1. Michael and Carol Karen Glaetzer Nurse Practitioner – Palliative Care Southern Adelaide Palliative Services Lecturer (B) – Flinders University

2. Michael >39 year old man with cerebral palsy and intellectual impairment >Lives with parents Carol and Donald >Presented to local medical surgery March 07 with headache >CT showed – posterior fossa lesion >Thought to be GBM >Excision and biopsy – histology inconclusive >Developed thyroid mass >Obstruction and tracheostomy >Histology – Medullary Ca Thyroid

3. Michael Treatment options – Surgery, XRT, Chemo Family declined 4 month hospital admission First seen in ICU, family wanted to explore home care options Prognosis thought to be 2 weeks Arrangements made for transfer home No regular GP Palliative Care Plan and Crisis Orders

4. Carol >Mother of Michael >Diagnosed with large breast mass 2 months ago >Currently undergoing chemo pre mastectomy >Keen to have Michael return home >Went on to have mastectomy, then further chemo and radiotherapy

5. NP Role >Case Coordination role >Organised local GP >Visited fortnightly or weekly in later stages >Clinical/Psychosocial assessment >Support to parents >Reviewed and titrated medications as required (dexamethasone and analgesia) >Phenytoin levels as needed – eventually changed to Clonazepam so monitoring not needed >Arranged in home respite for when Carol having chemo and radiotherapy

6. Outcome >Michael died at home 9 months after discharge from hospital >Cared for at home by his parents >Did not require any hospital admissions >Was seen twice by GP in 9 months, no other medical contact >Carol presented 2 days after Michael’s funeral with a pleural effusion

7. Outcome >Admitted for drainage and further staging >Found to have widespread lung metastases >Went home for 3 weeks >Did not want to put her husband through another death at home >Died at Daw House 5 weeks after Michael >Bereavement follow up provided to Don

8. Tessa

9. >80 year old lady >Lives with husband and son >Presented with 2-3 week history of weight loss and abdo pain >CT showed AAA, pancreatic mass and liver metastases >Emergency AAA repair and biopsy of mass – adeno ca pancreatic primary >Reviewed by Oncology – declined chemotherapy >Referred to Palliative Care Service

10. Tessa >Assessed through Triage Process >Sent appointment for NP Clinic >First seen 11/8/09 >Seen with husband and daughter >Full history taken, physical and psychosocial assessment >Still independent >Not needing any increased community supports at this stage

11. Issues Identified/Outcomes >Constipation an issue – gave advice >Only using Endone 5mg once daily >Concerned by 3 stone weight loss – referred for Megesterol/Dexamethasone Study >Arranged referral for Wheelchair >Follow up appointment 6 weeks

12. Second Appointment >22 September 2009 >Came with husband >Stable >Completed Megesterol Study >Now taking Endone 3 times a day – commenced on Oxycontin 10mg bd >Physical Examination – right calf swelling, warm and tender >Sent for Ultrasound – DVT confirmed – commenced Clexane

13. 3 rd Appointment >1 December 2009 >Increasing pain - Oxycontin increased to 20mg bd >Appetite poor >Obvious weight loss >Problems with constipation - Movicol >Epigastric mass larger >Continues on Clexane – mild ankle swelling >Family still managing care

14. 4 th Appointment >2 March 2010 >Pain increasing – needing to take regular breakthrough in afternoons – Oxycontin increased to 20mg tds >Appetite slightly improved >Further weight loss evident >Showering with husband nearby >Still not requiring any additional home supports >Discussed respite options, but declined >Next appointment 2 months

15. OPD Clinics >Opportunity for regular review >Needs based >Strengths identified >Encourages independence >Empowers individuals to take control >Resource efficient Essentials: >Constant reinforcement about what might happen and contingencies >Opportunity to respond with a home visit if/when the need arises >Communication back to GP and other relevant providers