Pain, Palliative Care, and Hospice Care Palliative medicine relieves suffering and improves the quality of life for patients with advanced illness. The goal is achievement of the best quality of life for patients and their families. The goal of all hospice agencies in the United States is to provide comfort to the patient. Comfort is defined by the patient or, if the patient is incapacitated, the patient's family. Alleviation of pain is critical to both. In this self-directed learning module is information you are expected to know in providing a safe and comforting environment for our patients, our guests and you. Carolinas Rehabilitation Target Audience: RN, LPN, PT, PTA, OT, COTA, SLP, TR, SW, MS, RT Contents Instructions 2 Learning Objectives 2 Module Content 3-7 Job Aid 8 Posttest 9
Instructions The material in this module is an introduction to important general information. After completing this module, contact your supervisor to obtain additional information specific to your department. Read this module. If you have any questions about the material, ask your supervisor. Complete the online post-test for this module. The Job Aid on page 8 may be customized to fit your department and then used as a quick reference guide. Completion of this module will be recorded under My Learning in PeopleLink. Learning Objectives When you finish this module, you will be able to: Discuss the different types of pain in a patient with cancer and be aware of ways of addressing it. State the role palliative care plays in patients with cancer. Understand the process and expectations associated with a hospice care referral and are prepared to explain this process to appropriate patients. Page 3 of 9
I. Cancer Pain and Pain Management Pain is a significant factor in how individuals can tolerate rehabilitation, chemotherapy, and radiation. It impacts their quality of life as both cancer survivors and when dying with dignity. Pain occurs in 50-70% of individuals in the early stages of cancer and in 60-90% of individuals in the late stages of cancer, and can occur for various reasons. The following may be causes of pain: Tumor pressure on a nerve or on an artery Tumor invasions of a bony area Cancer treatment causing inflammation Referred pain (pain felt at a location other than where the cause is located) from a tumor Managing Cancer Pain Pain management incorporates various approaches to prevent, reduce or stop the sensation of pain. Pain can be managed through pharmacological (with medications) and non-pharmacological techniques. Timing and dosage of pain medications will depend on each different patient and their varying activity levels during the day. Prescriptions will be discussed and determined by the patient s physician. Some nonpharmacological ways to treat pain are as follows: Heat (be sure to refer to MD orders) Ice (be sure to refer to MD orders) Relaxation techniques, such as guided imagery (visualization of improved health and/or positive thinking) or deep breathing techniques Repositioning for comfort Exercise Communication of Pain The Visual Analog Scale and Numerical Rating Scale are widely used tools in health care for individuals to express the amount of pain that they are experiencing. Barriers to Adequate Pain Control Self reported pain is not believed Confusion by the patient about addiction, tolerance, and physical or psychological dependency Concerns about adverse affects Bureaucratic restrictions Overdosing of medications, which may lead to death even though it is extremely rare
Page 4 of 9 Oncology Competency- II. Palliative Care Palliative medicine strives to relieve suffering and improve the quality of life for patients with advanced illness, while offering support to their families. Palliative medicine can be offered simultaneously with all other appropriate medical treatments. Consultations by physicians or nurse practitioners are provided in clinics, hospitals, skilled nursing facilities, and assisted living communities. Medical management is provided by a team of doctors, nurses, and other specialists who work together with a patient's other clinicians to provide an extra layer of support. What does Palliative Medicine do? Palliative medicine relieves suffering and improves the quality of life for patients with advanced illness. The focus includes pain control, physical symptoms, psychological issues, social situations, and spiritual concerns. The goal of palliative medicine is achievement of the best quality of life for patients and their families. Specifically, palliative medicine: Provides relief from pain and other distressing symptoms Integrates the psychological and spiritual aspects of patient care Offers a support system to help the family cope Who can benefit from Palliative Care? Patients with life-limiting illnesses Patients with uncontrolled physical symptoms Patients and/or families wishing to discuss: o Advance care planning o Goals of therapy o Comfort-directed therapy o Withdrawal of mechanical ventilation, artificial nutrition, and/or other forms of artificial life support Palliative Care Funding Palliative care is covered by Medicare, Medicaid, and private insurance companies. However, eligibility for these services is not based on a patient's ability to pay. Page 5 of 9
III. Hospice Care The goal of all hospice agencies in the United States is to provide comfort to the patient. Comfort is defined by the patient or, if the patient is incapacitated, the patient's family. This can help individuals experience freedom from physical, emotional, spiritual and/or social pain. Hospices typically do not perform treatments that are meant to diagnose or cure an illness, and they do not seek to hasten death or to extend life if the individual will suffer. It focuses primarily on end of life care, with the goal of easing the difficulties during the last stages of terminal illnesses. In order to qualify for hospice care, a patient must have certification from two physicians that he or she has less than six months to live if his or her disease runs its natural course; usually the patient's primary physician and the Hospice Medical Director will provide this certification. Patients can sometimes stay on hospice for longer than six months. If a patient stays on hospice for more than six months, certification is required by the hospice team with supporting evidence that the patient s condition is terminal. Insurance companies will usually continue to pay for hospice care in this situation. Benefits of Hospice