palliative & end of life care Flashcards
difference between conventional, and complementary and alternative medicine (CAM); what happens when you put together conventional w CAM therapies
conventional = healthcare system (MD, OD, PTs, psychs, nurses, etc)
CAM = adjuncts; stuff that might have proven/questionable evidence for their use
- complementary = additional
- alternative = in place
integrative medicine
other terms for conventional medicines
western/allopathic
chemo vs rad therapy
chemo - delivered intravenously; systemic treatment that targets rapidly dividing cells (hallmark of cancer cells) but it also affects other rapidly dividing cells throughout the body (e.g., hair follicles, GI tract, bone marrow); metastasized cell
rad therapy - radiation focused on a specific area in the body; mostly has side-effects for region/s near cancer cell site; for cancer cells that havent metastasized, earlier stages of cancer
if experiencing: anxiety
consider trying:
hypnosis, massage, meditation, music therapy, relaxation techniques
(integrative med)
if experiencing: fatigue
consider trying:
exercise, massage, relaxation techniques, yoga
(integrative med)
if experiencing: nausea and vomiting
consider trying:
acupuncture, aromatherapy, music therapy, hypnosis
(integrative med)
if experiencing: pain
consider trying:
acupuncture, aromatherapy, music therapy, hypnosis, massage
(integrative med)
if experiencing: sleep problems
consider trying:
CBT, exercise, yoga, relaxation technique
(integrative med)
if experiencing: stress
consider trying:
aromatherapy, tai chi, yoga, relaxation techniques, meditation, exercise, massage, hypnosis, music therapy
difference of palliative care and hospice
palliative care = supportive care; may help with effects from condition and/or treatment; multidisciplinary symptom mgmt (esp. prescribed for conditions w great sx. burden)
hospice care = end-of-life care, focused on comfort and raising pt.’s QoL rather than extending life
compression of morbidity types describe
what it is - what it does for the pt.
1. present morbidity
- gets sick + no intervention; disease will run its course
2. life extension
- with current medical options, life is extended; pt. also carries the disease for longer
3. shift to the right
- pt. practices healthy habits when they were younger (e.g., good diet, exercise) so start of disease shifts to right/starts later in life, and they live a longer life
4. compression of morbidity
- sickness starts relatively later bc of healthy habits but pt. opts for natural course of disease = aka dying earlier but better QoL
when does palliative care start
it can start along with diagnosis and treatment
hospice duration
~6mos or less -> death
can still get hospice tx even if you have years left to live
bereavement
period after death
describe the multidimensional nature of pain (what other dimensions/disciplines are involved during care?)
physical, social, psychological, spiritual
[EXAM] types of pain and differentiate
nociceptive - nociceptive stimuli; source can usually be identified (fully relieved by narcotics/analgesics)
- somatic
- can usually be localized; tends to originate from superficial nociceptors
- visceral
- inflammation; hard to localize but there is a reference area, diffuse discomfort
neuropathic pain - associated with issues in CNS (chronic pain = central sensitization)
- nerve damage symptoms (sensory/motor impairments)
- only partially relieved by narcotics; anticonvulsants/depressants may be indicated depending on pain severity
levels of pharmacological interventions and their characteristics
1: MILD (non-opioid)
- acetaminophen, NSAIDs
- VRS = 1-3/10
2: MODERATE (opioid)
- addictive; only given for moderate-severe pain
- VRS = 4-6/10
3: SEVERE (opioid)
- VRS = 7-10/10
* adjuvant
- analgesics; usually target different dimensions of pain (e.g., comorbidities)
- antidepressants, anticonvulsants, corticosteroids, local anesthetics, and calcium channel blockers
palliative sedation mechanism and effects
given when terminally ill patients suffer from intractable or unendurable pain and management measures have little to no affect in alleviating the pain experience
- using sedatives to induce reduced levels of consciousness so that pt. experiences less pain
- side effect is that: the more pt is sedated, the more their respiratory system is depressed; eventually this leads to death
describe the line of morbidity, disability, and mortality
morbidity occurs first, followed by disability, ends in mortality ; d/t new technology the distance between morbidity and mortality is increasing bc there are more life-prolonging procedures
the ethical issue behind life-prolonging procedures
do these procedures prolong life and maintain QoL or do they just delay death?
