What Does All this Mean from the Patient Perspective?. For patients, palliative care is a key to: relieve symptom distress navigate a complex and confusing medical system understand the plan of care help coordinate and control care options
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For patients, palliative care is a key to:
For clinicians, palliative care is a key tool to:
For hospitals, palliative care is a key tool to:
The next 2 presentations will help you:
Billings JA et al J Pall Med. 2001, AHA Survey 2002, Pan CX et al J Pall Med. 2001
Go to www.capc.org
Erin Rhatigan, RN, HPNC/ Community Hospital of the Monterey Peninsula
Beds are not available
All beds occupied
Patients ‘can’t get in’
Beds are available
Consult Service easier
Inpatient Unit Possible
Consult Service easier
Inpatient Unit Possible
‘Open’ inpatient unit
Primary Care‘Closed’ inpatient unit
Based on Revenues,
Based on Utilization,
Establishing Goals of Medical Care
Communicating Bad News
Get started and create the right setting: Plan what to say, create a conducive setting, allow adequate time, and determine who else should be present
Establish what the patient knows: Clarify the situation and context in which the discussionabout goals is occurring
Establish what the patient knows: What is known, access ability to comprehend, reschedule if unprepared
Establish and review the goals of care
Explore both what patients are expecting and hoping to accomplish: Help identify realistic and non realistic goals
Establish how much the patient wants to know? Recognize and support different preferences. People handle information differently
Establish the context of the current discussion: What has changed to precipitate the discussion?
Suggest realistic goals: Explore how goals can be achieved and work through unreasonable/nonrealistic expectations
Share the Information: Say it then stop (avoid jargon, pause frequently, check for understanding, use silence), don’t minimize the information
Discuss specific treatment(s) in context of goals of care: Will continuation or initiation of the treatment meet the goals of care?
Discuss alternatives to the proposed treatment and what will happen if the patient decides not to have the treatment
Respond empathetically to feelings: Be prepared for strong emotions and allow time for response, listen, encourage description of feelings. Allow silence
Make a plan and follow through: What treatments will be undertaken to meet goals. What treatments will not be utilized. Establish a concrete plan for follow-up
Review and revise periodically as needed
Planning/Follow up: Plan for next steps, discuss potential sources of support, give contact information, assess patient safety andsupports,repeat news at future visits
Document, disseminate (i.e., to family, other healthcare team members), and implement plan for withdrawal of treatment
3 items necessary for good pain and symptom management:
Moderate Pain (4-7/10): Begin an opioid combination product (acetaminophen + codeine, acetaminophen + oxycodone, acetaminophen + hydrocodone) and dose based upon opioid half life (3-4 hours) not acetaminophen half life (6-8 hours).
Severe Pain (8-10/10): Begin a strong standing opioid (hydromorphone, morphine sulfate, oxycodone) and titrate until pain relief is obtained or intolerable side effects develop. Long acting opioids (sustained release morphine/oxycodone, transdermal fentanyl) should be started after pain is well controlled and steady state is achieved.
Hopes and fears
Tools at www.promotingexcellence.orgIf you don’t ask you won’t know.Routine assessment is prerequisite to good symptom management.
Communication and decision-making
Pain and symptom management
Care coordination, commmunity resources for patients and families
1. Buckman R. How to Break Bad News: A Guide for Health Care Professionals. Baltimore: Johns Hopkins University Press, 1992 - The definitive guide for communicating bad news.
2. Meier DE, Back AL, Morrison RS. The inner life of physicians and care of the seriously ill. JAMA 2001; 286:3007-14. - Practical approaches to self care for physicians caring for seriously ill patients
3. EPEC - A continuing medical education program providing detailed protocols for major communication topics (www.epec.net)
4. The Center for Palliative Care of Harvard University Medical School - Continuing medical education programs in communication skills for practicing clinicians (http://www.hms.harvard.edu/cdi/pallcare/)
1. Doyle D, Hanks G, MacDonald N. Oxford Textbook of Palliative Medicine: Second Edition. Oxford: Oxford University Press, 1998. Comprehensive textbook of palliative care.
2. Morrison RS, Meier DE. Geriatric Palliative Care. New York: Oxford University Press, 2003. Comprehensive textbook of palliative care focused specifically on older adults.
3.Education for Physicians in End of Life Care www.epec.net- A continuing medical education program providing practical advice for managing pain and other symptoms
Site visiting programs
Go to the AAHPM annual meeting
Use the web
Learn by doing“Our hospital doesn’t have expertise in palliative care.”