Palliative & Hospice Care, Chronic Illness Trajectory

chronic illness trajectory

persistent changes in mental, physical, and spiritual health status, requiring long term management. NO cure, non-reversible, progressive

chronic illness

alteration in health or function

occurring for 6 months or more

lived experience

communicable or non-communicable dx

chronic disease

long duration

long latency period

no definitive cure

occurring for more than 3 months

number of adults in the USA with a chronic dx

6 in 10 adults

number of people in the USA with 2 or more chronic conditions

4 in 10 people

how much money is spent on healthcare costs

$35.5 trillion

top 2 chronic diseases in the US

heart disease and cancer

Chronic illness attributes

care transition, self care management, health related quality of life, uncertainty

care transition

care across transitions for ex. home → ICU

proactive care plan with goals

created, documented, executed, updated with patient

comprehensive, patient & family centered

shared across providers

revised as needed

self care management

process where you actively manage chronic illness

support behavioral skills

independence & autonomy, decision making

self-care

health related QOL

life satisfaction, concerns that may change over time

how their life is impacted by health & illness

affects both individual & family

uncertainty

unpredictable, subjective experience, ambiguity of illness, complex treatment

communication w/ HCP - inadequate info

inability to determine meaning of illness

prevents or delays coping

increased emotional and psych distress

chronic illness trajectory PHASES

onset, stable, acute, comeback, crisis, unstable, downward, dying

onset phase of CIT

s/sx are present, diagnostic period (pt has been diagnosed at this time)

stable phase of CIT

illness course and s/sx are controlled by treatment regimen.

treatment is working atm

acute phase of CIT

active illness with severe and unrelieved s/sx or complications. hospitalization may be required.

comeback phase of CIT

gradual return to an acceptable way of life

crisis phase of CIT

life threatening situation occurs, emergency services

unstable phase of CIT

unable to keep s/sx or disease under control

disrupted life, pt is working to regain control

hospitalization NOT required

downward phase of CIT

gradual and progressive deterioration (physical or mental)

increasing disability & s/sx

continuous alterations in ADLs

dying phase of CIT

relinquish ADLs & interests

let go

die peacefully

palliative care

improves QOL of pt. & families through alleviation of suffering using non-curative interventions.

• improving sx management and QOL

• ideally started at DIAGNOSIS (onset phase of CIT)

• interdisciplinary for holistic needs

• continuum of care

• can be billed as a specialty consult

what type of benefit is hospice?

Medicare Part A benefit

hospice care

• Medicare Part A benefit

• terminal illness w/ prognosis of < 6 months

• comprehensive medical support services

• no curative goals (palliative interventions), medicating for pain & comfort ONLY

• requires election (NOE) by pt/ pt rep.

• 12 month bereavement

what is the plan of care based on FIRST?

poc is always based on the patient’s goals FIRST. then, the team’s assessments, recs, and support second.

terminal secretions

wet, gurgling, crackling sounds people experience right before death.

• natural part of dying process, doesn’t cause discomfort for pt.

pharm intervention for terminal secretions

GLYCOPYRROLATE (anticholinergic)

• decreases stomach acid

• decreases saliva production

non-pharm intervention for terminal secretions

repositioning on the side to help reduce mucus pooling in lungs

anorexia/cachexia

EOL sx: muscle mass loss, weakness, weight loss, little appetite, decreased nutritional needs

pharm intervention for anorexia/cachexia

dronabinol (increases appetite, decreases pain)

non pharm intervention for EOL anorexia/cachexia

• cognitive behavioral therapy

• nutritional counseling

• highly nutritious foods

• small frequent meals

• favorite foods, oral care

The body no longer requires nutrition/ hunger is suppressed at EOL.

pharm intervention for EOL constipation

metoclopramide increases peristalsis and GI motility

non pharm intervention for EOL constipation

increased fiber, increased fluid intake

interventions for EOL diarrhea

pharm: antidiarrheals

nonpharm: modify diet

pharm interventions for EOL N/V

• ondansetron

• aprepitant

• promethazine

• metoclopramide

• dronabinol

non-pharm interventions for EOL N/V

• prevent & mitigate n/v

• quiet calm environment

mucositis

inflammation of mucosal membranes lining the digestive tract, VERY PAINFUL

pharm intervention for EOL mucositis

sucralfate, topical anesthetics

non pharm intervention for EOL mucositis

• diet changes

• no inflammatory foods

• salt water rinse

• hydration

• oral hygeine

• non alc mouthwash

• soft toothbrush

xerostomia

dry mouth lacking saliva (EOL). NOT relieved with IV fluids

non pharm interventions of xerostomia

• hard candy

• hydrated - water, ice chips

• sugar free gum

• lip balm

• nose breathing

• oral hygeine

• wet mouth w/ wet cloth or sponge

• toothette

• mouth spray

non pharm interventions for wound/skin breakdown

• reposition, turn

• floating heels

• elevate extremities

• proper diet/water intake

palliative care attributes

• multidisciplinary

• patient, family centered

• holistic