What two criteria are required for admission to hospice?
1. Patient must desire services
2. patient must be eligible (2 physicians must certify that patient has 6 months or less to live)
What are the overall goals of Palliative Care?
How can it help with pts family members?
How are these accomplished?
Prevent and relieve suffering
Improve quality of life for pts with serious, life-limiting illnesses
Others: lessen dependence upon family members which lead to caregiver strain
Accomplished: through a team oriented, interdisciplinary approach through a patient specific, emotional and spiritual support
What is the main difference between palliative and hospice care in regards to payment?
Hospice is similiar to palliative care, but since 90% of hospice is paid through Medicare, hospice patients must meet Medicare's eligibility requirements, which palliative care patients do not.
List differences between Palliative services to Hospice Services.
2. Stage of dz
4. Location of services
- Palliative:paid by insurance or self
- Hospice: Paid by medicare, medicaid
2. Stage of dz:
- Palliative: Any stage of the dz
- Hospice: Prognosis 6 months or less
- Palliative: given same time as curative tx
- Hospice: Excludes curative tx
4. Location of services:
- Palliative: typically happens in hospital
- Hospice: Wherever patient calls home
VALUE is a 5-step mnemonic to improve ICU clinician communication with families. What does it stand for?
V: Value comments made by the family
A: acknowledge family emotions
U: Understand the patient as a person
E: Elicit family questions
What is Center to Advance Palliative care's (CAPC) definition or focus of palliative care?
Palliative Care: focused on providing patients with relief from symptoms, pain and stress of serious illness, whatever the diagnosis.
What is Sutter's term, AIM, stand for?What is the symptom of palliative care that it focuses on, which leads to improved quality of life?
AIM: advanced illness management
Generally focuses on pain (among others) to improve quality of life
What are the 4 criteria for Sutter's AIM?
How many of the 4 is needed to fill the criteria?
1. Dx of cancer, advanced CHF, end stage pulmonary, hepatic, neurological, dementia or other
2. When Non palliative tx of primary dz is failing or losing effectiveness
3. Decline in functional and/or nuntritional status in 30 days
4. Eligible for hospice but refuses enrollment
*Requires 2 or 4
What is the NCP? Who can benefit from it?
NCP: National Consensus Project
It is for people who have conditions leading to dependence on life-sustaining tx and/or long term care for ADL's
Includes: progressive and chronic conditions
- acute and life threatening tx is required, but results in poor quality of life
- serious or terminally ill pts who are unlikely to recover
In Sutter's AIM criteria, a decline in functional and/or nutritional support status must be past __ days.
When a patient is being considered for palliative care in a hospital, list the people that can make referrals?
Who approves the referral and admits to palliative care?
Referral: patients, families, physicians, and other healthcare providers
Admission: Reviewed by palliative care team
List some examples why someone at Memorial Hospital might be considered for palliative care
Cancer pts with pain and other s/s
End stage heart or lung dz, and late-stage hiv DZ
Poorly controlled pain, trouble n/v, acute SOB, and unmanageable agitation or confusion
In Kaiser, list the inpatient palliative care team
Social worker (Gina Osbeck), LCSW
Chaplain (Raymond Dougherty), BCC
MD (Dr. Karen Lieder and Dr. Pirouz Fakhraei)
In Kaiser, list conditions why a patient is considered for Palliative Care
Pt understand he will never live free of the condition
Pt. needs recurrent ED visits or hospitalization
When pt experiences unrelieved pain or symptoms
When new chronic dx is made
Frailty apparent (weight loss, falls, decreased independence in ADLs)
1. Promotes RECOVERY and patient safety; patients admitted and discharged quickly ____
2. Promotes transition toward End of Life Care for patients with End stage illness ____
b. Home Care
What does ESAS assessment test for?
Edmonton Symptom Assessment: Gives scores of 0 to 3 (3 being severe dysfunction) to different functions including:
- mental status
What does the Palliative Performance Scales tests for? (5)
1. ambulation: full to death
2. activity and evidence of dz
3. Self care
4. Intake: normal to mouth care only
5. Conscious level: full to drowsy, coma and/or confusion
List the ECOG performance status scores (0-5)
0: full active, no restriction
1: restricted in physical strenuous activity, but able to do light work
2: ambulatory and can do self-care, but cannot carry out work activities
3: capable of only limited self care, confined to bed or chair >50% of waking hours
4: completely disabled
Which scale is this:
–100 = Normal; no c/o or evident disease
–90 = Able to carry on normal; minor S/S
–80 = Normal activity with effort; some S/S
–70 = Self care; unable to do normal activity
–60 = Requires occasional assistance
–50 = Considerable assistance; freq med.care
–40 = Disabled; special care & assistance
–30 = Severely disabled; hospitalization
–20 = Very sick; hospitalization indicated
–10 = Moribund; fatal processes progressing
–0 = DEAD
What is Xerstomia?
Dry mouth resulting from reduced or absent saliva flow, may be a symptom of various medical condition, radiation, meds, etc.
For a patient with agitation:
1. What is the initial sedative to try q4-8h?
2. What drug do you switch to if it doesn't work?
3. What eventually needs to be done after no relief for 24 hours?
1. Haloperidol 0.5-1mg, then titrate up if no relief (30mg)
2. If no relief from haloperidol, Lorazepam 0.5mg q1h (12mg)
3. If no relief after 24 hours, consultation with physician, rn, and pharmacist must be done
What is the first drug to treat anorexia?
