Yr4 Palliative Care - Lectures Flashcards
What is the definition of Palliative Care?
- List 8 Principles of Palliative Care.
Palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.
What is the evidence for Palliative care?
List which symptoms cause the most distress at the end of life.
- Dyspnoea
- Pain
- Incontinence
- Nausea
- Psychological suffering
Describe the Traditional Model of Palliative Care in comparison to the Current model of care in regards to the timing of referrals.
Timing of referrals - Palliative care referrals are generally made when there is need for :
1. Pain management
2. Symptom management
3. Psychosocial support
4. Counseling
5. Terminal care (often far too late!)
What is the Palliative Care-Enhanced Model?
What is the model of palliative care in Australia?
List the palliative care services available in WA.
List 5 Patient Factors Causing Particular Challenges in Communication in Palliative Care.
- What are the qualities of the health professional that may help/hinder communication?
Patient Factors Causing Particular Challenges in Communication
1. Hearing impairment
2. Visual impairment
3. Cognitive impairment
4. Dysphasia/ Dysarthria
5. Language/Cultural differences
Outline a Framework for Palliative Care in Community-based aged care patients.
What is Palliative Care? Define it.
Palliative care is person and family-centred care provided for a person with an active, progressive, advanced disease, who has little or no prospect of cure and who is expected to die, and for whom the primary goal is to optimise the quality of life.
When is palliative care
appropriate?
- Why do we have palliative care? (4)
Palliative Care is:
- applicable early in the course of illness
- in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy,
- includes those investigations needed to better understand and manage distressing clinical complications.
True or False: most people suffer severe pain when they die.
- What factors influence patient outcomes? (3)
Reality in Australia
Palliative Care Outcomes Collaboration data show:
- statistically significant improvement in pain and other symptoms over the last decade
- 26% of all palliative care patients report 1 or more severe symptom when starting palliative care
- This decreases to 13.9% as death approaches.
List 6 Adverse Effects of Opioids prescribed for pain in palliative care and their treatments.
- Constipation –> Aperients
- Drowsiness –> Psychostimulants
- Nausea/vomiting –> Antiemetics
- Dry mouth –> Artificial saliva
- Delirium –> (Anti-psychotics :( )
- Myoclonic jerks –> Anticonvulsants
- Hallucinations
List the 6 Principles of Symptom Control in Palliative Care.
- Evaluation
- Explanation
- Set realistic goals
- Continuity of care
- Monitor and review
- Prophylactic prescribing
What individual factors may affect how you prescribe in pall care?
Individualise:
1. Preference
2. Ability
3. Age
4. Pharmacokinetics
5. Current and previous drug history,
6. Duration of treatment
What are 3 outcomes measures for drug therapy in
palliative care?
Outcome measures of drug therapy in
palliative care
1. Hard to define and measure
2. Not curing
3. Not reducing disease burden
Why might PO meds not be suitable for palliative care patients?
- 2 conditions?
The absorption and handling of oral
medications may be disrupted
1. “Ileus”
2. Constipation
3. Mechanical obstruction
4. Extrinsic compression by ascites)
If nausea or vomiting present - Avoid oral route.
Gut dysfunction - Also diabetes & parkinsons = delayed gastric emptying = impact oral absorption
TRUE or FALSE: The steady state drug concentration is dependent on the size of the body.
In which circumstances may you be concerned about drug elimination in palliative care?
- Which drugs should be avoided when there is deranged liver function?
Elimination: Liver
- Advanced hepatic tumor load rarely causes significant effect
- Except in abnormal shunting of blood
from portal to systemic circulation
- Deranged liver function = Reduced first pass metabolism - Eg Targin (naloxone systemic absorption)
- CYP interactions
- Beware hepatotoxic drugs
- Avoid paracetamol if transaminases are up 3 x limit normal
- Valproate - can be hepatotoxic - used for seizure control = eg. Pt with a glioblastoma or pain relief
What considerations need to be made regarding drug elimination for palliative care patients?
- What is morphine? How is it metabolised?
- How is morphine & its metabolites eliminated?
- What GFR is a predictor of adverse effects?
- Which opioids would you give in impaired renal excretion?
