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PAlliative and Hospice Care A Primer for the Clinician Charlene M. Morris, PA-C Stonewall, NC 2.6.15.

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Presentation on theme: "PAlliative and Hospice Care A Primer for the Clinician Charlene M. Morris, PA-C Stonewall, NC 2.6.15."— Presentation transcript:

1 PAlliative and Hospice Care A Primer for the Clinician Charlene M. Morris, PA-C Stonewall, NC 2.6.15

2 Alicia De Troye: AAPA’s 2/14 Leadership Meeting

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4 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

5 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

6 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

7 From 13 to 55 million over 65!

8 Why We Die Heart disease: 597,689 Heart disease: 597,689 Cancer: 574,743 Cancer: 574,743 Chronic lower respiratory diseases: 138,080 Chronic lower respiratory diseases: 138,080 Stroke (cerebrovascular diseases): 129,476 Stroke (cerebrovascular diseases): 129,476 Accidents (unintentional injuries): 120,859 Accidents (unintentional injuries): 120,859 Alzheimer's disease: 83,494 Alzheimer's disease: 83,494 Diabetes: 69,071 Diabetes: 69,071 Nephritis, nephrotic syndrome, and nephrosis: 50,476 Nephritis, nephrotic syndrome, and nephrosis: 50,476 Influenza and Pneumonia: 50,097 Influenza and Pneumonia: 50,097 Intentional self-harm (suicide): 38,364 Intentional self-harm (suicide): 38,364 http://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm

9 He drew a circle that shut me out- Heretic, rebel, a thing to flout. But love and I had the wit to win: We drew a circle and took him in! -- Edwin Markham

10 Revised, improved version http://www.latimes.com/opinion/op-ed/la-oe-0407-silk-ring-theory- 20130407-story.htmlhttp://www.latimes.com/opinion/op-ed/la-oe-0407-silk-ring-theory- 20130407-story.html accessed 7.9.14

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12 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

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14 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?!

15 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

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17 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

18 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

19 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.

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21 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

22 Measure the Pain Verbal (ask for description) Verbal (ask for description) Visual Analog Scale Visual Analog Scale Observation! Observation!

23 Where do we go from here?

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25 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

26 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

27 Bowel Program Senna Senna Colace Colace Miralax Miralax Etc. Etc.

28 Other Rx Benzodiazepines Benzodiazepines Acetaminophen Acetaminophen Ibuprofen/Naproxen Ibuprofen/Naproxen Recreational (street) drugs Recreational (street) drugs “Dietary supplements” “Dietary supplements” Herbs, balms Herbs, balms

29 “I Don’t Want To Be An Addict” Fear of Opiates

30 Nonpharmacologic Treatment Options Speaking/music Speaking/music Acupuncture Acupuncture PT/massage/desensitization/touch PT/massage/desensitization/touch Ice/Heat Ice/Heat Biofeedback Biofeedback Potter. Adv Stud Med. 2004;4:31-40.

31 –Reassurance –Listening –Holding hands –Visualization –Patient empowerment –Stress counseling –Behavior modification

32 Death

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35 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

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37 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

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41 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

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43 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

44 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

45 Forever on Thanksgiving Day the heart will find the pathway home. -- Wilbur D. Nesbit

46 What we do for ourselves dies with us. What we do for others and the world remains and is immortal. - - Albert Pine

47 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/

48 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

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