good death concept (3 things)
- comfortable / free of discomfort
- around family
- in the environment you want
(focus, what is it not?) hospice care
cure, not care
often done at home or in nursing home
interdisciplinary hospice care team
physician, nurses, consultative professionals (PTs here), chaplains/spiritual leader, volunteers, home health aides, social workers/psychs
what do PTs do in hospice care? (3) give examples
- reduce pain
- optimize/improve remaining function
- enhance QoL
ex.: modalities, improve sleep and respiratory fx., reduce need for analgesics; energy efficiency/conservation pt educ. for pt. and family
models of therapy
rehab light
- performing light exercises while not depleting energy
rehab in reverse
- pt. gets progressively weaker so rehab activities get progressively lighter to accommodate decreasing ability
case management
- working with interdisciplinary hospice care team
specific tactics that PT can do in hospice care
- comfort care measures
- MLD to prevent edema
- therapeutic techniques (neurodevelopmental techniques; e.g., holding, rocking) to provide comfort
- ROM exercises to optimize movement
- pt. education regarding falls prevention (physically ability vs wanting to get out of bed)
- non pharm measures for pain mgmt (rocking, tens) - adaptive equipment and environment
- optimize environment to help with movement (e.g., trapeze, bedside commode)
- energy conservation techniques - exercise - to achieve functional goals, not just a way to spend time
describe progressive changes in terminal phase
month 6
- fxn is kinda fine; can ambulate, had some side effects from curative tx
- denial, anger
month 5
- physical weakness and weight loss
- depression & anxiety
month 4
- body is starting to fail
- loss of appetite
- hospice provides counselors to help w process
month 3
- beginning to withdraw
- pt. accepts theyre going to die/terminal disease
month 2
- increasing withdrawal
- sx. and pain increase
- may be bedridden at this point
month 1
- no appetite, care relies entirely on caregivers
- completely withdrawn; only close loved ones can interact w them
pain at the end of life
the main focus of hospice care process is to make sure there is as little pain as possible towards the end of life; comfort measures for pain mgmt, eventually palliative sedation that leads to death
other s&s at end-of-life (3)
delirium, fever, dryness of eyes and lips
delirium
MOST COMMON neuropsychiatric condition at the end of life
- global CEREBRAL dysfunction: disordered attention, awareness, cognition; may see visions
- stressful for pt. and caregivers
- seeing visions of dead family members
- difficult to initiate meaningful interaction
fever
- source isn’t looked for; invasive procedures are avoided bc comfort measures are focused on (pt.’s body may be adversely affected by getting culture samples)
- may be d/t chemo/rad therapy or infection
- measures to manage sx.
dryness of eyes and lips
- eyewash , viscine
- mouthwash
as the distance between morbidity and mortality grows,
it begs the question of prolonging life or delaying death; because would you rather a violent death, a “longer life” stuck in a hospital, or a death at home surrounded by loved ones?
legal and ethical issues in end of life care
1: right to die
2. palliative sedation
3. CV implants
4. advanced directives
right to die/self-determination
- physician aid in dying (PAD) or assisted euthanasia; giving pt. injection/certain amount of drugs (md provides means for pt to kill themselves)
palliative sedation
different from assisted euthanasia; palliative sedation is to alleviate pain, its effects however can lead to death while euthanasia is done to kill the pt. because they want to
CV implants
ex. pacemaker
- pt.’s choice if they want to stop it or have a directive to cut the machine at a certain point
- autonomy vs. non-maleficence/beneficence
- respecting the pt. free will or doing no harm
advanced directives
- pt.s can make this while theyre still alive
- living will, DNR/DNAR, DPOA, organ donor card, etc.
- living will: made before pt dies with instructions on what to do after their death
- dpoa (durable power of attorney): made before death with power to a representative/s for decision-making on what to do after pt. dies
circumstantial vs developmental loss
circumstantial loss
- happens out of nowhere; e.g., sudden death, fire, divorce, etc.
dev’tal loss
- comes with expected milestones/stage in life; e.g., kids moving out, retirement, death
stages of grief (pioneer of model and stages)
elisabeth kubler-ross
DABDA
- denial, anger, bargaining, depression, acceptance
“keen mental suffering or distress over affliction or loss; sharp sorrow; painful regret” (Random House, 2017)
grief
difference between clinical death, brain death, and persistent vegetative state
clinical death
- heart stops beating, lungs stop oxygenating blood
brain death
- 3 signs: coma, apnea, absence of brainstem reflexes
persistent vegetative state
- complex processes are absent and they can’t survive without life support but primal functions (e.g., breathing, blinking, swallowing) are present
what are the last hours of life called; duration
active dying - 24 hours
s&s when death is near
Pain
Delirium
Anxiety/restlessness
Dysphagia
Weakness/fatigue
Dyspnea
Myoclonus
Pressure injuries
Incontinence
Anorexia/nausea/vomiting
Arnold van Gennep, French folklorist, - model on rites of passage
separation -> transition, reintegration
steps for coping with grief (6)
Recognition of loss
Reaction to the loss (grief, sadness)
Recollection of deceased and memories
Relinquishing of ties/attachment
Readjustment of relationships, roles, etc bc deceased is gone
Reinvesting into new relationships, experiences
purpose of rites of passage (4)
- provide social support
- restore bereaved to society
- outline cultural obligations
- set limitations to formal mourning
rituals help with transition
“last offices” or “laying out”
preparing the body before mortician gets; nurses usually do this
complicated grief (DSM-V)
- prolonged grief (6+ months)
- intense longing or yearning for the deceased
- struggle with everyday tasks, form meaningful connections, etc.
- recurrent intrusive and distressing thoughts
risk factors for complicated grief
- sudden, pediatric, violent/MVA death
- disenfranchised mourners
- low socioeconomic status
- existing depression/anxiety
- death away from loved ones
personal grief (as health professionals)
Professional loneliness
Loss of professional meaning
Cynicism
Helplessness
Hopelessness
Frustration
Anger
Depression
Burnout
coping mechanisms for personal grief
prayer/meditation, exercise, writing, calling to family members/other clinicians, attending funerals and memorials