- Why may parenteral infusion of morphine minimise adverse side effects attributed to metabolites?
Morphine elimination
- mu-opioid receptor agonist
- principal effects in CNS and GIT
- metabolised in the liver to
1. Morphine-3-glucuronide
2. Morphine-6-glucuronide and others
- M6G is analgesic = 5 x potency of parent morphine & significantly contributes to analgesia in chronic dosing
What is the approximate absorption/half life of SR opioids?
- What options do we have for SR oral opioids? (6)
Sustained-release opioids
Most opioids have a rapid absorption and short half-life
- e.g. morphine: t½ = 2 to 4 hours
To maintain stable drug levels:
- Dose interval 4 hourly or less
- SR formulations alter the rate of dissolution
- the effective absorption is artificially slowed
What are the 3 options for Transdermal SR Opioids and how often are the patches changed?
- Role of Buprenorphine in Pall care?
Buphrenorphine different to other opioids because its a weak partial mu-opioid agonist and a weak kappa-opioid receptor antagonist.
- Considered safer
- Good for post-op patients
- Bad for pall care as the antagonist action can block other opioids that may be prescribed and there tends to be a ceiling effect so not good for pall pts with increasing pain
How does the time to peak and duration of IR compare to SR for Oral Opioids?
Pts require slow release & PR Immediate release for PRN/breakthrough
List 3 Advantages & 5 Disadvantages of SR Opioids?
SR Advantages
2. Convenience
2. Improved compliance
3. Less fluctuation in plasma levels
SR Disadvantages
1. Amount of drug bay be far higher than that contained in a single conventional (IR) dose
2. Damage to the SR mechanism poses risk - Consider if capsule of SR breaks you are dumping entire 24hr dose in one go = issues with tox
3. Once an SR drug releases it is difficult to stop
4. Impact of GI transit time on absorption
5. Opioid and anticholinergics may worsen delayed gastric emptying
What might duloxetine cause/exacerbate?
- Risk of dexamethasone?
- Naproxen?
- Give 2 examples of when side effects may be used beneficially?
A knowledge of ALL side effects is valuable
- The propensity for duloxetine to cause or exacerbate hyponatraemia could be a relative contra-indication!
- The risk of dexamethasone induced proximal myopathy might be a relative contraindication where mobility was already compromised.
- Naproxen may cause gastric intolerance
Discuss the role of Multi-modal analgesia vs. polypharmacy in palliative care?
Multi-modal analgesia vs. polypharmacy
Polypharmacy is common in the palliative care patient population because
- Patients are often elderly
- Multiple co-morbidities
- Multiple symptoms requiring palliation
The contemporary approach to effective analgesia encourages co administration of multiple drugs providing analgesia by differing mechanisms…
What are the different priorities in the management of chronic non-malignant vs. pain in patients receiving palliative care?
What are the 10 basic principles of analgesia in the palliative care patient?
10 Basic Principles of Analgesia in the Palliative Care Patient
- 1. Use the oral route when possible - Why?
- 2. Prescribe regular and prn analgesia for persistent pain?
- What dose of opioid would you give for rescue opioid?
- When would you increase the background opioid dose?
1. Use the oral route when possible
- Ease of administration
- Minimises risk
- Easily transferable to a home setting
- Rescue PRN dose for opioids = approx 1/10th of their daily background dose
- If PRN >3xday —> increased background opioid dose OR consider non-opioid responsive causes
3. Recognise and treat breakthrough pain
(BTP)
- What is BTP?
- Tx?
- Dose?
- Therapies for BTP?
Describe the ideal BTP management?
- BTP = breakthrough pain
Opioids for breakthrough pain relief - What is the dosing interval dependent on?
- What is the frequency of dosing for non-opioid analgesics dependent on?
- Why are IR opioids only used for PRNs?
Opioids for breakthrough pain relief
- IR opioid dosing interval in response to sub-therapeutic plasma levels is determined by Tmax (time to peak plasma level.)
- Breakthrough dosing intervals are dependant on the ROUTE of ADMINISTRATION rather than the particular opioid chosen.
- For non-opioid and adjuvant analgesics the dosing interval is related to the ½-life of the drug.
