Palliative, Hospice, and EOL care (Final) Flashcards
Palliative vs Hospice
Palliative: Paid by insurance, self. Any stage of disease, Same time as curative treatment, typically happens in hospital
Hospice: Paid by medicare, medicaid, insurance, 6 month prognosis (Main difference)
Palliative vs Hospice: What in common?
-Comfort care
-Reduce stress
-Offer complex symptom relief related to serious illness
-Physical and psychosocial relief
Palliative care has moved upstream based on multiple RCY that show benefit
Traditional Palliative Care
-Services were offered at the end-of-life stages
Modern Palliative Care
At the time of the life threatening diagnosis. Once there has been a 6 month prognosis then hospice care is called
Curative treatments
Hospice care you cannot (for the end of life) (Only comfort approach) (watch slide)
Palliative care you can
What if the patient lives longer then 6 months in hospice?
Is up the physician and life expecting still needs to be less than 6 months
-If that changes they can have a live discharge
Palliative and Hospice: Interdiscplinary
-Nurse
-Nurse Practitioner
-Physician
-Chaplain
-Pharmacist
-Social worker
Communication
-Is the fulcrum of all the care that is provided.
-Need conversations to figure things out. Like currative treatments
-If the acceptance of the patient is not there than maybe they are not ready for hospice or palliative care
Key Ideas
-Strong collaboration and communication between and among professionals is a prerequisite to communication with patients and families
3 conversations
Family meeting:
-Ensure key topics
-Ensure family understands information
-Provide emotional support
Nurse and family conversation:
-Elicits family’s goal and needs
-Elicit understanding of prognosis
-Provide emotional support
Nurse and physician conversation:
-Elicit physician perspective on prognosis and goals
Unique Communication Skills in the Nurse: Patient Relationship near end of life
-Develop and accurate and shared understadning of the patients situations including disease features, prognosis without treatment, psychosocial concerns and needs
-Respond empathically to patients’ emotions
It is importance to note that responding to emotions is not fixing the emotion
Hyperboleander
Remember that patients can not move forward if their emotions are not addressed. What is the nurse accepting reponse?
- Accepts what the patient says non-judgmentally
-Acknowledges that patients ought o hold their own views and feelings
-Validates the importance of the patients contributions in a therapeutic relationship
The “I WISH” statement
-Starting with I WISH demonstrates alignment with patient
-Implicitly acknowledges “it won’t happen”
NURSE statments
N: Name the emotions
U: Undestanding
R: Respect the role of the caregiver
S: Support
E: Explore
It is important to note that acceptance is not the same as agreement. It is important to note that acceptance is not the same as agreement. A physician could accept that a patient wishes to be cured of cancer, yet not agree that it is is possible.
The “I WORRY” Statement
-Shares a possibliyt of bad outcome
-“I worry that even with more machines that we will not be able to help him get better”
SILENCE IS
Empathic
-It shows support for the patinet
-Do not just sit there do something or Do not just do something sit there!
ACP
The frequency of ACP converstations between patients and HCP remains low in clinical practice
ACP
The process of discussing illness and end of life (EOL), clarifying values and goal, and preferences through written documents and medical orders
Early goals of care vs a late goals of care (Know These)
Living Will
A written document in which a patient wishes regarding the administration of medical treatment are described if the patient becomes unable to communicate in the setting of a serious or terminal medical conditions
MOST
A portable document of physician/provider medical order
Legal Advance Care Planning Documents in Kentucky
-Kentucky living will
-Five wishes
Kentucky Living Will
Living will form has two sections
1. Health care surrogate designation
2. Teratment wishes
You can also decide whether to donate any of your organs in the event of your death
-Requires 2 witnesses or it must be notarized. Law prohibits relatives, heirs, health care providers from being witnessses
Five Wishes
-An advance directive form that is legal in 42 states.
-It provides a means to a legally document choices for medical treatment, comfort, and care wishes
-Five wishes meets the legal requirements for an advance directive in Kentucky
-2 witnesses or notarized
Hot button issues
-Informed consent
-Withdrawing life sustaining treatment
-DNR’s
-Artificial Hydration / Nutrition
What influences EOL care
-Ethnicity
-Intercultural aspects
-Family and Relationships
-Class
-Generation
Death with Dignity - Medical Aid in Dying (MAID)
-Competent, terminally ill patient with a prescription for a lethal dose of medication, upon the patients request, which the patient intends to use to end his or her own life
-Not same as:
-Pain medication to hasten death
-Palliative sedation
-Euthanasia
The Dying Experience (Weeks - Months - Years)
-Social Withdrawal (weeks to months)
-Food (Decreases) (Body is prepping for death)
-Sleep (Not sleeping or sleeping a lot more) (Not AOx4)
-Disorientation
-Restlessness
-Decreased sense
-Incontinence
-Physical Changes (Lower blood sugar) (higher heart rate)
Syndrome of Imminent Dying (Hours - Days - Weeks)
Early:
-Bed Bound
-Lost of intrest of drink
-Cognitive changes - Increase time sleeping delirium
Middle:
-Further decline in mental status to obtundation (slow to arouse, brief periods of wakefulness)
Late:
-Death rattle
-Coma
-Fever
-Altered respiratory pattern. (Long apnea between each breath) (Wait for infants)
-Mottled extremities
Family Concerns
-Is my loved on in pain?
-Aren’t we just starving my loved one?
-What should we expect; how will we know that time is short
-Should I/we stay by the bedside?
-Can my loved on hear what we are saying?
-What do we do after death?
Morphine and Hastened Death
-No difference in survival with absolute opiod dose or change in dose
-Morphine-related will be evidence in drowsiness, confusion, loss of LOC before signficant compromised respiratory drive
-If the intent for using morphine in the scenario is to relieve pain and not to cause death and accepted dosing guidelinse are follow :
-The treatment is considered ethical
-The risk of a potentially dangerous adverse secondary effects particularly hastening death is minimal
-The risk of resp depression is WAY over estimated
Greif And Bereavement
-Anticipatory grief (Prior to death)
-Bereavement (Post mortem)
KNOW THE MODELS OF GREIF IN THE PP
