Foundations of Palliative Care Series

Transcription

1 Foundations of Palliative Care Series Developed by: Tim Sakaluk MD, Ingrid See CPL, Tammy Dyson SW, Sharon Salomons SCP!!!!!! This course was developed in collaboration with the UBC Learning Circle to support palliative care within the First Nations communities.!

2 Homework Exercises!How was this for you?!

3 Values &! Beliefs! Forging Relationships! Ongoing Support! Actively Dying! Grief &! Bereavement!

4 Grief and! Bereavement! Actively Dying! Ongoing Support! Forging Relationships! Values & Beliefs! Each builds on the previous!

5 3. Ongoing Support

6 Transition points Changes in function are often a good indicator to reassess situation! Identify transition points and implications on whole person care!!

7 Modify PPS summarize Unable to do most activity Normal or 40%! Mainly in Bed! Mainly Extensive disease! assistance! reduced! Full or Drowsy +/- Confusion! Totally Bed 30%! Bound! Unable to do any activity Normal or Total Extensive Disease! Care! reduced! Full or Drowsy +/- Confusion! Totally Bed 20%! Bound! Unable to do any activity Minimal to Total Extensive Disease! Care! sips! Full or Drowsy +/- Confusion! Totally Bed 10%! Bound! Unable to do any activity Mouth care Total Extensive Disease! Care! only! Drowsy or Coma +/- Confusion! 0%! Death!

8 Loss and its implications Personal independence physical, financial! Family and social roles/relationships! Altered world view! Control! Stability!

9 Advance Care Planning is: A process whereby a capable adult engages in a plan for making personal and health care decisions in the event that they become unable to do so themselves.! 9

10 What ACP is not It is not just for seniors or palliative patients! Not the responsibility of one person on a healthcare team! Is not a tick box, a singular conversation or event! It is not euthanasia/assisted suicide! It is not the No CPR form! It is not a goals of care conversation! It is not financial (POA-EPOA)! 10

11 ACP definitions & tools Temporary Substitute Decision Maker a representative that has been identified by a client or has been appointed by the PGT!! Power of Attorney a representative that can make limited to extensive financial transaction on behalf of that of a client!! Representation Agreements Sec 7 and Sec 9! 11

12 Assessment in Palliative Care

13 Assessment Assessments in palliative care are quite different than in other areas.! The focus of assessments is holistic, focusing on those things important to an individual. This often includes identifying symptoms, coping mechanisms, stressors and sources of angst.! It is hoped through the identification of symptoms that a client s quality of life can be enhanced.!!

14 Baseline Assessment o What are the person s goals of care?! o What gives the person s life meaning?! o What stressors does the person have?! o What is the person s current functional status?! o What symptoms are affecting the person s quality of life?! Fatigued?!! Reduced appetite?! Pain?!Nauseated?! Anxiety?! Short of breath?!constipated?!confused?!

15 The Importance of Spiritual/Psychosocial Assessment o An acknowledgement of strengths and opportunity to build upon them! o A support to explore beliefs and meaning! o Strengthen religious/spiritual practices! o Life review the value of reminiscence! o Grief support re: living with what has been lost! o Exploration of where hope may intersect suffering!

16 Baseline Spiritual Assessment What has been your experience of illness?! Do you consider yourself to be a spiritual/religious person?! Do you find this to be helpful to you now?! How is your spirituality helping you to cope with your situation?!! (Listen for content that reflects the 5 spiritual needs.)!

17 Baseline Psychosocial Assessment An opportunity to explore external and internal factors that are affecting a client s quality of life and experience of illness! o What feels the most important to you now?! o Is this something that your healthcare team can support you with?! o What relationships affect your Quality of Life (+/-)?! o How have you coped with hardship in the past?!

18 Edmonton Symptom Assessment Scale (ESAS) Convenient tool, validated in cancer clients! Readily available on the internet! Allows for assessment of symptoms (mostly physical)! Allows for monitoring of trends! Allows for successfully monitoring of interventions!

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21 Common Physical Symptoms! Pain! Nausea! Dyspnea! Constipation!!! Delirium! Asthenia (fatigue)! Cachexia!!!