- When using opioids to relieve breakthrough pain, the intent is to rapidly raise the opioid plasma levels to exceed the present (temporary) analgesic threshold.
- Because a rapid response is desired use only immediate-release opioids on a prn basis.
- If you can be certain that plasma opioid levels have already peaked without the desired analgesic effect, it is reasonable to repeat the IR opioid dose.
Principles of Pain Management in Palliative Care - 4. Use the analgesic ladder as a guide?
Why do we Consider using multi-modal analgesia in pall care?
- Why do we need a variety of pharmacological agents to control pain? (give examples)
- Sub-maximal dosages of two, three or more drugs may result in improved analgesic efficacy and fewer adverse effects than maximal dosages of a single drug.
- Non-opioid analgesics should be continued when opioids are introduced IF THEY HAVE BEEN OF BENEFIT, and may be helpful even for patients on moderate doses of opioid
Multi-modal Analgesia
- Why must you understand the mechanism of pain before you can choose an appropriate analgesic?
- When would you reduce paracetamol dose?
- What is the role of NSAIDs in pall care analgesia?
Using multi-modal analgesia in practice
- Classify the type of pain: Nociceptive (Somatic/Visceral) vs. Neuropathic
- Understanding the different mechanisms of pain can help guide the choice of analgesic agent
- Make use of the wide range of oral or transdermal sustained-release opioids now available along with appropriate non-opioids
- When patients are entering the terminal phase use imagination and all available forms of administration (parenteral infusions, sublingual, transdermal, rectal) to continue using multi-modal therapy where possible if of proven benefit
How do we do conversion doses for methadone?
You don’t! Remember that if you are ever asked to convert to or substitute methadone for an opioid, insist on the need to seek advice from an expert and experienced Pain Specialist or Pall Care Specialist.
What can too little opioid analgesia cause in the palliative care patient? (2)
What can too much opioid analgesia cause? (6)
- Apply patch at same time of last dose of SR oxycontin as it will take up to 24hrs to ready steady state
- Need to check her renal function —> if she’s in renal failure she may be accuulating oxycontin which is causing her disorientation/drowsiness ALSO is this her usual dose
- Could use a subcut infusion of morphine - steps: 1. 40mg oxyctonin convert to 60mg of oral morphine (x1.5) then convert oral morphine to subcut morphine by diving by 3 = 20mg of subcut morphine over 24hrs
- Always covert to morphine and oral then to whatever you need
Analgesic equivalents
- A patient is prescribed morphine 10mg injection 4-hourly prn subcutaneously
- Patient became unresponsive
- Respiratory rate 8/minute
- Pupils pin-point
- Use the opioid conversion guide to calculate equi-analgesic alternatives to oral oxycodone 40mg/24 hours.
Ongoing management
An appropriate regimen might include:
1. IV paracetamol
2. Rectal indomethacin
3. Equivalent analgesic dose of an opioid
4. Confidence that depressed level of consciousness is due to the disease process, rather than overdose of opioid
Principles of Pain Management in Palliative Care
- Why do we Avoid mixing different opioid analgesics where possible? (6)
- How can we be proactive in managing side-effects?
- No proven benefit
- Causes confusion
- Increases risk of errors
- More difficult to calculate appropriate background and prn doses
- Sometimes necessary due to lack of availability of suitable preparations e.g. fentanyl, methadone
- In some situations, changing to another opioid (opioid rotation) can be helpful
Principles of Pain Management in Palliative Care
- What are some red flags from the history that may mean we have missed something in regards to a patient’s pain?
- What is the 10th principle of pain management in pall care?
- Rapidly escalating opioid requirements usually mean we have missed something!
- Morphine requirements exceeding 250mg orally per day (or equivalent for other opioids) should prompt a review
- Be alert to dose-limiting side effects.
List 9 Potential Goals of Care in Medicine?
- How might a person’s goals of care
impact on decision-making?
Historically, a dichotomous division of goals of care
- Focus on curing illness Little attention to relief of suffering, care of dying
- Hospice / palliative care arose in response to a need.
Can multiple goals of care exist in medicine?
How might goals of care change? What potential precipitating factors can you think of for this?
Describe the Contemporary model of intent of treatment.
