Palliative and Hospice care Flashcards
1
Q
What is Palliative Medicine?
A
- Palliative medicine was formally
recognized by the American
Board of Medical Specialties in
2006. - It is a holistic, team-based care
approach for patients and their
families experiencing serious
illness. - Palliative medicine is practiced
in a variety of settings, and
adaptable to patient
populations and available
resources
2
Q
High-level evidence for palliative care:
A
- improves patient and family quality
of life - reduces healthcare cost and
utilization - reduces patient/family financial
burden, and in some cases, - improves survival and length of life.
3
Q
Two main barriers identified to referrals for palliative care
A
- The awareness of palliative care services among pts their
families - The tendency of clinicians to equate palliative care with end of
life care
4
Q
àOver half of hospice patients are
enrolled in hospice for ___ days or less
A
30
5
Q
How can you increase awareness of and utilization of Palliative Care?
A
- Perform the basic physical, psychological, Psychiatric, social, spiritual assessments and document patient choices and goals of care discussions in any specialty
do you practice.
v Document and sign POLST forms
v Document code status
v Bill for advanced care planning
6
Q
Criteria for Obtaining a Palliative Consult - Primary
A
- The “surprise question”
- Difficult to control physical or psychological symptoms
- ICU stay >7 days
- Lack of documented goals of care (POLST, AD, living will)
- Disagreement or uncertainty among pt, staff or family (i.e.
prognosis, GOC)
7
Q
Criteria for a Palliative Medicine Consult - Secondary
A
- Awaiting or deemed ineligible for organ transplant
- Emotional/spiritual/existential/relational distress
- Request for palliative/hospice services
- Patient is a candidate/receiving consultation for:
- Feeding tube
- Tracheostomy
- Initiation of dialysis
- Ethics concerns
- LVAD or AICD
- LTACH placement
- Bone marrow transplant
8
Q
Interdisciplinary Team Assessment for palliative care
A
- Palliative assessment builds on the medical H&P by including
holistic and comprehensive aspects of patient’s needs - Each member of the interdisciplinary team performs their own
assessment and then develops their own plan of care based on
their skills and scope of practice & scope of competence
9
Q
Biopsychosocial Assessments for palliative care are interested in determining:
A
- how a patient is processing the
information about disease
management and prognosis, - how they are adapting to any changes
in functional status, change to their
identity, daily routine, and - how the patient/family are coping with
the burdens, condition or prospect of
dying
10
Q
Fentanyl transdermal
A
- efficacy based on pt’s amount of
available fatty tissue (think about
cachexia, muscle wasting, etc) - Preferred in renal failure
- DON’T GIVE TO OPIOID NAÏVE
PATIENTS, please
11
Q
Symptom Management in palliative care: Continuous Pain
A
- Combine Short/Long Acting Opioids/Opiates
- Find the initial effective dose
- Start SA PO opioid q1-2h PRN for 1-2 days
- Record how may PRN doses uses & ask about SE, efficacy (pain scale)
- Goal is PRN 1-3 times/day
12
Q
Nausea symptom management: V.O.M.I.T
A
- Vestibular – Receptors: cholinergic, histaminicà scopolamine,
promethazine - Obstruction (non-mechanical) – Receptors: cholinergic, histaminic,
5HT3 –> stimulate the mesenteric plexus/Senna - (dys)Motility – Receptors: same as obstruction + 5HT4 à prokinetic like
metoclopramide - Infection/Inflammation – Receptors: same as obstruction +neurokinin1
- Toxins – Receptors: dopamine 2, 5HT3à
13
Q
The 5 Disease Trajectories
A
- Sudden Death
- Terminal Illness
- Major Organ Failure
- Frailty/Debility and Failure to Thrive
- The Catastrophic Event
14
Q
Sudden Death
A
- Sudden cardiac arrest,
aortic/abdominal dissections,
stroke, trauma/homicide/suicide,
drug overdose - The lesson: there is no time to
prepare or tie up loose ends - Therefore, it is never too early to
talk to your patients about
advance planning; even if they are
in optimal health
15
Q
