Palliative care/end of life

Question 1

Palliative Care:

Answer 1

an approach that improves the quality of life of patients & their families facing the problem associated with life-threatening illness, through the prevention & relief of suffering by means of early identification & impeccable assessment & treatment of pain & other problems, physical, psychosocial & spiritual.

Question 2

End-of-life Care:

Answer 2

Generally refers to the last few days of life when a
person is irreversibly dying, AKA the terminal phase (difficult to identify)

Question 3

Hospice:

Answer 3

a health care delivery system under which support & services
are provided to a patient with a terminal illness, focus is on comfort rather
than curing an illness.

Question 4

Palliative care acknowledges:

Answer 4

• Uncertainty
• Potential for suffering in a potentially
  life-limiting condition (ie cancer)
• How a family defines quality of life &
  suffering for their child
• A framework for decision making
  between care provider & the family

Question 5

Mainstay of outpatient care for most pain

Answer 5

NSAIDS

Question 6

PAIN MANAGEMENT:
IV OPIOID ANALGESICS

Answer 6

• Severe pain not responsive to oral opioids
• IV opioid titration to relief
• Based on severity, location of pain, & age
• Bolus dose
• Continuous IV infusion
• Patient Controlled Analgesia (PCA)
• Patients ≥ 6 years old (morphine, hydromorphone)
• IV ketorolac (NSAID) may also be used

Question 7

PSYCHOSOCIAL SUPPORT:
PATIENT & FAMILY in palliative care

Answer 7

• Answer child questions openly & honestly
• Guide &/or support parents in discussions about
  death/dying with the patient & siblings
• Support for making funeral arrangements,
  financial concerns

Question 8

CHILDREN’S CONCEPT OF DEATH:
TODDLERS

Answer 8

• Cognitive Development
• Egocentric, concrete thinking
• No cognitive understanding of death
• Response to Stress?
• Irritability, changes in sleep-waking, clinginess,
  regression, tantrums

Question 9

Helpful interventions for Toddlers in palliative care:

Answer 9

• Maintain routines
• Keep familiar people & objects at hand
• Prompt response to physical &
  emotional caretaking needs
• Accept need for increased physical &
  emotional comfort
• Continue acquisition of developmental skills

Question 10

CHILDREN’S CONCEPT OF DEATH:
EARLY CHILDHOOD

Answer 10

• Cognitive Development
• Developing some concept of time
• Limited sense of time permanence
• Curious but concrete in thinking
• View death as deliberately caused
• Magical thinking about causes of illness & death
• Death is not a permanent state

Question 11

Helpful interventions for Early childhood in palliative care

Answer 11

• Simple, concrete explanations to questions
• Find out what they want to know
• Reassurance that death & illness are not the
  result of their thoughts or wishes
• Keep familiar people & objects at hand
• Play!

Question 12

CHILDREN’S CONCEPT OF DEATH:
MIDDLE CHILDHOOD

Answer 12

• Cognitive development
• Beginning to apply logic
• Accept points of view other than their own
• Death is seen in context of experience
• Pets, grandparents, TV/Movies
• Can understand death is permanent

Question 13

Helpful Interventions for palliative care in middle childhood children

Answer 13

• Find out how they perceive & understand what is
  happening & respond accordingly to their questions
• Acknowledge feelings of sadness, fear, & anger as
  normal
• Allow age-appropriate control (whenever possible)
• Maintain normal routines (whenever possible)
• Play!

Question 14

CHILDREN’S CONCEPT OF DEATH:
ADOLESCENCE

Answer 14

• Mastering themselves as individuals
• Developing moral, ethical,
  & spiritual beliefs
• ↑ reliance on peers for emotional support
  & information
• Adult awareness of death develops

Question 15

Helpful interventions for adolescence in palliative care:

Answer 15

• Open, honest communication
• Allow as much control as possible in
  decisions about own health care
• Discuss & respect wishes
• Disposition of belongings, funeral
  planning, what happens to their body
• Assist patient in accomplishing important life tasks & activities that give meaning to life
  and/or legacy

Question 16

High risk for complicated grief reactions

Answer 16

• Absent grief, delayed grief, & prolonged or
  unresolved grief
• Siblings are also at risk for complicated grief
  & require special attention

Question 17

T/F Grief is an illness

Answer 17

F - * NOT AN ILLNESS
* Presents as pervasive
distress due to a
perceived loss

Question 18

5 Circumstances to Consider Withdrawal of Medical Life Support

Answer 18

1. Brain death
2. Persistent vegetative state (PVS)
3. Treatment will delay death
   without significantly relieving the suffering caused by the condition
4. Child’s life may be saved, but at
   the cost of physical & mental impairment that makes life intolerable for the child
5. Additional treatment with potential benefit will cause further suffering

Question 19

Persistent vegetative state (PVS)

Answer 19

• Child totally dependent for all cares, has no ability
  to interact meaningfully with his environment.
• Lack of cortical peaks in the somatosensory
  evoked potential may be helpful in making
  prognosis of PVS (Tournay, 2000)

Question 20

WITHDRAWAL OF MEDICAL LIFE SUPPORT: discussion points with family

Answer 20

• Have a gentle but frank discussion with the family
• Discern their understanding of the child’s situation & prognosis
• Be sensitive & do not demand immediate answers
• It may take several conversations
• Spiritual support may be helpful & should be offered
• Help them identify & define what quality of life means to their child & family
• What would be an intolerable life for the child?

Question 21

WITHDRAWAL OF MEDICAL LIFE SUPPORT: Present in a clear & understandable format the child’s:

Answer 21

1. Medical condition
2. Test results
3. Treatments attempted
4. The child’s ability to survive or function & interact with his environment
5. Why current or additional treatment will be futile or cause suffering

Question 22

ADVANCE CARE PLANNING steps:

Answer 22

1. Identify decision makers
2. Asses the patient/family’s
   understanding of the illness
   & prognosis
3. Goals of care are determined for current & future intervention
4. Decide on use or abandonment of life-
   sustaining techniques & aggressive medical
   interventions

Question 23

Advanced Directives (AD)

Answer 23

→ Oral & written instructions for future medical care
* E.g. Living Will, 5 Wishes

Question 24

5 Wishes

Answer 24

• A document that allows persons to state their wishes:
• Who can make decisions for them
• Type of medical treatment wanted
• How comfortable they wish to be
• How they want people to treat them
• What they wish their loved ones to know/thelastvisit.com/wp-

Question 25

ONCE THE FAMILY MAKES THE DECISION TO WITHDRAW SUPPORT CREATE A PLAN, which includes:

Answer 25

• Time & place of withdrawal?
• Who will be there with them?
• Specific requests for environment?
• Who will perform the withdrawal?
• Explain what the anticipated course
  will be following withdrawal of support
• Offer the opportunity for rituals, prayer, or private time prior to or during the withdrawal
• If death is anticipated quickly after withdrawal, any specific religious requirements for the body after death should be arranged in advance