Multiple goals of care
- Multiple goals often apply simultaneously
- Goals are often contradictory
- Certain goals may take priority over others
- You need to understand what the patient’s priorities and preferences are every step of the way
Goals may change
- Some take precedence over others
- The shift in focus of care: may be gradual, may be rapid, is an expected part of the continuum of medical care.
- Review with any change in:
1. Health status
2. Advancing illness
3. Setting of care
4. Treatment preferences
Outline a 7 step protocol to
negotiate goals of care.
- What happens when the physician cannot support a patient’s choices? Examples?
- Create the right setting
- Determine what the patient and family know
- Explore what they are expecting/ hoping for
- Suggest realistic goals
- Respond empathically
- Make a plan and follow-through
- Review and revise periodically, as appropriate
What 5 things must a person have/do in order to have capacity?
- Who can determine capacity?
- What does it vary by?
- Does a person with dementia have capacity?
“Capacity” implies the ability to understand and make own decision.
Patient must:
1. Retain and understand the information
2. Use the information rationally
3. Appreciate the consequences
4. Come to a reasonable decision for him or herself
5. Communicate the decision
Any doctor can determine capacity
* Capacity varies by decision
* Other cognitive abilities do not need to be intact
How can we tell if death is approaching?
- Early? (4)
- Mid? (4)
- Late? (4)
- If a patient is entering the terminal phase, what should you STOP doing? (2)
- If a patient is entering the terminal phase, what should you START doing? (4)
Is death approaching?
EARLY
1. Bed bound
2. Loss of interest and/or ability to eat and drink
3. Cognitive changes
4. Increasing time spent sleeping and/or the onset of delirium
MID
1. Further decline in mental status
2. Slow to rouse to stimulation
3. Only brief periods of wakefulness
4. Death rattle = Pooled oral secretions that are not cleared due to loss of swallowing reflex
LATE
1. Coma
2. Fever - Usually from aspiration pneumonia
3. Altered respiratory pattern - Periods of apnea, hyperpnoea or irregular breathing
4. Mottled extremities
What are 8 common family concerns for a dying relative and how might you answer these?
- Are they in pain? - agitated, grimacing, tachycardic, localising
- Starving? - normal trajectory, food & fluids only for comfort/pleasure at this point
What are the 5 Main Symptoms to be controlled at the end of life?
Which guidelines can help address these?
- Dyspnoea (Community and Inpatient)
- Nausea and Vomiting
- Pain
- Respiratory Tract Secretions
- Terminal Restlessness/Agitation
Palliative Care in the ED – Case 1
* A 32-year-old single mother of 2 children was diagnosed with Stage 2B squamous cell carcinoma of the cervix 6 years ago.
* She initially underwent transposition of the ovaries and chemo-radiation using both external beam irradiation and brachytherapy.
* A pelvic recurrence was treated with further chemotherapy but with limited response.
* The patient is brought into ED by her mother because of drowsiness (difficult to arouse) and mild confusion.
What investigations would you order & why? (6)
Describe her management (5).
Investigations
1. Corrected serum Ca - normal
2. Haemoglobin– normal
3. WCC - normal
4. CRP 14
5. Urea 64 mmol/L
6. Creatinine 282 umol / L
Management
1. Exclude and correct electrolyte imbalance
2. Urinary catheter
3. Ultrasound or CT imaging
4. Urgent stenting of ureters if survival estimate is in the order of months to years
5. Consider acute management of pain
Case 1 - A 32-year old single mother of 2 children was diagnosed with Stage 2B squamous cell carcinoma of the cervix 6 years ago. Presents with the following.
Progress
- Mildly anaemic with markedly elevated WCC and CRP
- Serum calcium again normal
- Admitted for treatment of urosepsis and another stent change
- What else is going on?
- Management options? (3)
Clinical diagnosis of chronic opioid toxicity - Management
3 options:
1. Reduce opioid dose
2. Use a different route of opioid administration
3. Opioid rotation: transition to methadone
Palliative Care Emergencies - Case 1
- 52 year old man, Ca Prostate with bone metastases.
- Several fractions of palliative XRT to ribs and spine over previous 6 months for pain control.
- Opiates & adjuvants titrated for pain, but issues with toxicity.