What do you give next if no relief?
What is the third drug if still no relief?
1st: Megestrol (anticancer) PO QD for 1 week
2nd: Ritalin BID for 2-3 days
3rd: Consider Prednisone
With Bladder Spasms tx, list what protocol is with each process
1. If indwelling catheter is present
2. If urinalysis is negative
3. If there is positive urinalysis
1. If indwelling catheter is present:
- assess cath fxn., irrigate
- Give oxybutinin (antisposmadic) BIDx48 hours
- Scopolamine (anticholinergic) PRN
2. If urinalysis is negative:
- Oxybutinin BID x48 hours
- Scopolamine PRN
3. If there is positive urinalysis:
- Contact MD
- Promote fluids
List Bowel tx for stepped care program
1. Stool softner or gentle laxative
- Docusate (no opioids) or Senokot (with opioids)
2. If no BM, add Milk of Mag or Bisacodyl
3. If still no BM, perform rectal exam to r/o impaction
4a. If not impacted, Magnesium Citrate OR Fleets
4b. If impacted: fleets enema, soften with glycerin suppository then manually disimpact
- follow with tap water enema until clear
List tx for Candidiasis (oral)
1. Nystatin susp swish and swallow QID OR Clotrimazole Troche five times a day
2a. If improved, continue 7-10 days
2b. If not improved, Fluconazole x14days
List tx for Candidiasis (Perineal)
1. Clotrimazole (Lotrim) 1% lotion
2a. If improved after 2days, continue 7-14 days
2b. If not, one time dose Fluconazole
List tx for hiccough
1. Baclofen (antispastic)
2. Then Haloperidol TID (antipsychotic, but also has anticholinergic and alpha-adrenergic blocking)
3. Metoclopramide (antiemetic, but also for hiccups)
4. If still no relief, consider anesthesia consult
List tx for Mucositis
1. Sodium Bicarbonate rinses
2. If no relief, magic mouthwash swish/spit q1h
3. If still no relief, consider other analgesic such as PCA
List tx for Pruritus after establishing probable cause
1. If obstructive jaundice
2. If not obstructive jaundice
- Cholestyramine (lipid lowering agent associated with elevated levels of bile acids)
2. Not jaundice:
- Hydroxyzine (antihistamine) PO tid
- Promasome lotion or Diphenhydramine
List tx for type of Secretion saliva problem:
1. Diminished saliva (Xerostomia)
- encourage PO fluids and oral care
- Artificial saliva
- hard candies
- if hx of radiation, Pilocarpine 4% (opthalmic drops) PO tid
List tx for type of Secretion saliva problem:
1. Increased secretion w/ or w/out trach
2. Thick Secretions
1. Consider Scopalamine patch
2. Guafenesin and increase fluid intake
List acute management of seizures
1. Lorazepam stat, repeat in 15 min PRN with max 8mg
- If hx of seizures, draw anticonvulsant drugs
What are the biggest symptom issues when looking at palliative care? 4
sleep and depression
List alternatives for opioid admin if PO nor IV Access is available
Use Fentanyl patch
SQ infusion of PCA using 27 gauge needle
Long acting opioid to rectal, vaginal or stoma route with Fentanyl injection used SL
List tx for complaints of dyspnea
1. Fentanyl nebulizer 25 mcg
2. O2 2-6 LPM
- If no relief, Morphine
- If still no relief, Lorazepam
Other than pain management, Morphine (Roxanol) and MS Contin are common treatments for what other symptom?
How are both used in different circumstances?
Roxanol: SL for mild, moderate, or severe SOB.
MS Contin: only for unremitting dyspnea at rest
1. List tx for Bronchospasm with audible wheeze
2. List tx for mild CHF with resp. distress
1. Albuterol 1-2 puffs or nebulizer
- If no relief, add Ipratopium (Atrovent) 1-2 puffs
2. Furosemide one dose
- If end stage, consider fentanyl nebulizer
List general guidelines for Opiates
How do you wanna start?
What do you want to consider?
1. Start low and titrate slowly
2. Consider renal and hepatic fxn
3. Look for respiratory depression if given with sedative as well
What is the VOMIT acronym for causes of emesis? List tx for each letter
- Scopolamine patch or phenergan
O: Obstruction (opiates)
M: Mind (dysmotility)
I: Infection (irritaion of gut)
T: Toxins (taste and other senses)
- Haldol or Zofran
List tx for sleep disturbance
- Temazepam if no relief
WHO's guideline for pain relief ladder include what 3 things?
Amount of pain a patient reports, assessing it, and treating accordingly
1. Pain persisting or increasing: non-opioid tx, w/ or w/out adjuvant
2. Opioid for mild to moderate pain
3. Opioid for moderate to severe pain
Which organization defined palliative care as this:
Approach that improves quality of life to pts and families facing problems from life-threatening illness by relieving suffering thru an early ID and assessment and tx of pain
WHO: World Health Organization
List the common things pts WANT out of palliative care
Avoid inappropriate prolongation of dying process
Achieve sense of control and quality of life
Relieve burdens on family
Strengthen relations w/ loved ones
What is the most IMPORTANT aspect during palliative care as a nursing intervention?
Impeccable assessment and ongoing assessment of s/s and responses to the team's interventions.
Should NOT BE RESERVED for the final days of life
List 5 hallmarks that indicates pt health status is declining and needs palliative care recognition
Anorexia: weight loss w/out intending to lose weight