The patient, family, and caregivers are the unit of care. Benefits of participating in hospice care can include exposure to a variety of disciplines that may help address challenges that the patient or family are experiencing. Services including the following: Skilled nursing services Equipment needs assessment 24-hour on-call staff for emergencies Bathing and personal care assistance Spiritual care services Bereavement support for families and loved ones experiencing grief and loss, which may also extended to the community at large Management of pain and other symptoms to ensure the patient's comfort Medical social work visits for counseling, support and advocacy Trained volunteer support for respite, companionship, and other needs Comprehensive individualized care and coordination of core medical services with the patient's physician and the hospice physician Liaisons with appropriate community resources for other necessary services Coordination of care plan, if hospitalization becomes necessary Assistance with advance care planning Page 6 of 9
Levels of Hospice Care Hospice also offers different levels of care within its services, which include: Routine Home Care o This accounts for the majority of hospice days of care. o The hospice staff visits on an intermittent basis at a frequency designed to meet the care, teaching, and support needs of the patient and family. Continuous Care o This is provided only in a time of crisis and is to be used only as necessary to maintain the patient at home. Short-term General Inpatient Care o This is available for the patient requiring pain control or acute and chronic symptom management. o It may be provided in a hospital, nursing facility, or hospice inpatient unit. Inpatient Respite Care o This is designed to relieve the caregivers of patients being cared for at home. o It may be provided occasionally for up to five days at a time. o Care may be provided in a nursing home, acute care facility, or hospice inpatient unit. Hospice Care Funding Some hospice services are covered by reimbursement from Medicare, Medicaid, and private insurance. Those on Medicare or Medicaid may be eligible for a special hospice benefit. Payment for services not covered by insurance is based on the patient's ability to pay. Those eligible for care are not denied hospice services because of an inability to pay. Hospice seeks contributions from individuals, foundations, corporations, communities of faith, and civic organizations to help pay for services not covered by reimbursement. Memorials, bequests, planned gifts, and other contributions are gratefully received and are important sources of funding. Page 7of 9 Oncology Competency-
References Hospice & Palliative Care Charlotte Region 2007-2011. http://www.hpccr.org/index.cfm Marieke H.J. van den Beuken-van Everdingen et al. High prevalence of pain in patients with cancer in a large population-based study in the Netherlands. Pain 132 (2007) 312-320. MHJ van den Beuken-van Everdingen et al. Prevalence of pain in patients with cancer: a systematic review of the past 40 years. Annals of Oncology 18 (9) (2007): 1437-1449 Page 8 of 9 Oncology Competency-
Job Aid I. Cancer Pain and Management Cancer Pain is an important factor in how patients tolerate rehabilitation, chemotherapy, and radiation. It impacts their quality of life as both cancer survivors and when dying with dignity. Pain management incorporates various approaches to prevent, reduce or stop the sensation of pain. It can be managed through pharmacological (with medications) and non-pharmacological techniques. The barriers to adequate pain control are self reported pain that is not believed, confusion about addiction, tolerance, physical and psychological dependency, concerns about adverse affects, bureaucratic restrictions, and overdosing of medications which may lead to death (despite being extremely rare). II. Palliative Care Palliative medicine strives to relieve suffering and improve the quality of life for patients with advanced illness, while offering support to their families. Palliative medicine can be offered simultaneously with all other appropriate medical treatments. Palliative medicine relieves suffering and improves the quality of life for patients with advanced illness. The focus includes pain control, physical symptoms, psychological issues, social situations, and spiritual concerns. The goal of palliative medicine is achievement of the best quality of life for patients and their families. III. Hospice Care The goal of all hospice agencies in the United States is to provide comfort to the patient. Comfort is defined by the patient or, if the patient is incapacitated, the patient's family. This can help individuals experience freedom from physical, emotional, spiritual and/or social pain. Benefits of participating in hospice care can include exposure to a variety of disciplines that may help address challenges that the patient or family are experiencing. There are different forms of hospice care, which are determined based on the patient s or family s needs. Page 9 of 9 Oncology Competency-
Post-test Name: Date: 1. What percentage of patients with cancer develops some form of pain? a. 50-70% of individuals in the early stages of cancer and in 60-90% of individuals in the late stages b. 20-30% in any stage c. 60-90% in individuals in the early stages of cancer and in 50-70% of individuals in the late stages d. 100% of patients with cancer 2. Which is a barrier to adequate pain control? a. Self reported pain is not believed b. Concerns about adverse affects c. Confusion about addiction, tolerance, physical and psychological dependency d. All of the above 3. Palliative medicine can be offered simultaneously with all other appropriate medical treatment. a. True b. False 4. Specifically, Palliative medicine: a. Provides relief from pain and other distressing symptoms. b. Integrates the psychological and spiritual aspects of patient care. c. Offers a support system to help the family cope. d. All of the above 5. Hospices typically do perform treatments that are meant to diagnose or cure an illness, and they do seek to hasten death or, primarily or unduly, to extend life. Hospice care is primarily end of life care, with the goal of easing the difficulties of the last stages of terminal illnesses. a. True b. False 6. What are the different levels of Hospice Care? a. Routine Home Care b. Continuous Care c. Short-term General Inpatient Care d. Inpatient Respite Care e. All of the above