Week 6 - End of life care Flashcards
There are 3 main trajectories of physical decline in people with advanced illness:
- Rapid decline, typically cancer
- Intermittent decline, typically organ failure
- Gradual decline, typically frailty or dementia
What do you do for early palliative care?
- Identify early
- Look at the different dimensions
- Discuss the trajectories with patients and carers
- Plan, integrate with ongoing disease management and communicate
Where is community-based palliative care provided?
- Peoples homes
- Residential aged care
- Accommodation for those experiencing a mental health illness
- GPs
- Community palliative care day clinics
Where is hospital-based palliative care provided?
- Inpatient palliative care beds
- Other inpatient beds
- ICUs
- EDs
How many National Palliative Care Standards are there?
9
What is the National Palliative Care Standard 1?
The person’s needs are reassessed on a regular basis
What is the National Palliative Care Standard 2?
The person is supported to consider, document and update their future care goals, including in an advance care plan
What is the National Palliative Care Standard 3?
The family and carers are provided with a clear plan for emergency and out of hours events
What is the National Palliative Care Standard 4?
There are protocols and procedures in place for escalation of care where required, based on assessed needs
What is the National Palliative Care Standard 5?
Care plans demonstrate appropriate actions to support seamless transition between care settings
What is the National Palliative Care Standard 6?
The service provides education about loss, grief and bereavement to staff, volunteers and other community providers
What is the National Palliative Care Standard 7?
The values and culture of the service explicitly support the provision of person-centered palliative care
What is the National Palliative Care Standard 8?
The service engages in robust and rigorous clinical audit review
What is the National Palliative Care Standard 9?
Staff undergo training to ensure delivery of culturally safe care
What does the PREPARED framework stand for?
P: Prepare for the discussion R: Relate to the person E: Elicit patient and caregiver preferences P: Provide information A: Acknowledge emotions and concerns R: Realistic hope E: Encourage questions D: Document
Aim of palliative care:
- Symptom alleviation/control
- Support and reassurance of patient as well as relatives - the relatives often suffer the symptoms with the patient and feel helpless
- Maximising quality of living
Principles of palliative symptom management:
- Evaluation
- Explanation
- Discussion
- Individualized treatment
- Monitoring
- Dose escalation
Common palliative symptoms other than pain:
- Anorexia/ cachexia
- Dyspnea
- Nausea and vomiting
- Dehydration
- Restlessness
- Disorientation
- Confusion
- Fatigue
- Constipation
- Diarrhoea
- Pruritus
- Spiritual distress
- Depression
- Xerostomia
What is Xerostomia and how can it be managed?
Xerostomia is having a dry and painful mouth, it is caused by radiotherapy to head and neck and some medications like tricyclic antidepressants, antihistamines and anticholinergics. It can be managed by small frequent sips and general mouth care such as water, sprays, oral balance and lip balm
Palliative nursing management:
- Reassurance, ‘being with the patient’
- Cool air - fan or open window
- Elevated position of comfort
- Plan activities
- Humidifiers or nebulized saline for thick secretions +/- effective
- Opioids (oral/IV/SC) and also reduces anxiety
- Oxygen (individualised plan)
- Medications to reduce secretions no more effective than placebo
What can nausea and vomiting be a result from palliative?
- The disease itself
- Medication the person is on
- Chemotherapy and/or radiotherapy
- Constipation
- Chemical imbalance
- Hormonal imbalances
- Anxiety and fear
- Mechanical obstruction
Management of nausea and vomiting in palliative:
- Check they are taking anti-nausea medication as prescribed (eg. Before meals)
- Check when they last had a bowel action
- Small amounts of food or drink may make them feel better
- Suggest they rest and try some relaxation exercises
- Ensure that the person has a bowl or bucket within easy reach should they need to vomit
Management of fatigue in palliative:
- Assess
- Look for and manage reversible causes
- Individual exercise program may benefit some
- Encourage the person to practice ‘energy conservation’ eg. Rest before and after activities; only do what is absolutely necessary
- Minimize or ‘roster’ visitors
- Pharmacology: low dose methylphenidate potentially effective, Erythropoiesis stimulating agents for chemo-induced anaemia cautiously given side effects
What factors is fatigue related to in palliative?
Lack of sleep, low oxygen in the blood, poor diet, depression, the effects of chemotherapy or radiotherapy, infection or the disease.
Routine assessment of delirium:
hyperactive delirium (agitation/arousal/restlessness), hypoactive (drowsiness/lethargy/reduced arousal)
Nursing management of delirium/restlessness:
- Be calming, speak in quite tones
- Lightly massage hands or forehead
- Read or play soothing music
- Ensure patient is safe-LoLo bed
- Falls mat
- Remove clutter
- Reduce environmental stimuli
- Frequent surveillance
What cam constipation be caused by?
- Reduced fluid intake
- Poor diet
- Lack of exercise
- An obstruction or partial obstruction
- The disease process
- May be a side-effect of some medications, especially strong analgesics
Management of constipation:
- Thorough history and examination
- Encourage fluids
- High fibre diet if person is up to it
- Small amount of exercise if practicable
- Record frequency and quality of bowel actions
- Give regular aperients– especially if patient on opioid analgesics
What factors can diarrhoea be caused by?
- Obstruction
- Surgery
- The disease itself
- Malabsorption
- Hormonal imbalances
- Dietary supplements
- Radiotherapy
- Infections
- Dehydration
- Anxiety and fear
Management of Pruritus (itching of the skin):
- Antihistamines such as PHENERGAN may help
- Encourage wearing loose-fitting soft fabrics such as cottons which allow for circulation of air over the skin
- Increase fluid intake, and balanced diet
- Tepid baths and use additives such as PINE TARSAL
- Cut finger and toe nails short and consider use of cotton mittens and cotton socks to reduce injury due to scratching
Common symptoms of dehydration:
Headache, nausea, vomiting, cramps and dry mouth, cracking of oral mucosa and inflammation
Management of dehydration:
- Re-hydration often causes more problems than its cures
- Offer small, frequent sips if patient able to tolerate
- Offer icy-poles or ice chips to suck
- Keep mouth clean
- Keep mouth moist Comfort: ice chips, frozen juice/icy poles, grapeseed oil + peppermint mouth washes, lip balm
Benefits of dehydration in end stage of life:
- Increased urine output, more need for toileting/incontinence, catheterization
- Increased GIT secretions, increased nausea and vomiting
- Increased respiratory secretions relieves coughing and congestion
- Increased pharyngeal secretions, increased difficulty in swallowing and less feeling of choking/drowning
- Decreased natural analgesia in last days
- Ketosis due to starvation also has analgesic effect
What does the Gibbs Reflective Cycle involve?
- Description
- Feelings
- Evaluation
- Analysis
- Conclusion
- Action plan
