Rural Palliative Care Networking Group Meeting January 28, 2014 Staples, Minnesota
Agenda Welcome and Introductions Educational Session Symptom Management at End-of-Life Part II Presented by Laura Scherer, RN, Director, Unity Family Home Care and Hospice Round-robin discussion Wrap-up and next steps
Clinical Review for the Hospice and Palliative Nurse Symptom Management Anxiety, Delirium/Agitation. and Depression 3
Objectives 1. Define anxiety, delirium/agitation, and depression that is present at the end of life. 2. Identify possible etiologies of anxiety, delirium/agitation, and depression at the end of life. 3. Assess for the physical and psychosocial aspects of anxiety, delirium/agitation, and depression that are common at the end of life. 4
Objectives 4. Describe pharmacological and nonpharmacological interventions for anxiety, delirium/agitation, and depression that can be included in the plan of care at the end of life. 5. Describe the patient and family instructions needed for patients and families at the end of life. 5
Domains of Quality Palliative Care Clinical Practice Guidelines of Quality Palliative Care Domain 2: Physical Aspects of Care Guideline 2.1 Pain, other symptoms, and side effects are managed based upon the best available evidence, with attention to disease-specific pain and symptom, which is skillfully and systematically applied. 6
Anxiety Feeling of deep sense of unease without an identifiable cause Prevalence - varies 7
Causes of Anxiety Poorly controlled pain Altered physiologic states Medications Withdrawal from alcohol/medications Medical conditions Physiological/Emotional/Spiritual distress 8
Assessment of Anxiety Physical symptoms Cognitive symptoms Pain Bowel/bladder Familiarity with environment Interview questions Explore psychological and emotional dimensions 9
Pharmacological Treatment of Anxiety Antidepressants Blocks serotonin reuptake Benzodiazepines acts on limbic-thalmic-hypothalmic area of the CNS producing anxiolytic, sedative, hypnotic, skeletal muscle relaxation Neuroleptics blocks dopamine reuptake 10
Non-pharmacological Treatment of Anxiety Coping skills Reassurance and support Manage stress and decrease stimulation Symptom management Complementary therapies Counseling 11
Anxiety Patient & Family Education Review causes Monitor for signs and symptoms Avoid stimulation Patient safety Discuss unresolved issues 12
Anxiety References 1. Kazanowski M. Symptom management in palliative care. In: Matzo ML, Sherman D W, eds. Palliative care nursing: Quality Care to the End of Life. New York, NY: Springer, 2006: 319-344. 2. Pasacreta JV, Minarik PA, Nield-Anderson L. Anxiety and depression. In: Ferrell B R, Coyle N, eds. Textbook of Palliative Nursing. 2nd ed. New York, NY: Oxford, 2006: 375-399. 3. Bednash G, Ferrell BR. End-of-Life Nursing Education Consortium (ELNEC Geriatric ). Washington, DC: Association of Colleges of Nursing, 2007. 4. Breitbart W, Chochinov H, Passik S. Psychiatric aspects of palliative care. In: Doyle D, Hanks G, MacDonald N, eds. Oxford Textbook of Palliative Medicine. New York, NY: Oxford, 2003. 5. Berry PH, ed. Core Curriculum for the Hospice and Palliative Nurse 2nd ed. Dubuque, IA:Kendal/Hunt; 2005. 13
Delirium/Agitation Delirium a global, potentially reversible change in cognition and consciousness that is relatively acute in onset Common in patient near death (approx 88%) Agitation - excessive restlessness accompanied by increased mental and physical activity 14
Delirium/Agitation Prevalence Almost half of patients experience delirium/agitation in last 48 hours Experienced by 77-85% of terminally ill cancer patients 15
Causes of Delirium/Agitation Infection Malignancies / Tumor burden and secretions Renal or hepatic failure Metabolic abnormalities (low/hi Na, low K, hi Ca, low/hi glucose, hypothyroid, renal/liver failure) Hypoxemia Sensory deprivation Medications Fecal impaction / Urinary retention Vitamin deficiencies 16
Assessment of Delirium/Agitation Distinguish from other related symptoms Physical assessment History Spiritual distress Consider medical etiologies 17
Assessment of Delirium/Agitation Established tools Mini-Mental Status Examination (MMSE) www.chcr.brown.edu/mmse.pdf Memorial Delirium Assessment Scale (MDAS) www.painconsortium.gov Delirium Rating Scale (DRS) 18
Assessment of Delirium/Agitation Established tools Confusion Assessment Method (CAM) www.hartfordign.org/publications/trythis/issue13.pdf Neecham Confusion Scale (NCS) www.unc.edu/courses/2005fall/nurs/213/001/neuropsychiatric /neecham.html 19
Treatment of Delirium/Agitation Correct underlying cause Consider symptomatic and supportive therapies At end of life, causes may not be reversible and medications are indicated 20
Treatment of Delirium/Agitation Pharmacological interventions Neuroleptics blocks dopamine uptake; metabolized by the liver Haloperidol (Haldol ) Severe agiation 21
Treatment of Delirium/Agitation Benzodiapines Midazolam (Versed ) Anxiolytics Lorazepam (Ativan ) Atypical Antidepressants blocks dopamine uptake selectively, but with less anticholingeric effects Risperidone 22
Non-pharmacological Treatment of Delirium/Agitation Encourage presence of family Avoid excessive stimulation Reorient if indicated Familiar people and items Acknowledge visions Complementary therapies 23
Delirium/Agitation Patient & Family Education Reassure patient and family Review symbolic language Review medications Sensory stimulation if indicated Instruct how to reorient 24
