N401 Palliative Care Giddens

Prolonged dwindling

Ins seen in patients with dementia or alzheimer's disease, disabling stroke and frailty Patients who follow this disease trajectory do not have cancer or chronic disease states that lead to organ failure - these patients are more likely to die at older ages Patients who reside in LTC settings are most likely following this type of disease trajectory where the prolonged insidious decline in function will eventually lead to multiple organ failure and death

Comfort Care

Is an approach to the care of the dying that emphasizes the relief of discomfort rather that the cure of illness or prolongation of life. Physical, social, and emotional needs are the first priority, even when treatment such as high dose pain medication may have the effect of hastening death

End of life care

Is more often than not used synonymously with hospice care and identifies a time defined aspect of care End of life care is somewhat evident in its use and terminology in that it is te care the patient and family receive in the actively dying, terminally ill, or near death phase of life

Multiprofessional approach

Is one in which several subspecialists independently make patient care consultations and recommendations to the patient's plan of care

Palliation

Is the relief or management of symptoms without providing a cure. To palliate is to reduce the severity of an actual or potential life threatening condition or a chronic debilitating illness.

The palliative care team is composed of the following disciplines (5)

Nursing Social services Physician Spiritual Care Ancillary Services: volunteers, techs, PT, OT, art and music therapist, pharmacists, psychologists, and psychiatrists

The premise of palliative care is to promote the optimal management of symptoms that are common to chronic disease states in a coordinated manner

Optimal symptoms management promotes improved physical functioning and patient perceived quality of life

WHO definition of palliative care

Palliative care is the active total care of patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms, and of psychological, social and spiritual problems is paramount. The goal of palliative care is achievement of the best quality of life for patients and their families. Many aspects of palliative care are also applicable earlier in the course of illness in conjunction with therapies such as anticancer treatment

Palliation is the reduction of symptoms without elimination of the cause

Palliative care refers to the provision of care for patients who are diagnosed with a disease or condition without a cure

What are the first priority in comfort care?

Physical, social, and emotional needs, even when treatment such as high dose pain medication may have the effect of hastening death

Some goals of palliative care

Prevent or treat as early as possible the symptoms of a disease or the associated side effects caused by treatment of the disease Prevent or treat they psychologic, social and spiritual problems related to the disease or its treatment Help patients with chronic or life threatening disease to live more comfortably

Comfort care can be multidimensional

Such as providing attention to the patient's emotional and spiritual dimensions along with their physical care needs

The past 2 decades have witnessed a dramatic growth in the percent of the population diagnosed with diabetes and cardiovascular disease, driven in large part by increased rates of obesity

The incidence of stroke, pulmonary disease, and mental disorders, such as depression is also rising, mostly related to an aging population

Palliative care refers to the provision of care for patients who are diagnosed with a disease or condition without a cure

This approach encompasses: A focus on the care of the patient, not on the cure of the disease or illness A supportive role, including symptom management An interprofessional approach to the delivery of care Individualized holistic care that addresses the unique needs of the patient and family Collaborative communication among patients, providers, and families to determine realistic goals A focus on the quality of life verses the length of life Care provided early in the course of disease that extends into the end of life

The successful palliative care team collaborates on providing "best practice" to address the multiple needs of the patient and family

This is accomplished through the development and maintenance of an integrated, individualized plan of care

Hospice nurses utilize comfort care and symptom management during the terminal stages of disease

This is often viewed as palliative care

CHF, COPD: often experience disease exacerbations that insidiously lead toward a poor prognosis

This trajectory of disease follows a long term limitation with intermittent exacerbations and sudden dying - typical of organ system failure Patients who follow this disease trajectory often live for several years with their chronic disease and may have minor dunctional limitations in ADLs Patients who follow this disease trajectory will typically die suddenly from a complication or an cute exacerbation

In palliative care

a tem addresses the needs of both the patient and teh family - bbiological, psychologic, emotinal, social, and spritural

Comfort measures are predominantly carried out in the

actively dying phase of life

Palliative experts believe that palliative care SHOULD NOT

be used synonymously or confused with the term end of life care

Comfort care IS NOT symptom management,

but describes the nursing interventions used to promote comfort - comfort care provides important interventions to support the patient and family at the end of life

Using the term end of life care to describe palliative care

does not adequately describe the complex problems and high case mix of patients who require the skills of effective palliation (chemotherapy, radiation therapy, or blood transfusions)

The current health care system spends a majority of US dollars

during the last 6 months of life, when patient care if often fragmented between multiple providers and care settings

In recent years, the trend has been to initiate palliative care practices and principles

earlier into the management of advanced disease

End of life care in the form of hospice care utilizes palliative care for the imminently dying by

introducing a team of health care professionals at the end of the patient's life This type of care delivery often promotes a discontinuous model of care rather than a coordinated continuous delivery of patient care

