bereavement?

Answer 14

• Bereavement is the time we spend adjusting to loss.
• There is no standard time limit and there is no right or wrong way to feel during the bereavement period
• everyone must learn to cope in their own way. The time spent in a period of bereavement may depend on how attached the person was to the person who died, and how much time was spent anticipating the loss.
• As with grief, it is individual and complex.
  Bereavement counselling can offer an understanding of the mourning process and explore areas that could potentially prevent you from moving on.

Question 15

What are the 7C’s of quality hospice palliative care

Answer 15

Competence
Consistency
Coordination
Climate
Cooperation
Communication
Compassion

Question 16

What are the 6 dimensions of palliative care?

Answer 16

1. preserving integrity
2. doing for
3. valuing
4. finding meaning
5. empowering
6. connecting

Question 17

Describe how end of life is a personal experience

Answer 17

Completion with worldly affairs
Completion of community relationships
Meaning about one’s individual life
Love of self
Love of others
Completion of family/friend relationships
Acceptance of the finality of life/ ‘Fading away’ with dignity and at peace
New self beyond personal loss
Meaning about life
Surrender to the unknown
“Letting go”

Question 18

HPC services in Fraser health: Clients served

Answer 18

Patients and families with a life threatening illness or facing end of life issues
Anticipated prognosis of weeks or months rather than years
Primary intent of treatment is improved quality of life not cure of disease.
Patient/family agree to the referral or to consultative support
DNR/”No Code” Status will be required for admission to a Hospice Unit but NOT for admission to the Program.

Question 19

Fraser health: patient services available

Answer 19

visits by a Home Care nurse
community health care workers
support from consultation team for managing symptoms such as pain and nausea
family conferences
grief and bereavement counseling
hospice volunteer visits
access to Hospice Facility/ specialized hospital beds(tertiary beds) in acute care.
equipment and supplies

Question 20

Role of the community palliative team.

Answer 20

Education and support to care providers, the community, individuals and families
Consultation around pain and symptom management, discharge planning
Coordination and planning of care
Participation in case conferences
Services in residential care, acute care, and in the community

Question 21

Why consult?

Answer 21

Any health care provider can ask for advice and support from the team members re:
pain & symptom management
psychosocial issues
ineffective family or caregiver coping
care planning
end of life issues
assessment re: need for hospice, acute or tertiary palliative care bed

Question 22

Settings for care

Answer 22

Tertiary Hospice Palliative Care Unit(Burnaby) 
Acute care ( SMH, PAH, ARH)
Hospice beds (Burnaby,Tricities, Delta)
Home
Residential care

Question 23

What are some situations where it is appropriate for referral to tertiary?

Answer 23

difficult pain syndromes
complex physical symptom assessment/management
complex psychological/spiritual/social issues
significant family /caregiver distress
extensive support required to improve QOL
complex care planning exceeding resources at present community site

Question 24

What is acute care?

Answer 24

Short stay beds are utilized for patients requiring diagnostic tests and treatment
Consultation from the Hospice Palliative team can occur in acute care

Question 25

What is the admission criteria to hospice?

Answer 25

End-stage, length of stay (LOS) maximum 3 months with average expected to be 16-22 days
Symptom management plan in place
DNR (Do Not Resuscitate) must be written
Patient may be admitted under family physician
Family physician involves consultation team
FH resident with patient placement as close to own community as possible.

Question 26

How does one qualify for residential care?

Answer 26

People with many months to live who cannot remain at home can be cared for in long term care facilities
Palliative care teams can be consulted to provide support to patients in a residential facility