Definitions PAlliative Care is the treatment of a patient´s physical, emotional, social and spiritual needs. It seeks to improve quality of life for a person with a serious or life-threatening medical condition, and for his or her family. PAlliative Care is the treatment of a patient´s physical, emotional, social and spiritual needs. It seeks to improve quality of life for a person with a serious or life-threatening medical condition, and for his or her family. http://www.cchospice.org/General_Overview.aspx
Hospice Care: designed to alleviate pain and control the symptoms of disease with expertise and compassion. In addition to physical care, hospice provides spiritual, social, and emotional support. An extension of Palliative Care
The Aging of the US http://www.nytimes.com/interactive/2011/02/04/business/aging- population.html?_r=0http://www.nytimes.com/interactive/2011/02/04/business/aging- population.html?_r=0 Accessed 7.8.14
When to recommend or refer When to recommend or refer Open dialogue early Open dialogue early 1.Advance directives 2.Medical power of attorney 3.Family and patient desires 4.Address cultural and religious concerns Decline is obvious Decline is obvious Family request Family request
Atul Gawande, MD Wrote Being Mortal Wrote Being Mortal Discusses what we want for our aging/ seriously ill: safety vs. Discusses what we want for our aging/ seriously ill: safety vs. What THEY want: independence, comfort and food WHO gets to choose?! What THEY want: independence, comfort and food WHO gets to choose?!
A patient and friend Ms. Elsie Ms. Elsie Admitting diagnosis: end-stage CAD Admitting diagnosis: end-stage CAD Died well within a week Died well within a week
The Process Call to Hospice Call to Hospice 1.Identify diagnosis 2.Sign the request/co-sign for PAs 3.Consider home visit or Hospice facility
Hospice Nurses Angels, wonderful, loving, a blessing Angels, wonderful, loving, a blessing PAtient advocates and guides for clinicians PAtient advocates and guides for clinicians YOUR and the patient’s escort through the process YOUR and the patient’s escort through the process
Overall Management –Control pain –Improve function and quality of life Comfort Comfort Social/society/spiritual Social/society/spiritual –Avoid therapeutic toxicity when possible –Pharmacologic and nonpharmacologic measures should be used American College of Rheumatology Subcommittee on Osteoarthritis. Arthritis Rheum. 2000;43:1905-15.
IASP Definition of Pain “ An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage” International Association for the Study of Pain
Measure the Pain Verbal (ask for description) Verbal (ask for description) Visual Analog Scale Visual Analog Scale Observation! Observation!
Rx Considerations Analgesic options, outpatient: Analgesic options, outpatient: –Acetaminophen –NSAIDs (COX-2) –Tramadol –Codeine ± acetaminophen –Hydrocodone/oxycodone ± adjuvant Common concerns Common concerns –Analgesia ceiling –GI ulcers, platelets –CNS, GI effects –CNS, GI effects, disorientation –CNS, GI effects
Breakthrough Pain Cancer as its model Cancer as its model Opiates and atypical opiates Opiates and atypical opiates –Quick onset: transmucosal fentanyl citrate (OTFC) and fentanyl buccal tablet (FBT) –Short Acting: hydromorphone immediate release (IR) –Long acting: Tramadol ER, Oxymorphone ER, Morphine ER Future: Fentanyl iontophoretic transdermal system Future: Fentanyl iontophoretic transdermal system –efficacy and side effects similar to standard intravenous patient- controlled analgesia (IV-PCA) Sufental trandermal patch Sufental trandermal patch Schmerz. 2007 Aug 9; [Epub ahead of print] Nauck F, Eulitz N. Schmerz. 2007 Aug 9; [Epub ahead of print] Nauck F, Eulitz N.Nauck FEulitz NNauck FEulitz N Cancer pain management : Basic therapy and treatment of breakthrough pain. Pharmacologic Treatment of Chronic and Breakthrough Pain CME/CE Pharmacologic Treatment of Chronic and Breakthrough Pain CME/CE Martin E. Hale, MD, http://www.medscape.com/viewarticle/558587 Accessed 8/12/07 Martin E. Hale, MD, http://www.medscape.com/viewarticle/558587 Accessed 8/12/07http://www.medscape.com/viewarticle/558587
Bowel Program Senna Senna Colace Colace Miralax Miralax Etc. Etc.
Euthanasia and Right to Die Initiatives Washington and Oregon Washington and Oregon Rx Provided after screening and family/medical support Rx Provided after screening and family/medical support Interesting outcomeS! Interesting outcomeS! 10. Assisted Suicide (Sec. 1553) Forbids the federal government or anyone receiving federal health funds from discriminating against any health care entity that won't provide an "item or service furnished for the purpose of causing... the death of any individual, such as by assisted suicide, euthanasia, or mercy killing." ACA provisional statement
How comfortable are you? Continuing care for survivors Continuing care for survivors Attending the memorial or funeral Attending the memorial or funeral Writing a personal note Writing a personal note Visiting the family Visiting the family
Bereavement Care Bereavement Care The final component of “end of life care.” Bereavement counseling to survivors by the hospice team and other sources for up to a year after the death of their loved one. The final component of “end of life care.” Bereavement counseling to survivors by the hospice team and other sources for up to a year after the death of their loved one. Rx as necessary eg: anxiety or sleep Rx as necessary eg: anxiety or sleep Time Time
Children and Babies Grief Grief is complex; it encompasses a wide range of emotions that can come and go in waves. You are not alone. With time, you and your family will experience new happy moments together. http://www.sesamestreet.org/griefhttp://www.sesamestreet.org/grief Accessed 7.7.14
Grieve not, nor speak of me with tears, but laugh and talk of me as if I were beside you... I loved you so -- 'twas Heaven here with you. Grieve not, nor speak of me with tears, but laugh and talk of me as if I were beside you... I loved you so -- 'twas Heaven here with you. --Isla Paschal Richardson --Isla Paschal Richardson
Forever on Thanksgiving Day the heart will find the pathway home. -- Wilbur D. Nesbit
What we do for ourselves dies with us. What we do for others and the world remains and is immortal. - - Albert Pine
What Should We Do? Listen Listen Guide our patients and families Guide our patients and families Gather resources Gather resources Call write and visit our legislators! http://cqrcengage.com/ncapa/ Call write and visit our legislators! http://cqrcengage.com/ncapa/http://cqrcengage.com/ncapa/
We must all die. But that I can save him from days of torture, that is what I feel as my great and ever new privilege. Pain is a more terrible lord of mankind than even death itself. — Albert Schweitzer, 1931