22 What is pain? The International Association for Study of Pain defines pain as an unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage!

23 Emotional! Physical! Intellectual! Interpersonal! Total Pain! Spiritual! Bureaucratic! Financial!

24 Pain Is not universal but is a common symptom! Seen in many diseases including heart failure, renal failure and cancer!

25 Effective Pain Assessment (or O P Q R S T U V) Onset when did the pain start?! Provokes or palliatives what makes it worse and what makes it better?! Quality what does it feel like? (Burning, aching, stabbing)! Radiates where is it? Does it involve any other areas? What relieves it?! Severity how bad is it? Small, medium, or large, or scale from 0/10! Timing when does it happen? Onset? Duration?! Understand the meaning of the pain and impact on quality of life (QOL)! Values what values does the client hold about pain control and medications?!

26 How do you know if a client has pain?

27 You cannot tell by looking at a client if they are in pain! You must ask them

28 Classification of Pain Nociceptive! Neuropathic! Mixed!

29 Somatic Pain Tissue damage to skin, muscle or skeletal elements! e.g. bone metastases, tumours invading muscle, osteoarthritis, skin ulceration from tumour!

30 Somatic Pain Descriptors Aching! Throbbing! Boring! Deep! Grinding! Usually well-localized! Worse with movement!

31 Visceral Pain Damage to hollow or solid organs! e.g. chronic pancreatitis, bowel obstruction, hepatomegaly,!

32 Visceral Pain Descriptors Sharp! Cramping! Aching! Often not well-localized!

33 Neuropathic Pain Pain caused by direct injury to a nerve or by abnormal nerve function secondary to compression or infiltration of nerve tissue by tumour, radiation, chemotherapy, or surgery!

34 Neuropathic Pain Descriptors Burning! Pins and needles! Stabbing pain! Hot or Cold Crawling! Scratching!

35 What are some barriers to pain management? Knowledge (eg how to use the medications safely)! Fears (eg that the medications speed up dying)! Beliefs (eg that the medications lead to addictions)!

36 Opioid-phobia Link!

37 Pain Treatment If occasional pain, prn dosing may be sufficient! If constant or regular pain, then around the clock dosing is needed! For most short acting opioids this is a q4h dose unless otherwise indicated! The goal of around the clock dosing is to prevent pain! If this goal is not achieved, a breakthrough dose can be given to achieve better pain control!

38 Even with around the clock dosing, clients can still develop pain: breakthrough pain! A breakthrough dose is prescribed with the q4h dose. It is usually half of the q4h dose.! If the client is taking more than 3 breakthrough doses per day, may need to titrate the baseline dose.!!

39 Principles of Analgesic Use in Palliative Care! Do not forget total pain of the client! ü Review and reassess comfort level daily until ü pain is stable! Use a step approach in choice of analgesic and ü go to next step if pain not relieved! Match the strength of analgesic to the severity of ü the pain!!

40 ü Use round the clock dosing! ü Use the oral route whenever possible! Always have a breakthrough medication q1h at 10% of ü the 24 hour total dose or 50% of the Q4hr dose! Always use IR medication for breakthrough! ü Always titrate with IR medication! ü!

41 ! ü ü ü ü ü Start with lower dose if client is opioid naïve, frail, elderly, or has liver/kidney failure! SC dose is ½ of oral dose! Use adjuvant medications and non-drug approaches when needed! Change to SR medications only when optimal comfort achieved and small bowel absorption is reliable! Educate the client/ family re: pain control and opioid side effects ( nausea, constipation, sedation)!

42 Tips For Good Pain Management Thorough medical history! Good pain assessment! Recognize certain medications will effect elderly more! Taking medication when the pain starts! Round the clock dosing if in moderate to severe pain! Evaluate relief and don t hesitate to make changes if needed!

43 Complementary Pain Therapies Discussion!

44 Questions? Please send in your homework by Friday, October 31! Can to: or fax to the Home Hospice office: !

45 End of DAY TWO THANK YOU! See you Monday, November 3!