Palliative Care. Patricia M. Burhanna, MSN, ANP-C Adult Nurse Practitioner Palliative Care Services

Transcription

1 Palliative Care Patricia M. Burhanna, MSN, ANP-C Adult Nurse Practitioner Palliative Care Services

2 Objectives By the end of the session the participant will: Be familiar with the concept of palliative care Describe the domains of palliative care Understand when it is appropriate to have discussions of goals of care

3 What Is Palliative Care An approach which improves the quality of life of patients and families facing 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, psychological, and spiritual World Health Organization, 2007

4 Palliative Care: What It Really Is A medical specialty Focuses on relief of pain and other symptoms of serious illness Appropriate at any point in serious illness Not dependent on prognosis Can be provided in conjunction with curative and life prolonging treatment Assist with end-of-life issues and care

5 Palliative Care: What Does It Do? Provides relief of pain and other symptoms Uses a team approach to address needs of the patient and the family Enhances quality of life through patient autonomy Offers a support system Neither postpones nor hastens death

6 Palliative Care: What Does It Do? Identifies immediate and long term goals Provides access to advanced planning Optimizes symptom control and functional capacities Promotes an improved quality of life

7 Palliative vs Hospice PALLIATIVE Any time during illness Provided at the same time a curative treatment Not limited to the terminally ill Can assist with endof-life decision of care HOSPICE Last 6 months of life Curative treatments often stopped Limited to the terminally ill Focus on comfort care Provides care for end-of-life only

8 Comparison Curative Life Prolonging Treatment Palliative Care D E A T H Curative Life Prolonging Treatment Palliative Care D E A T H

9 How Do We Rate End-of-Life Care? Majority of Americans are critical of the care dying people receive in U.S. 6 out of 10 Americans rate our health care system s care of the terminally ill as fair or lower 25% rate it as poor Last Acts.2002

10 Palliative Care Family Satisfaction (Following Patient Death) With: Control of pain - 95% Control of non-pain symptoms - 92% Support of patient s quality of life - 89% Support for family stress/anxiety - 84% Manner in which you were told of patient s terminal illness - 88% Overall care provided by palliative care program- 95% Source: Post-Discharge/Death Family Satisfaction Interviews, Mount Sinai Hospital, New York City

11 Identifiers for Palliative Consult Frequent admissions for advanced illness Multiple co-morbidities Prolonged length of stay In ICU with poor prognosis or for extended period of time Multiple transfers from extended care facility Difficult pain and symptom management Advanced care planning, code status

12 Other Identifiers for Palliative Conflict among patient and family regarding treatment plan and decisions of care Lack of response to curative treatment Changes in goals of care Consideration of hospice care Spiritual distress Unresponsive Withholding or withdrawing therapies

13 Who Benefits from Palliative Care? Any patient with a chronic, progressive or life threatening illness Examples: Advanced cardiac or pulmonary disease Advanced renal disease Progressive neurological diseases (ALS) Cancer Dementia or Alzheimer s Palliative Care is best introduced early in a patient s care

14 Domains of Palliative Care Communication Assessment and treatment Psychosocial and spiritual support Care coordination Bereavement support

15 Case Scenario This patient is an 86 year old female with a history of CHF and chronic renal failure. She has been treated medically for a number of years. Now her disease has progressed to the point that dialysis is being discussed. She is alert and oriented x3. She is severely limited in her activity tolerance and fatigues easily. She told the doctors she does not desire CPR or dialysis. When the social worker called family to discuss discharge issues, some family members became angry.

16 Communication

17 Communication Discuss the scope of illness, likely progression, and treatment options with the patient and family Assist in identifying realistic goals and values Discuss likely benefit and burdens of choices Help with decision making Develop plan of care to achieve patient goals

18 Palliative Appropriate? 55 year old female with a high grade carcinoma with metastasis to liver, lung and spine. She was diagnosed within previous week Patient c/o pain in the upper back that radiates around into the diaphragm region Patient is separated from her spouse and does not have completed POA forms Patient cares for herself and is able to perform ADLs

19 Seven Months Later The patient had treatments with chemotherapy which she elected to stop Experienced acute tubular necrosis requiring hemodialysis Experienced T8 metastatic tumor with compression fracture and paraplegia requiring surgical intervention Patient now needs assistance with ADLs POA form is completed

20 Case Scenario A 62 year old female has been admitted with complaints of uncontrolled nausea and vomiting. She has a history of squamous cell carcinoma of the hypopharynx. She has a G-tube for nutritional support due to obstructive dysphagia from increasing tumor size. She also has a complaint of aching pain in her neck and head. Her pain is rated at 9/10 at worse and best is 3/10.

21 Assessment and Treatment Full patient history and physical Review of current treatment history through chart and care providers Done by medical doctor or nurse practitioner Medical plan implemented

22 Typical Symptoms in Palliative Care Dyspnea Nausea Anorexia/cachexia Constipation Weakness Pain Skin issues Fatigue Anxiety Delirium Depression Sleep problems Hopes and fears Spiritual crisis

23 Psychosocial and Spiritual Support Listens actively Supports as needed, may refer to support groups Manages interactions of patient and family Facilitates family communications Establishes a supportive relationship

24 Care Coordination Coordinates and shares information Communicates care plan to patient & family Communicates to all involved health professionals Communicates with responsible providers when patients transfer

25 Bereavement Support Grief and bereavement risk assessment is routine and ongoing A core component of the palliative program Utilizes the philosophy of hospice Information on loss and grief provided to families before and after death

26 Palliative Care: Reasons for Consult Pain and symptom control Discharge issues Complex decision making End-of-life decision making Unmet needs of the patient Unmet needs of family and loved ones

27 The Goals of Palliative Care Patient satisfaction Patient comfort Decreased readmissions into the hospital Decreased visits to the ER Shortened stays in the hospital

28 Think About This Many patients admitted to a SNF from a hospital are readmitted to a hospital within 30 days Many of these readmissions can be controlled by you

29 When To Start Those Discussions Not much evidence based information out there This means use your gut Be assertive and stand up for your resident

30 When Is It That Time? Dementia Noticeable changes in eating and drinking Increased needs for daily care toileting, walking etc May not be hospice appropriate yet but declining New arrival from a hospital with minimal knowledge of goals of care

31 When Is It Time? The beginning of increasing needs for hospitalizations Recurrent pneumonias Recurrent UTI despite hydration Need for long term antibiotics with history of multiple co-morbidities

32 Information on the Web Interact II (trademark) CAPC.org getpalliativecare.org

33 Message to Remember Palliative care is not giving up, but affirmation of a shift in focus from cure to improvement of quality-oflife and symptom management.

34 Thank You