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Palliative Care. St William’s Parish Pat Treston 20 th September 2006. To cure, occasionally To relieve , often To comfort, always. Definition of Palliative Care.

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Palliative Care

St William’s Parish

PatTreston

20th September 2006


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To cure, occasionally

To relieve, often

To comfort, always.


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Definition of Palliative Care

  • “Palliative Care provides for all the medical and nursing needs of the patient for whom cure is not possible, and for all the psychological, social and spiritual needs of the patient and the family, for the duration of the patients illness, including bereavement care”


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Palliative Care

Hospice Care

Terminal Care


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Quality of Life

Hopes, Dreams, Aspirations

Day to day reality


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The causes of suffering

Pain

Physical symptoms

Spiritual

Psychological

Cultural

Social


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Total Suffering

Pain

Physical symptoms

Spiritual

TOTAL SUFFERING

Cultural

Psychological

Social


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Interdependence of various causes of suffering

Pain

Physical symptoms

Spiritual

Psychological

Cultural

Social


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Interdependence of various causes of suffering

Pain

Physical symptoms

Spiritual

Psychological

Cultural

Social


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Multidisciplinary Team

  • Medical

  • Nursing – CNC. Registered Nurses, ENs, AINs

  • Physiotherapist

  • Occupational therapist/Dietician

  • Counsellors/psychologists

  • Bereavement counsellors – adult, children

  • Pastoral care workers

  • Volunteers


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Goals of Palliative Care

  • To relieve and prevent suffering:

    by controlling pain and other physical symptoms

    by addressing psycho- spiritual distress

    by recognizing role of cultural factors

  • To involve people important to the patient

  • To promote a degree of acceptance by the patient and family

  • To provide a process of care that guides the patient’s understanding and decision making

  • To achieve a peaceful death

  • To provide bereavement support for families/loved ones.


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Characteristics of Palliative Care

  • Patient centred

  • Family Centred

  • Comprehensive

  • Continuous

  • Co-ordinated

  • Teamwork

  • Regular review


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Pain Management

Relief and prevention:

  • Thorough assessment

  • Explanation, education

  • Reassurance

  • Treatment appropriate to stage of disease

  • Radiotherapy / Chemotherapy


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Principles of Using Analgesics

  • Use of appropriate drug for type of pain

  • Use of appropriate drug for severity of pain

  • Combinations of drugs

  • Use of adjuvant analgesics

  • Adequate dosage

  • Dose titrated for each individual patient

  • Time dosage according to duration of action of drug


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Principles of Using Analgesics

  • Strict scheduling to prevent pain, not just when it occurs

  • Provision of breakthrough medication

  • Written instructions on medication use

  • Anticipation and treatment of side effects

  • Keep regime as simple as possible

  • Use of oral route where possible


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Opioids

  • Morphine – slow release, rapidly acting. p.o/s.c

  • Oxycodone – SR, rapidly acting

  • Hydromorphone – injection, liquid

  • Fentanyl – Patches, injection

  • Methadone - tablets


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Facts v. Myths about Morphine

  • It is not addictive

  • Does not mean death is close

  • Will not hasten death

  • Individual doses vary widely

  • No maximal dose

  • Not everyone needs to take it


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Case Study

  • Jim Smith, 65 years old

  • Married to Mary, 2 sons John & Peter in Brisbane, daughter Susan in Melb.

    (all married with young children)

  • Persistent cough in January 2005

  • Dx : Large cancer R lung

  • Treated with radiotherapy to control size of tumour – not curative

  • No spread elsewhere, esp. brain


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Case Study

  • June 2005 – chest wall pain and increasing breathlessness, esp. on exertion.

  • Referred to Mt Olivet Home Care Service

  • 7/7/2005 Commenced on SR Morphine with extra Morphine mixture, bowel medication, equipment arranged, domiciliary nurses.

  • 3 weeks later, distressing productive cough, fever, increased pain, more breathless.

  • Probable chest infection


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Case Study

1/8/2005 Admitted to Palliative Care Unit

  • “I don’t want any treatment. I want to die”

  • Reasons explored –

    Tired of feeling unwell, debilitated

    Demoralised by pain and breathlessness

    Not clinically depressed

    Enjoyed visits from work mates, grandchildren, watching sport on TV.


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Case Study

  • Informed of pros and cons of antibiotics

  • Goals of treatment

  • Commenced on antibiotics

  • Morphine dose increased

  • Oxygen

  • Nebulised saline

  • Physiotherapy

    → good symptomatic improvement.


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Case Study

  • Family meeting – decision →home with extra supports, home oxygen.

  • Pain well controlled, mobilising short distances, using extra morphine for breathlessness on exertion.

  • Mood reactive, accepting, dealing with practicalities – will, EPOA, Advanced Health Directive.

  • 12/8/2005 Discharged home


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Case Study

  • Condition reasonably stable for next 2 weeks

  • Relatively sudden onset of confusional state :

    no sleep for 2 nights, restless, disorientated, refusing oxygen, not eating.

  • 26/8/2005 Readmitted PCU - delirium

  • Many potential causes – medication, infection, spread to brain, low oxygen levels

  • Investigations – ?reversible cause


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Case Study

  • Found to have high calcium level

  • ? Competent to make decision about treatment

  • Discussed with family :

    Best symptomatic treatment if effective, potentially life prolonging (AHD)

  • Treatment not administered

  • Managed with haloperidol (anti psychotic) and other medications as required


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Case Study

  • 28/8/2005 Condition deteriorating , physically weaker, pain apparently controlled, breathless at rest, still refusing to keep oxygen on, sleep disturbance, increasing confusion/disorientation, suspicious, irritable, unable to have lucid conversation with family.

  • Family distressed +++

  • 2 days later, found wandering in the corridor, breathless and unsteady, abusive, angry, physically aggressive, lashing out at staff, overtly paranoid and fearful – telling visitors he was going to be killed.

  • Danger to himself and others


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Case Study

  • Discussion with family - probable terminal restlessness, irreversible, portent of approaching death.

  • Joint decision made to sedate patient

  • Commenced on larger doses of antipsychotic medication, sedative agents and analgesics in syringe driver.

  • Remained drowsy with some periods of awareness, ? recognised family members.


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Case Study

  • Over next few days appeared to be pain free, oxygen continued

  • Minimal oral intake, sips of water when awake.

  • Daughter arrived from Melbourne – very distraught at deterioration in father’s condition.

  • Accused staff of allowing him to die of starvation and dehydration.

  • Explanation / reassurance.

  • Mouth Care


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Case Study

  • Medications continued, given extra analgesia prior to bathing/ moving as appeared to grimace and moan.

  • Medication for terminal secretions

  • 5 days after commencing sedation died peacefully with family at the bedside.


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Death should simply become a discrete, but dignified exit of a peaceful person from a helpful society without pain or suffering and ultimately without fear”

Phillipe Aires


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“ You matter because you are you.

You matter to the last moment of your life and we will do all we can to help you-

Not only to die peacefully,

But to live until you die”

Cecily Saunders


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