Palliation

Supportive care

Medical interventions to improve quality of life The patient is not actively dying (difference between comfort care) - Fluid replacement therapy - Blood transfusions - Psychological or spiritual needs of the patient or family (therapist, social workers, ministers) - Focus is not on symptom management but focus on physical issues (dehydration give fluid, low RBCs give blood, want to correct issues)

Bad death

Pain; not having one's wishes followed at the end of life; isolation, abandonment.

Palliation

The relief or management of symptoms without providing a cure

Purpose of an advance directive

To provide guidance on life sustaining treatment should the patient be unable to speak for him/herself

End of life care

a time defined aspect of care (weeks to days of life left) - Used synonymously with hospice care - Symptom management - Comfort care - Weeks to days of life - Medicare coverage: prognosis of less than 6 months

Comfort care

actively dying - Interventions for comfort management - Provide patient and family reassurance - Reduction in physical functioning

Disorientation

decreased metabolism and slowed circulation to the brain - Identify yourself whenever you speak to the person - Reorient the person as needed - Speak softly, clearly, and truthfully

Restlessness

decreased metabolism and slowed circulation to the brain - Play soothing music; aroma therapy - Do not restrain - Massage persons forehead - Reduce number of people in room - Talk quietly - Keep room dimly lit - Keep noise level to a minimum - Consider sedation if necessary

Comfort care

focus on relief of discomfort rather than curative or prolongation of life (pt. is actively dying) - Physical, social, and emotional needs are priority - High dose pain medication may have the effect of hastening death - Patient is actively dying - Positioning, oral care, skin care (basic but important) - Interventions for comfort management not symptom management

Good death

free from avoidable stress and suffering for patients, families, and caregivers; consistent with clinical practice standards

Fluid and food decrease

metabolic needs have decreased - Do not force food or drink (Don't want to make pt. aspirate) - Offer small sips of liquids or ice chips if alert enough to swallow - Oral care

Increased sleeping

metabolism is decreased - Spend time sitting quietly with the person - Do not force person to stay awake - Talk to the person as you normally even if no response

Palliative care

no cure diseases but pt. is not actively dying - Aggressive symptom management: dyspnea, fatigue, anxiety, depression - Prevention of exacerbations: CHF, COPD - Promote activity, increase physical functioning - Rehabilitation

Exemplars of palliative care

palliation, comfort care, supportive care, end of life care

Incontinence

perineal muscles relax - Keep perineal area clean and dry - Use disposable underpads, chux, disposable undergarments - Consider a foley

Breathing pattern change

slowed circulation to the brain may cause breathing pattern to become shallow, irregular, apneic (cheyne-stokes), or shallow - Elevate person's head - Position on side

Congestion and gurgling

unable to cough up secretions effectively - Position on side (so they don't aspirate) - Administer meds to decrease production of secretions (atropine-we give when the pt. is bradycardic and will dry up the pt. it's an anti-colinergic) - Suction or not? (Yes for the comfort of the pt.)

End of life care

- Admission to hospice care - DNR order - Expectation that death will occur within 6 months of admission to hospice care - Patient no longer seeks aggressive disease management - Symptom management

DNR orders

1. Can be written as part of an advance directive 2. Spouse (can be initiated by spouse, they are next in command) 3. Joint family decision 4. Slow code (pt. passed away, walk slowly to the room, go through the motions) 5. Chemical code only (no intubation, no compressions- they will give drugs and go through ACLS protocol) 6. The dysfunctional family

Inter-professional team

1. Nursing (RN- will work with physician and family, give meds-pain and anxiety) 2. Social Service (Valuable in helping the family and pt. make decision with end of life care, Durable Medical Equipment (DME) in community) 3. Physician (key person for comfort medications-only meds ordered, no IV's in hospice, no antibiotics will be considered) 4. Spiritual care (Depends on what the pt. wants) 5. Ancillary services (DME companies, Equipment- commode, wheelchair)

Criteria for making this directive: patient must be able to perform 3 tasks

1. Receive information (not necessarily oriented X 4) 2. Evaluate, deliberate, and mentally manipulate information 3. Communicate a treatment preference

Goals of palliative care

1. early prevention or treatment of symptoms 2. prevent or treat psychological, social, and spiritual problems r/t the disease or it's treatment 3. assist patients to live more comfortably

Attributes of palliation

- Focus on care of the patient not the cure - A supportive role including symptom management - Inter-professional approach to delivery of care (nurse, therapists, physician, minister, dietician, social worker, ect.) - Individualized holistic care that addresses the unique needs of the patient and family - Collaborative communication with patients, families, and providers to determine realistic goals (with or without the pt. family) (Any RN can call an ethics conference) - Focus on quality of life rather than length of life (what can we do to make the pt. more comfortable) - Care provided early in the disease that extends into the end of life (hospice does not necessarily mean they are going to die right away)

Perception of death

- U. S. Health Care System focus: prevention, early detection, cure. - Difficult for many health care providers to accept death as an outcome of a disease - Often seen as failure - 1995 study: poor quality of dying by hospitalized patients - IOM recommendation: major initiative needed to improve the end of life care facilitating a good death.

World Health Organization

- no longer just focused on cancer - disease not responsive to curative treatment - control of pain and other symptoms - includes psychological, social, and spiritual problems

Physical signs of death

-Coolness of extremities -Increased sleeping -Fluid or food decrease - Incontinence -Congestion and gurgling -Breathing pattern change -Disorientation -Restlessness

Scope of palliation

-Supportive care -Comfort care -End of life care

Advance directives

A legal document stating the care they would like at end of life that would positively affect the dying experience for the patient and family

Pathophysiology of dying

A. Direct Causes - Heart failure, cardiac dysrhythmias, MI, cardiogenic shock - Respiratory failure, PE, respiratory arrest - Shock

Health Policy: U. S. Department of Health and Human Services

A. Four goals to support persons with concurrent multiple chronic conditions 1. Provide better tools and information to health care and social service workers who deliver care to these individuals 2. Maximize the use of proven self-care management and other services by these individuals (how can we have the pt. to the best of their ability continue to take care of their self) 3. Foster health care and public health system changes to improve the health of these individuals (how can we as nurses affect changeactive participation in committee work, lobbying for better pt. care and better staffing patterns) 4. Facilitate research to fill knowledge gaps about individuals with multiple chronic conditions

Supportive care

Deals with medical interventions to increase the quality of life - Aggressive use of laboratory analysis - Bone marrow stimulating factors - Referral to specialty physicians to manage pulmonary disease and symptoms - Used in lung cancer patients undergoing oncology care - Pt. is not actively dying

Coolness of extremities

circulation decreased; skin may become mottled or discolored - Cover person with blanket - Do not use electric blanket, hot water bottle, heating pad