- You are called re escalating pain & deteriorating mobility.
What do you think? - True or False
- This sounds like neuropathic pain?
- He’s definitely been drinking too much beer?
- The neurological signs are typical for cord compression?
- The neurological examination is reassuring?
- This sounds like neuropathic pain = TRUE
- He’s definitely been drinking too much beer = FALSE - no evidence for this although alcohol can cause a proximal myopathy
- The neurological signs are typical for cord compression = TRUE although they are not exactly typical
- The neurological examination is reassuring = FALSE
Diagnosis & Management?
= Cord Compression - Needs MRI to confirm sites & Dexamethasone 16mg daily
What do you think? - True or False
- The appearances of his face and chest wall are consistent with him being a heavy drinker?
- He has sarcoid?
- The priority is to organise a brain scan to exclude brain metastases?
- His steroids should be increased again?
- This man will probably die within the next 6 months?
- Diagnosis?
You diagnose SVCO
- He is given 16mg dexamethasone
- An SVC stent is inserted radiologically with relief of symptoms
- He is discharged home and recommences chemotherapy as planned
- This man will probably die within the next 6 months = FALSE = Median survival ~8 month
59-year-old man with Laryngeal Ca, total laryngectomy
- Recurrence right neck with extensive, erosive, fungating disease
- Painful
- Close to carotid artery
- Analgesia titrated and is comfortable
- NG tube feeding established
- Community nurses report bleeding with dressing changes, which is becoming more marked over time.
Management?
- The nurses should stop dressing the wound = FALSE - but maybe minimise changes
- This man must be admitted to hospital = FALSE, not if he wants to be at home.
- Nothing can be done if the bleeding gets worse = FALSE
- It is important to discuss future care at this stage = TRUE - Need to discuss pt’s wishes should bleeding become a more prominent feature of his disease/ what to do if catastrophic bleed.
59-year-old man with Laryngeal Ca, total laryngectomy
- Recurrence right neck with extensive, erosive, fungating disease
- Painful
- Close to carotid artery
- Analgesia titrated and is comfortable
- NG tube feeding established
- Community nurses report bleeding with dressing changes, which is becoming more marked over time.
What do you think? - True or False
- You better watch what you do, she’s got friends who are lawyers?
- It is unlikely that she has a significant infection?
- The brain mets/radiotherapy have probably made her dizzy?
- She definitely needs admission to hospital?
Management?
What conditions could be causing her problems? (7)
- You better watch what you do, she’s got friends who are lawyers = Always TRUE
- It is unlikely that she has a significant infection = FALSE - Lack of temperature is unreliable/false reassurance because if you are 1/52 post chemo = neutropenic = may not mount a temperature.
- The brain mets/radiotherapy have probably made her dizzy = FALSE - could be but more likely to be 2nd to septic shock.
- She definitely needs admission to hospital = TRUE - She needs urgent IV BS Abx with pseudomonas cover.
Management…
- Bloods in hospital show that she is neutropenic. She remains apyrexial but is hypotensive and tachycardic.
- She is commenced on oxygen, IV fluids and broad spectrum antibiotics and makes a good recovery.
- She returns to ED again 15 days after her 4th cycle of chemotherapy. Her husband reports that she has been becoming increasingly vague and forgetful over the past week and she vomited this morning.
What do you think? - True or False
- Hypercalcaemia is rare in breast cancer?
- Once treated, the hypercalcaemia is unlikely to recur?
- Prognosis is likely to be less than 3 months?
- It is important that she sorts her will, EPA, EPG as soon as possible if the confusion resolves?
- Hypercalcaemia is rare in breast cancer = FALSE - quite common
- Once treated, the hypercalcaemia is unlikely to recur = FALSE - Need to actively monitor/follow up
- Prognosis is likely to be less than 3 months = TRUE for symptomatic hypercalcaemia
- It is important that she sorts her will, EPA, EPG as soon as possible if the confusion resolves = TRUE - poor prognosis
- What are 4 key elements of palliative care?
- List 6 Members of the palliative care team.
- Is palliative care the same as end-of-life care?
- What is the general approach to symptom control in palliative medicine?
