C1, C2 Continuing the Conversation: What is CRITICAL in providing comfort care?

Transcription

1 C1, C2 Continuing the Conversation: What is CRITICAL in providing comfort care? Lorelei Sawchuk, RN, MN, CHPCN(C) Nurse Practitioner & Supervisor Palliative Care Program Royal Alexandra Hospital Edmonton, AB th Annual Palliative Care Conference Edmonton, AB

2 Conflicts of Interest Declaration None 2

3 Objectives Utilizing the RMC Goals of Care Designation, the healthcare professional working at a patient s beside will be able to: Translate the care needs of palliative patients designated as C1 or C2 level of care What is expected and what do I do when C1 or C2 care is prescribed? 3

4 Advanced Care Planning & Goals of Care Resources Conversations Matter Video Series Conversations Matter Guidebook Healthcare Professionals Goals of Care Order Form Advanced Care Planning Tracking Record Quick Reference Pocket Card E-Learning Modules 4

5 Purpose of Goals of Care Designations To reflect a patient s values & beliefs regarding: Care to receive Location of care Alberta Health Services Advance Care Planning: Goals of Care Designation (Adult) Policy RMC: Understanding the Goals of Care Designations 5

6 Where & How We Choose to Die 6

7 Common Symptoms at End of Life Pain Tiredness (Lack of Energy) Drowsiness (Feeling Sleepy) Nausea Lack of Appetite Shortness of Breath (Dyspnea) Depression (Feeling Sad) Anxiety (Feeling Nervous) Wellbeing (How you feel overall) 7

8 Common Hospital Interventions Imaging: Xray, CT, MRI Intravenous Oxygen Blood Tests Medication Pills Needles Vital Signs Rehabilitation Repositioning in bed Toileting Voiding & bowel movements Nutrition 8

9 Overview of RMC R Medical care & interventions include resuscitation followed by ICU to cure or control of illness M Medical & interventions to cure or control health condition without resuscitation or ICU C Medical care & interventions without cure or control of health condition Maximal symptom control & maintenance of function Alberta Health Services Advance Care Planning: Goals of Care Designation (Adult) Policy RMC: Understanding the Goals of Care Designations 9

10 Dialysis 10

11 C Level of Care Medical care & interventions focused on comfort Care aimed at maximum symptom control & maintenance of function without cure or control of illness C1: Transfer may be possible to better understand or control symptoms including surgery C2: Physical, psychological & spiritual care anticipating imminent death (hours to days). Do not usually transfer for care needs Alberta Health Services Advance Care Planning: Goals of Care Designation (Adult) Policy RMC: Understanding the Goals of Care Designations 11

12 Surgery 12

13 Painful Bone Metastasis Radiation 13

14 Pleural Effusions Thoracentesis PleurX 14

15 Ascites Paracentesis Abdominal PleurX 15

16 Infections 16

17 M2 vs C1: The Role of Antibiotics By way of example, a person with an M2 designation who develops a new pneumonia would receive treatment aimed at cure of the pneumonia, but only in the current location of care. A person with a C1 designation who develops pneumonia might seek treatment that would relieve potential pain, dyspnea and distress, whether or not the treatment could fully resolve the pneumonia. Sometimes antibiotics would be contemplated for such a patient, with the sole intent of relieving symptoms. 17

18 Transfusions How would this help? What would the concerns be? 18

19 Intravenous Antibiotics Diuretics 19

20 PICC Lines 20

21 Blood Tests Always ask will this make the person more comfortable in easing symptoms 21

22 Blood Glucose Management 22

23 Less Painful Pokes IM or Subcut EZ Set Butterfly 23

24 HDC Pneumothorax 24

25 How thirsty are you? 25

26 Artificial Hydration Prolong life? Why? Can improve comfort by preventing toxic effects caused by pain medication Can ease the worries of the family Why not? Prolong life? Decrease phlegm (respiratory secretions) Decreases breathing problems from heart failure & fluid in the lungs (pulmonary edema) Reduce swelling (edema) Does not help a dry mouth Does not help thirst if mouth is well cleaned and moistened 26

27 Hypodermoclysis (HDC) Clysis IV fluids given through a small needle into the fatty (subcutaneous tissue) just under the skin Little worry if accidentally pulled out 27

28 By Mouth By spoon By sponge By straw Sips At risk 28

29 Mouth Care 29

30 Artificial Nutrition 30

31 Management of Agitation Restrain (yourself) Calmness Chemicals Haloperidol Methotrimeprazine Midazolam 31

32 Oxygen 32

33 Medication 33

34 34

35 35

36 36

37 Medication Review Acetaminophen 650 mg po QID Centrum Forte 1 tab po Daily Enalapril 10 mg po BID Folic Acid 5 mg po Daily Heparin 5000 units SC q12h Lasix 40 mg po QAM Metformin 850 mg po BID Morphine ER (Long acting) 60 mg po BID Pantoprazole 40 mg po daily Peg 3350 packet 17G po QAM Prednisone 7.5 mg po Daily Rosuvastatin 10 mg po Daily Vitamin B6 25 mg po QHS Maxeran 10 mg po/sc Q6H PRN Morphine 5 mg SC Q4H PRN Zopiclone 3.75 mg po QHS PRN 37

38 Vital Signs 38

39 Skin Care Resposition Resist 39

40 Voiding Bathroom Commode Bedpan Incontinence products Texas condom catheter for men Foley catheter Monitor for urinary retention! 40

41 Bowel Care 41

42 Peace & Privacy? Preference Communication! 42

43 43

44 44

45 Summary Goals of Care are Not contracts Conversations Opportunities to share concerns and wishes 45

46 C1, C2 Continuing the Conversation: What is CRITICAL in providing comfort care? Lorelei Sawchuk, RN, MN, CHPCN(C) Nurse Practitioner & Supervisor Palliative Care Program Royal Alexandra Hospital Edmonton, AB th Annual Palliative Care Conference Edmonton, AB 46