Delirium/Agitation References 1. Emanuel L, von Gunten C, Ferris F. The Education for Physicians on End of Life Care (EPEC) Curriculum. Washington, DC: American Medical Association, 2003. 2. Breitbart W, Chochinov H, Passik S. Psychiatric aspects of palliative care. In: Doyle D, Hanks G, MacDonald N, eds. Oxford textbook of palliative medicine. New York, NY: Oxford, 2005. 3. Lichter I, Hunt E. The last 48 hours of life. Journal of Palliative Care 1990;6:7-15. 4. Pereira J, Bruera E. The frequency and clinical course of cognitive impairment in patients with terminal cancer. Cancer 1997;79:835-842. 5. Caraceni A. Delirium in palliative medicine. European Journal of Palliative Care 1995;2:62-67. 6. Kuebler KK, Heidrich D, Vena C, English N. Delirium, confusion, and agitation. In: Ferrell BR, Coyle N, eds. Textbook of Palliative Nursing. 2nd ed. New York, NY: Oxford, 2006:401-420. 25
Delirium/Agitation Additional References Bednash G, Ferrell BR. End-of-Life Nursing Education Consortium (ELNEC). Washington, DC: Association of Colleges of Nursing, 2009. 26
Depression Intense and often prolonged feelings of sadness, hopelessness and despair 27
Depression Prevalence 25 77% terminally ill population 22% of nursing home residents Often not recognized at end-of-life 28
Causes of Depression Medical conditions Pain Treatment-related factors Medications Psychological factors Financial issues 29
Assessment of Depression Symptoms associated with medically ill Enduring sad mood Hopelessness Fatigue Diminished ability to make decisions 30
Assessment of Depression Risk factors Medical co morbidity Male > age 45 Stressful life events Uncontrolled pain 31
Assessment of Depression Screening tools Mini-Mental Status Examination (MMSE) Beck Depression Inventory Geriatric Depression Scale Cultural influences Cultures may judge severity of depressive symptoms differently Symptoms should not be dismissed because it is seen as a characteristic of a particular culture Chinese may use the term imbalance Latino/Mediterrean may say nerves, headaches 32
Assessment of Depression Ask questions regarding Mood Behavior Cognition Suicide assessment risk factors Psychiatric disorder Depression Alcohol abuse 33
Treatment of Depression Optimal Pharmacological Non-pharmacological Interpersonal interventions Complementary 34
Pharmacological Treatment of Depression Antidepressants Blocks serotonin, (5HT) reuptake SSRIs Considered as first line treatment For debilitated patients start at 1/3 dose 35
Pharmacological Treatment of Depression Tricyclics Blocks reuptake of various neurotransmitters at the neuronal membrane Improves sleep Effective on 70% of patients treated 36
Pharmacological Treatment of Depression Stimulants Stimulates CNS and respiratory centers Increases appetite and energy levels Improves mood Reduces sedation 37
Pharmacological Treatment of Depression Other Steroids Improves appetite Elevates mood Non-benzodiazepines Useful in patients wit mixed anxiety/depressive symptoms 38
Non-pharmacological Treatment of Depression Counseling reinforce goals and interventions of care plan established by interdisciplinary team Behavioral interventions Provide directed / structured activities Focus on goal attainment / prepare for future adaptive coping 39
Non-pharmacological Treatment of Depression Cognitive interventions Assist patient to reframe negative thoughts into positive thoughts Interpersonal interventions Build rapport with frequent, short visits Mobilize family and social support systems Complementary therapies Guided imagery Art and music therapy 40
Non-pharmacological Treatment of Depression Specific Behavioral Strategies Negotiate structured schedule Realistic goals Positively reinforce 41
Depression Patient & Family Education Review signs and symptoms Instruct on prevalence Review medications Review non-pharmacological interventions Provide private opportunity to talk 42
Depression References 1. Bednash G, Ferrell BR. End-of-Life Nursing Education Consortium (ELNEC ). Washington, DC: Association of Colleges of Nursing, 2009. 2. Pasacreta JV, Minarik PA, Nield-Anderson L. Anxiety and depression. In: Ferrell BR, Coyle N, eds. Textbook of Palliative Nursing. 2nd ed. New York, NY: Oxford, 2006:375-399. 3. Breitbart W, Chochinov H, Passik S. Psychiatric aspects of palliative care. In: Doyle D, Hanks G, MacDonald N, eds. Oxford Textbook of Palliative Medicine. New York, NY: Oxford, 2005. 4. Wrede-Seaman L. Symptom management algorithms: A handbook for palliative care. Yakima, WA: Intellicard, 1999. 43
Questions? Please join us on May 6 for Part 3 or 3 Symptom Management Respiratory, Fatigue, & pressure ulcers Laura Scherer RN, CHPN Director at Unity Family Home Care and Hospice laurascherer@catholichealth.net 320-631-5595 44
Round-Robin Discussion
Wrap-Up and Next Steps Next meeting Tuesday, May 6, 2014, 10 am noon Knute Nelson Grand Arbor hosting 4403 Pioneer Road SE Alexandria, MN 56308 Educational Session: Symptom Management Part III Respiratory, Fatigue, & pressure ulcers Presented by Laura Scherer
Questions? Janelle Shearer, MA, RN, BSN 952-853-8553 or 877-787-2847 jshearer@stratishealth.org www.stratishealth.org
Stratis Health is a nonprofit organization based in Minnesota that leads collaboration and innovation in health care quality and safety, and serves as a trusted expert in facilitating improvement for people and communities. This effort is sponsored by UCare and supported by Stratis Health.