Terminal Illness
A
- Cancer, tuberculosis
- Opportunity for advance care
planning, palliative, hospice,
“getting affairs in order” - Slow steady decline followed
by precipitous decline then
death
16
Q
Major Organ Failure
A
- Progression or “normal disease
trajectory” of chronic diseases
such as: heart failure, kidney
disease, pulmonary
disease/COPD, PHTN, some
neurological diseases - Slow, progressive decline in
function punctuated by crises
or exacerbations
17
Q
Frailty/Debility
A
- Dementia, Parkinson’s, other
neurodegenerative diseases - Crises are rare and changes in
status are sometime
imperceptible - Slow, protracted decline
- Exacts a heavy toll on
caregivers
18
Q
The Catastrophic Event
A
- Stroke, Hip fx, MI, fall/trauma
resulting in brain injury
19
Q
Five signs emerge most during the last 3 days before death:
A
- Pulselessness of the radial artery
- Respiration with mandibular movement
- Decreased urine output
- Cheyne-Stokes breathing (apnea on/off)
- Death Rattle (terminal respiratory secretions)
20
Q
Eight Additional Death Signs
A
- Non-reactive pupils
- Decreased Response to verbal stimuli
- Decreased Response to visual stimuli
- Inability to close eyelids
- Drooping of the nasolabial fold
- Hyperextension of the neck
- Grunting of the vocal cords
- Upper gastrointestinal bleeding
21
Q
Signs of Imminent Death
A
- Weakness, fatigue, functional decline
- No longer able to independently transfer
- Decreased oral intake
- No evidence to back increased caloric intakes alters course
- Are they dehydrated?
- Strong debate for & against parenteral fluid
- Non-oral routes of drug administration may be needed
22
Q
Death Rattle
A
- Accumulation of airway secretions & decreased ability to
swallow - Usually due to fatigue or neurological dysfunction
23
Q
Death rattle symptoms
A
- Symptoms: gurgling, crackling, dyspnea, agitation, decreased sleep, coughing
spells, predisposes to infections (pneumonia) - Distressing to family
- Educate & reassurance
- Some Solutions:
- Positioning
- Encourage to cleanse the mouth
24
Q
Hospice Benefit INCLUDES
A
- Services from a hospice-employed physician, nurse practitioner (NP), or other physicians (PA - ahem)chosen by the patient
- Nursing care
- Medical equipment
- Medical supplies
- Drugs to manage pain and symptoms
- Hospice aide and homemaker services
- Physical therapy
- Occupational therapy
- Speech-language pathology services
- Medical social services
- Dietary counseling
- Spiritual counseling
- Individual and family or just family grief and loss counseling before and after the patient’s death
- Short-term inpatient pain control and symptom management and respite care
25
To qualify for hospice:
* A principal hospice diagnosis (ICD-10)
* A prognosis of 6 months or less based on the clinical guideline established if the disease follows its “usual course”
26
T/F you can initiate palliative care at the diagnosis of a diagnosis
T
27
Documenting Decline: Clinical Status
* Recurrent or intractable serious infections such as pneumonia, sepsis
or pyelonephritis
* Progressive inanition as documented by:
* Weight loss of at least 10% body weight in the prior six months, not due to reversible
causes such as depression or use of diuretics;
* Decreasing anthropomorphic measurements (mid-arm circumference, abdominal girth),
not due to reversible causes such as depression or use of diuretics;
* Observation of ill-fitting clothes, decrease in skin turgor, increasing skin folds or other
observation of weight loss in a patient without documented weight;
* Decreasing serum albumin or cholesterol.
* Dysphagia leading to recurrent aspiration and/or inadequate oral intake documented by
decreasing food portion consumption
28
Documenting Decline: Signs & Labs
* Decline in systolic blood pressure to below 90 or progressive postural hypotension;
* Ascites;
* Venous, arterial or lymphatic obstruction due to local progression or metastatic disease;
* Edema;
* Pleural/pericardial effusion;
* Weakness;
* Change in level of consciousness.
29
T/F Lab testing is not required to establish HOSPICE eligibility
T
30
