Class 16: Palliative Care

What is palliative care

• It is the relieving of symptoms of an incurable, life-limiting illness

• supports people who are LIVING with a life-limiting illness

• is Holistic care: Physical, psychological, spiritual, social

• Can be implemented anywhere along the person’s illness trajectory, not just “at the end”

Palliative approach

• Aims to provide comfort to patients and improve quality of life through whole person-centered care

• All healthcare professionals who provide any form of care to patients with life-limiting illnesses should be able to provide basic or generalist-level _____

How do we identify patients who may need palliative care

• Any person, at any age, who is suffering from the stress and symptoms of a life-limiting illness.

• Patient’s with advanced stage illness, unmanaged symptoms, steady decline

• Patient/family expressing wishes to discuss goals of care, ACP

What are life limiting illnesses

• Cancer

• ALS

• Alzheimer’s Disease

• COPD

• End stage heart disease, liver disease, kidney disease

• Parkinson’s Disease

• Dementia

• Frailty

When should palliative care be implemented?

• Ideally, as soon as a person is diagnosed with a life-limiting illness

• Progression of disease

• Poorly managed symptoms, high symptom burden

Symptoms of concern

• Pain

• Nausea

• Constipation

• Fatigue

• Sleep disturbance

• Anxiety

• Shortness of breath

• Depression

• Loss of appetite

• Tiredness

• Emotional and psychological stress

Who is the palliative care team?

• Physicians

• Nurse Practitioner

• Registered Nurses

• Licensed Practical Nurses

• Social Work

• Administrative Support

• Pastoral Care

• Allied Health (SLP, Dieticians, PT, OT)

What is your role?

• Be knowledgeable

  • About the patient, their illness, their symptoms

• Be an advocate for patients

• Don’t be afraid to ask the medical team questions

• Be present for the patient

• Be a spokesperson for Palliative Care and help to dispel myths

• Acknowledge that this is difficult, saying hard things is hard!

• Ask about special rites or ceremonies, religious and cultural needs

What is the difference in palliative care and end of life care?

• Palliative Care

  • Follows the patient along their illness trajectory, for weeks, months and often sees ups and downs (bumps in the road) with some plateaus

  • Gradual decline in status

• End of Life Care

  • More predictable, steady decline

  • Weeks, days, hours

How do we know a patient is approaching end of life?

• Eating less (poor appetite, early satiety)

• Spending more time in bed

• Sleeping more

• Increased pain

• Incontinence

*Decline can be slow (over weeks to months) or rapid (days to hours)

-this is a good predictor of “how long” patient may have left

What can you do at EOL?

• Has code status been discussed?

• Keep the room quiet, is there a quiet space available for families?

• Can the visitation rules be modified, might take an email to Manager or Director

• Can family members sleep over?

• Would the family like pastoral care?

• Consult Social Work (counselling)

• Tell the families what you see, tell them what worries you

• Mouth Care, protect pressure points, suggest a foley catheter, would oxygen help?

• Ask the medical team to ensure EOL medications are ordered

End-of-life medications 

• Can any oral medications be discontinued?

• Ensure medications are ordered subcut and subcut port is placed

• Opioids for pain

• Antinausea/antiemetic

• Anxiolytics

• Medications for secretions

Opioids for pain

• Morphine

• hydromorphone

• fentanyl

• methadone

Antinausea/antiemetic

• Maxeran

• Zofran

Anxiolytics

• Lorazepam

• Midazolam

• Haldol

Medications for secretions

• Scopolamine

• Glycopyrrolate

What to expect at the end?

• Changes in breathing, increased secretions

• Difficulty swallowing

• Weak voice

• Color change

• Temperature changes

• Changes in level of consciousness

• Confusion

• Agitation or restlessness

When a patient dies…

• Give the family time

• Place a sign on the door

• Notify the medical staff

• Families are often unsure what happens next (funeral home etc)

• It’s ok to be sad, we are not robots

Palliative Emergencies

• Bleeding

• Airway obstruction

• Seizures

• Malignant Bowel Obstruction

•  Intractable symptoms

  • Pain

  • Nausea

  • SOB

What do I do if there is an emergency?

• Know the disease, ask questions

• Anticipate what might happen, plan for it

• Ask the medical team what the plan is

• Are there medications available in the event of an emergency?

• If it happens, stay calm

  • Patient and family will look to you

Are there other options?

• Palliative sedation

  • Refractory pain, nausea, vomiting, bleeding

  • Seizures

  • Restlessness, agitation

• MAiD