Comfort care is a term that is often used by physicians and nurses in the context

of the dying, terminally ill, or seriously ill and dying patient

End of life care is a quantitative term, and limits the opportunity to expand the use of

palliative care into the management of chronic disease

Comfort care is predominantly used by nurses who attend to the dying patient and family by providing

physical comfort measures such as repositioning and oral and skin care, while valuing the ongoing medical management of the patient's symptoms

Palliative care can further be defined as specialized care that is used to

reduce the severity of a disease or slow its progression rather than providing a cure for the disease

Supportive care in the oncology setting

refers to those aspects of medical care focused on the physical issues that accompany cancer. Supportive care may consider the psychologic and spiritual needs of the patient and his or her family in the broader sense of cancer management Therefore supportive care for the oncology patient is used to manage the adverse effects caused by antineoplastic therapies through the utilization of what is considered the broad rubric of palliative interventions

Palliative care is appropriate for those patients who are living with symptomatic incurable diseases such as

severe chronic renal failure, COPD, or CHF and for those patients for whom there is no cure or reversibility to their underlying disease pathophysiology.

Nurses spend more time with patients during the advancing stages of their disease

than any other health care discipline

Hospice and end of life care are parts of palliative care and/or supportive and comfort care;

the reverse is not true

Reserving the use of palliative care interventions for symptomatic patients at the end of their life prevents

the use of effective symptom management in the care of patients living with chronic disease states

Cancer: typically maintains function for a substantial period of time

then as the disease becomes overwhelming, the patient's status declines rapidly in the final months and days of life

The US department of health and human services produced four overarching goals to support and maintain optimal health and quality of life for patients with MCCs

1. Provide better tools and information to health care and social service workers who deliver care to individuals with MCCs 2. Maximize he use of proven self care management and other services by individuals with MCCs 3. Foster health care and public health system changes to improve the health of individuals with MCCs 4. Facilitate research to fill knowledge gaps about individuals with MCCs

The medicare hospice benefit is available to patients when they receive a prognosis for survival of

6 months or less - patients who receive this type of care are expected to die

The focus of care ina curative approach remains on the cure and rehabilitation of disease

Care is often planned on the basis of routine protocols and delivered through the traditional medical model The goal of care is to alter or attempt to eradicate the disease process despite disease futility and symptom burden Care is largely determined by diagnosis and medical specialty services Curative care is evidence based and traditionally and historically practiced in routine health care, and provides the familiar and expected approach to disease management

Scope of palliation

Comfort, supportive, end of life, and hospice care

Supportive care

Least well defined area of care that is used in the management of symptoms and palliation Supportive care employs the use of medical interventions to prevent, control and/or relieve the complications of disease and the associated side effects of specific therapies Supportive care is similar to comfort care and palliative care because it is used to improve the patient's quality of life Supportive care frequently used in the oncology setting and is primarily based upon the medical interventions used to support the cancer patient, such as providing blood transfusions, managing fluid replacement therapy, or administering bone marrow stimulating agents Supportive care includes specific interventions and is NOT viewed as a holistic approach to the patient because the focus is predominantly medical and interventions are used to return the patient to a stable hemodynamic state

The biomedical approach to chronic disease management is typically overseen with a curative rather than a palliative focus

Health care providers often approach chronic disease management in an aggressive manner, seeking a cure or a recovery or investigating contributing factors associated with disease and disability

Goal of palliative care

Achievement of the best quality of life for patients and their families

An increasing number of nurses will be required to support the needs of the growing and aging patient population

An aging population can benefit from the integration of skilled palliative care interventions used to support the management of symptomatic chronic disease Optimal symptom management can enhance quality of life and help to maintain ideal physical functioning

Palliative care should be integrated into the management of chronic symptomatic disease that increases in its intensity and use as the patient approaches death

At times there is a fine line between palliation and a curative approach to disease management

As mentioned previously, because most clinicians perceive palliative care to be terminal or end of life care only, there is often a withdrawal of active treatment as compared with the active management of the disease process

Because of this, the management of distressing symptoms and the provision of psychosocial and spiritual support that accompany comprehensive palliative care are often reserved for the last weeks and days of life

_______ is considered the final outcome in hospice care and the services provided for the patient and family at the end of life include comfort and palliative care (symptom management)

Death

Symptom management

Effective symptom management requires the use of the best possible evidence to support the specific pharmacologic interventions to manage the multiple symptoms that frequently accompany chronic diseases and the dying process Many health care professionals become involved in the holistic approach of the patient (physicians, nurses, social workers, spiritual advisors, nutritionists) Symptom management differs from supportive care and comfort care in that it is all encompassing and not specific or limited in use to the end of life or to the oncology patient population

Interprofessional Team approach involving health care professionals from different disciplines is

central to optimal palliative care practice and quality outcomes

Palliation is NOT equivalent to ______

cure, but is the reduction of undesirable effects resulting from the incurable disease or condition