Key elements of palliative care
1. Symptom relief, particularly sufficient analgesia
2. Assistance in the organization of adequate, needs-based care
3. Support regarding social services
4. Psychological support of patients and their families
Members of a palliative care team
1. Physicians (including palliative care specialists)
2. Nurses
3. Social workers
4. Psychologists
5. Chaplains
6. Pharmacists
Palliative medicine is not synonymous with end-of-life care. It is often used to improve a patient’s quality of life even as life-prolonging therapy continues.
Overview of symptom management in palliative patients.
- Pain?
- Gastrointestinal?
- Pulmonary?
Address reversible underlying causes of symptoms as long as the investigations and treatment required are consistent with the patient’s care plan and wishes.
Overview of symptom management in palliative patients.
- CNS?
- Terminal phase?
Outline the Modified WHO Analgesic Ladder.
Modified WHO Analgesic Ladder
This illustration shows a stepwise, bidirectional algorithmic approach to the management of acute and chronic pain. Acute pain is initially treated with the strongest analgesic for that intensity of pain and then stepped down. Chronic pain is treated from the bottom up. The original WHO analgesic ladder was unidirectional (escalating) and included only the first 3 steps; other authors have since modified the ladder, by adding the fourth step including interventional procedures (e.g., nerve blocks) for unrelenting pain.
Define 6 Types of pain.
- List some Non-pharmacological therapies for pain releif in palliative care.
- What are the 1st line Nonopioid options for analgesia in palliative care?
- Options for neuropathic pain?
- Options for metastatic bone pain?
- Nociceptive pain: caused by damage or potential damage to tissue (excluding neural tissue).
- Neuropathic pain: caused by damage to a somatosensory nerve
- Nociplastic pain: caused by altered nociception despite there being no underlying tissue damage
- Mixed pain: the simultaneous or concurrent presence of nociceptive, neuropathic, and/or nociplastic pain in one area of the body.
- Emotional pain: a term used to describe both mental suffering and the impact of emotions on the experience of pain.
- Total pain: the combination of physical, social, spiritual, and psychological/emotional pain components.
Which patients should receive a palliative approach to care?
List 6 Oral Opioid options & the equianalgesic doses of oral opioids?
Methadone
- Conversion factors have not been provided for methadone.
- Methadone conversions are complicated.
- Prescribing should be restricted to medical specialists with experience of methadone prescribing for pain management.
List 2 Subcutaneous Opioid options & their conversion from oral to subcut?
List 2 transdermal Opioid options & their conversion from transdermal to oral?
List 2 sublingual Opioid options & their conversion from sublingual to oral?
Why do we need an
Opioid Conversion Guide? (3)
- What is important to consider when using the WA opioid conversion guide?
- There are many opioids and many formulations available (e.g. tablets, patches, injections)
- Each opioid medication binds to opioid receptors differently
- Therefore, a different amount of each opioid is needed to have the same analgesic effect
What is an Equianalgesic dose?
For the WA Opioid conversion guide, what does green/ purple indicate?
Equianalgesic doses of oral opioids
The guide is colour coded as a visual prompt:
- GREEN shaded opioids are those STRONGER than morphine mg for mg
- PURPLE shaded opioids are those WEAKER than morphine mg for mg
What is the conversion factor of morphine to oxycodone?
- If If a patient is taking Oxycontin (ie. (that is, 15 mg oxycodone x 2 doses/day or 30 mg oxycodone/day), what is their daily oral morphine dose?
What is the equivalent of 30mg morphine/day to oxycodone?
What is the conversion factor of morphine to codeine?
- If a patient is taking Panadeine Forte® 2 tablets qid - that is, (2 x 30 mg codeine) x 4 doses or 240 mg codeine/day what is their daily oral morphine dose?
What is the Practical
equianalgesic
dose of 10mg morphine to oxycodone?
What is the Conversion factor and Practical equianalgesic dose for 10mg morphine for:
1. Tapentadol?
2. Tramadol?
What is the Equianalgesic
subcutaneous dose for 30 mg oral morphine?
What is the Equianalgesic
subcutaneous dose for 6mg oral hydromorphine?
- Conversion factor for oral to subcut morphine?
