Palliative and End of Life Care

What are the principles of palliative care? (Acute, chronic?)

Holistic care of persons w/ serious health suffering from a severe illness (Acute or chronic)

What is the goal of palliative care?

- When should it start?

- Symptom management

- @ Dx

What are physical elements of palliative care that need to be assessed?

- Symptoms

- Effectiveness

- Cultural, spiritual, and emotional

What Psychological elements of palliative care? (4ish)

- Anxiety

- Depression, Delirium

- PTSD

- Sub Abuse

How does culture affect palliative care?

- Views on illness and treatment

- Who makes decisions

What time frame for HOSPICE care?

- GOAL?

- < 6 mo to live

- Max QOL, NO cure = dignified death

-

What is capacity?

Ability of pt to make HC decisions

What does Capacity REQUIRE?

1. Understands info

2. Risks/benefits and alts

3. Communicate clearly w/ HCPs

4. Logic in decision making

What are Advance directives?

Tells team what to do when code or incapacitated.

What if a person has to Living Will or POA?

2 HCPs make decision

What is a living will?

- Organ donation?

Advanced directive in writing

- On driver's license, overrides family

What are the 5 Wishes - Advance Care Planning?

1. Make decisions (when I can't)

2. Med treat do/do not want

3. How Comfortable

4. Treat me

5. Loved ones to know

What is Bereavement?

Period of time AFTER detah when grief/mourning

What is grief?

- What stages?

- Rxn to death of loved one

- Denial, Anger, Bargain, Depress, Accept

what can cause respiratory symptoms? (4)

- Can it be reversed?

- Cardiac (P edema)

- Pulmo

- Oncologic (Malig. P effusion, tumor)

- Trauma

- Not always

What do you educate family about resp s/s?

- Not = distress at EOL

- Relief = pt self reports! (not RR/SpO2)

What are Respiratory Symptom Treatments- pharm?

- Albuterol/Ipratropium (bronchodilate)

- ABx (palliative)

- Benzos

- Steroids

- O2 (can prolong)

- Glycopyrrolate: (dry secretions)

- Opioids

Respiratory Symptom Treatments- nonpharm?

- Increase HOB

- Fan (air hunger feeling) - Pursed lip breathing

- Education (EOL resp sx)

What is RDOS- respiratory distress observation scale? (OBJECTIVE) (8)

- (0, 1, 2)

- > 4+ = medicated?

- HR (< 90, 90-109)

- RR (=< 18, 19-30,)

- Restlessness

- Accessory M (N/A, slight, pronounced)

- Paradoxical breathing

- Grunting at end-exp

- Flaring

- Fear?

What are Delirium symptoms? (4ish)

- What types?

- Agitate

- Alt. attention, perceptions

- Impaired cog.

- Hallucinate

- Hyper/hypoactive or mixed

The longer delirium lasts?

Longer = more chance pt has perm. damage

What is treatment for delirium?

- Alarms off/calm

- Sleep/wake

- Soft Music

- Underlying

- Reorient

- Support family (sx distressing)

What meds for delirium?

- Haldol (PO, IM, IV)

- Seroquel

- Riperidone

What is the patho of N/V? (2)

- V center (medulla) = N from trigger

OR

- CTZ in brainstem = chem stim or movement

What are PHARM treatments for N/V? (6)

- Prevention

- IV Fluids (not EOL)

- Anticipate N (benzo)

- Antiemetics

- Metoclopramide (T low motility)

- Steroids

What are non pharm treatments of N/V?

- Aromatherapy

- Acupunture

- Healing

- Touch/reiki

What are constipation causes?

- Dz (CA, IBD, Parkinson's, ESRD, DM II, SCI, stroke)

- Meds (chemo, opioids, antihistamines, BP, antidepress)

what should you assess if someone is constipated?

- Ab pain

- Anorexia

- Flatus, bloat, cramp (No flatus = obstruction?)

- Oozing stool

- Pain/ strain

What are Non-pharm treatments for constipation?

- Acupuncture

- Massage

- Position (Left side)

- Mobility

- Dietary (Avoid dairy)

What is Psychosocial symptom management? (Nonpharm)

- Relax

- Control what they can

- Safe environment (reflection on life)

- RN = outbursts not personal

What is Peripheral sensitization?

- Injured! Be careful

Nociceptors Sensitized in PNS post injury or inflammation > CNS

What is Central sensitization?

- Can lead to?

- Neurons sensitized (CNS)

- Unrelieved acute pain can = chronic pain

What is Transduction?

Conversion of a noxious stim = elect signal to NS= pain

- Nocioceptors activate

What is Neuropathic Pain?

- AbnL processing of sensory input

What is CENTRAL neuropathic pain?

- Ex?

- From primary lesion or CNS problem

= MS, post stroke

What is PERIPHERAL neuropathic pain?

- Ex?

- Direct nerve damage = pain @ nerve site

- DM neuropathy

What is DEAFFERENTATION neuropathic pain?

- Ex?

- Loss or alteration in afferent nerve

- Phantom limb pain

What are Neuropathic pain treatments? (6)

- Antidepressants

- Anticonvul (Gabapentin, Pregabalin)

- Cannabinoids (Marinol)

- Corticosteroids

- local anesthetic

- GABA R agonist (Baclofen)

What are non-pharm interventions for pain?

- physical?

- Cognitive?

- Acupuncture, heat, cold, exercise, massage, Reiki

- Deep breath, distract, relax, imagery, hypnosis, Music

What is Critical Care Pain Observation Scale (CPOT)?

- Intubation?

- DOES NOT?

- What score = pain?

- Pain in nonverbal high-acuity pts.

- Intubated or not...

- NOT intensity measure

- 3+

What are BARRIERS OF PAIN MANAGEMENT?

- Addiction

- Tolerance

- Phys. dependence

- Pseudo addiction (mimics, from uncontrolled pain)

What does the Pasero Opioid Induced sedation scale consist of (POSS)? (S, 1, 2, 3, 4)

- What action? (Monitor RR...)

- S = sleep, easy to arouse

1 = AxO. No action, increase?

2 = occasionally drowsy but easy to arouse; no action, increase?

3 = Freq drowsy, drifts off during convo ; decrease the opioid dose

4 = somnolent w/ minimal or no R to stimuli; DC the opioid (naloxone)

What do Hospice and Palliative care BOTH do?

- Sx relief

- Holistic

- QOL

- Caregiver support

What is Medical Futility?

- What does treatment do?

- intervention may have effect but NO benefit to pt

- T = prolongs death and does not change prognosis

What does the nurse do in Withdrawal of Care?

- Document convo (rationale for decision)

- Assess pt/family (FICA)

- COMFORT environment

- Sx come back...

What are CARDIAC sx at EOL?

- Decrease/irreg HR

- Weak pulse

- HypoTN

What are PULM sx at EOL?

- Pattern (Cheyenne Stokes)

- Accessory M

- Secretions, wheeze, crackle

- Death rattle

What are GI sx at EOL?

- Dehydrate

- Incontinence

What are NEURO sx at EOL?

- Decreased LOC

- Hallucinations

- Agitate, restless

What are GENITOURINARY sx at EOL?

- Oliguria... Anuria

- Incont., retention

What are MSK sx at EOL?

- Immobile

- Fatigue

- Dysphagia, no gag

When do you do Post Mortem Care?

- Do unless they need med examination

Post Mortem Care:

- What do you do?

- Family time (bedside)

- Pt position (Stuck, rigor mortis)

- Paperwork w/ family (Death certificate)

- Final bath

- In brief

- Remove lines