If a patient is taking MS Contin® 30 mg bd - that is, 30 mg oral morphine x 2 doses/day or 60 mg oral morphine/day, what is the daily subcut morphine dose?
What are the 2 Transdermal preparation conversions for opioids?
What is the oral morphine equivalent for a 200mg buprenrophine tablet?
What is the oral morphine equivalent for a 200mg fentanyl lozenge?
Outline an evidence based clinical guideline for adults in the terminal phase for Management of Dyspnoea (Community)?
- Which meds? doses?
Outline an evidence based clinical guideline for adults in the terminal phase for Management of Dyspnoea (Inpatient)?
- Which meds? doses?
Outline an evidence based clinical guideline for adults in the terminal phase for Management of Nausea & Vomiting?
- Which meds? doses?
Outline an evidence based clinical guideline for adults in the terminal phase for Management of Pain?
- Which meds? doses?
Outline an evidence based clinical guideline for adults in the terminal phase for Management of Terminal Restlessness /Agitation?
- Which meds? doses?
What is Demoralization Syndrome?
- What is its place in palliative care? How does it differ from depression?
- How do we treat for it?
Demoralization Syndrome
- Persistent sense of meaninglessness & loss of purpose in life [>2 weeks]
- Sense of being stuck, trapped
- Helplessness
- Hopelessness
- Often isolated or alienated
- May develop into a desire to die
- May be co-morbid with depression = loss of pleasure or interest in activities for long periods of time.
What is Existential Distress?
What is Spiritual Distress? Examples?
Spiritual Distress
- Disease as a punishment (e.g. infidelity giving cervical cancer)
- Abandonment by God (e.g. disease progression)
- Loss of meaning/demoralisation (e.g. loss of faith)
- Fatalism, God’s will
- Fear of God’s rage (e.g. spiritual doubt)
- What is Spirituality?
- What is spiritual care and how can high quality spiritual care be delivered?
What is spiritual care?
- Relates to meaning and purpose
- Delivered in response to feelings
- Value the person
- Seek to get to know & understand them
- Explore the meaning of their illness, their relationships, their life
- Explore the need for reconciliation
- Celebrate the majesty and mystery of life - through nature, meditation, stillness, religious symbols & rituals
List 8 Features of Successful Adaptation in Spiritual Distress.
Explain the role of interprofessional (multidisciplinary) teams in the management of patients with life-limiting illness and their families, and how this varies in 5 different care contexts.
Interprofessional (multidisciplinary) teams play a crucial role in the management of patients with life-limiting illnesses and their families across various care contexts. These teams consist of professionals from different disciplines, such as doctors, nurses, social workers, psychologists, chaplains, pharmacists, and therapists, who collaborate to provide comprehensive care tailored to the unique needs of each patient and their family. Here’s how their role varies in different care contexts:
How do you effectively communicate with:
1. people with life-limiting illness
2. their families
3. medical colleagues
4. other healthcare professionals?
Effective communication involves actively listening, providing clear and accurate information, being sensitive to individual needs and preferences, and fostering collaborative relationships with patients, families, and colleagues. By prioritizing communication and teamwork, healthcare professionals can ensure that patients with life-limiting illnesses receive compassionate, person-centered care that addresses their physical, emotional, and spiritual needs.
How do we communicate in an effective and culturally safe way with Aboriginal and Torres Strait Islander patients, their families and communities regarding palliative care?
By approaching palliative care with cultural respect, sensitivity, and humility, healthcare professionals can foster trust, build meaningful relationships, and provide care that is tailored to the unique cultural and spiritual needs of Aboriginal and Torres Strait Islander patients and their families.
How can you elicit patients’ hopes and values in order to facilitate person-centred advance care planning?
- 10 Strategies?
- Eliciting patients’ hopes and values is essential for facilitating person-centered advance care planning, which aims to align medical care with the patient’s goals, preferences, and values.
- By using these strategies to elicit patients’ hopes and values, healthcare professionals can facilitate meaningful advance care planning conversations that empower patients to make informed decisions about their future care that align with their values and priorities.
Why is it essential to recognise the unique culture, beliefs, values and customs of each individual with a life-limiting illness and how these factors are used to guide care decisions?
- 7 Points
