Palliative Care

Cheruiyot sambuMSCN/BSCN/DCN

CLINICAL NUTRITIONIST

• Palliative care (pronounced pal-lee-uh-tiv) is specialized medical care for people with serious illnesses. It focuses on providing patients with relief from the symptoms, pain, and stress of a serious illness—whatever the diagnosis. The goal is to improve quality of life for both the patient and the family.

Definition of palliative care

• Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.

-WHO 2002

Main aims

Avoid the avoidable suffering

Building Capacity : empowerment to adjust, relief and support the unavoidable suffering

Wellbeing

Promote comfort

Improve the Quality of Life

Comprehensive Care

• Interdisciplinary team care- nursing services, medical, social, pastoral counseling, home health aide.

• Bereavement counseling• Dietary counseling• Physical therapy• Occupational therapy• Speech therapy• Investigations and drugs• Durable medical equipments and

supplies.

SERVICES PROVIDED BY PALLIATIVE CARE

The Interdisciplinary Team

• Physicians• Nutritionists• Nurses• Psychologists/psychiatrists• Social workers.• Physiotherapist . • clinical psychologist .• Pharmacist • Volunteers • Chaplains/pastoral care workers• Home attendants etc

Why we need palliative care?• inappropriate communication

between physician and patient and family.

• inappropriate pain control.• Load of symptoms in the end of life

.• Majority of diagnosed patient are

in late stage .• Mechanical medicine, use in the

technology and rise in the life expectancy.

• inappropriate communication between physician and patient and family.

• inappropriate pain control.• Load of symptoms in the end of life

.• Majority of diagnosed patient are

in late stage .• Mechanical medicine, use in the

technology and rise in the life expectancy.

What does Palliative Care Provide to the Patient?

• Helps patients gain the strength and peace of mind to carry on with daily life

• Aid the ability to tolerate medical treatments

• Helps patients to better understand their choices for care

PRINCIPLES

• provides relief from pain and other distressing symptoms;

• affirms life and regards dying as a normal process;

• intends neither to hasten nor postpone death;

• integrates the psychological and spiritual aspects of patient care;

PRINCIPLES…

• offers a support system to help patients live as actively as possible until death;

• offers a support system to help the family cope during the patients illness and in their own bereavement;

• distressing clinical complications.

PRINCIPLES…..

• uses a team approach to address the needs of patients and their families, including bereavement counseling, if indicated;

• will enhance quality of life, and may also positively influence the course of illness;

• is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy,

ELEMENTS OF PALLIATIVE CARE1.PRIMARY GOAL:

The primary goal is to prevent and relieve sufferings imposed by disease and their treatment, achievement of best possible quality of life for patients and their families regardless of the stage of the disease or need for other therapies.

Elements…

2.PATIENT POPULATION:Patients of all ages experiencing a debilitating chronic or life threatening illness, condition or injury.

3.PATIENT AND FAMILY CENTERED CARE:The uniqueness of each patient and family is respected. The patient family constitute the unit of care.

4.TIMING OF PALLIATIVE CARE:It ideally begins at the time of diagnosis of a life threatening or debilitating condition and continues through cure, or until death and into the family’s bereavement period.

Elements…..

5.COMPREHENSIVE CARE:Palliative care employs multidimensional

assessment to identify and relieve sufferings through the prevention or alleviation of physical, psychological, social and spiritual distress.

6.INTERDISCIPLINARY TEAM:Team work is an integral part of the

philosophy of palliative care. Require the expertise of various providers in order to adequately assess and treat the complex needs of seriously ill patients and their families.

Elements….7. COMMUNICATION SKILLS:

Effective communication skills are requisite in palliative care. These includes appropriate and effective sharing of information, active listening, determination of goals and preferences, assistance with medical decision making, and effective communication with all individuals involved in the care of patients and their families.

Elements….

8. SKILL IN CARE OF THE DYING AND BEREAVED:Team must be knowledgeable and skilled in providing care for the dying and the bereaved.

9.CONTINUITY OF CARE ACROSS SETTINGS:Palliative care is integral to all health care delivery system settings (hospital, emergency dept, nursing homes, home care, assisted living facilities, outpatient and non traditional environments such as schools. The palliative care team collaborates with professional and informal care givers in each of these settings.

Elements….

10. EQUITABLE ACCESS:Palliative care teams should work toward

equitable access to palliative care across all ages and patient populations, all diagnostic categories, all health care settings including rural communities, and regardless of race, ethnicity, sexual preferences or ability to pay.

11. QUALITY IMPROVEMENT:Palliative care services are committed to

the pursuit of excellence and high quality of care which enhances the quality of life.

PHILOSOPHY OF PALLIATIVE CAREWe believe• Access is Foundational -

Palliative care services should be available to all who require care.

Philosophy……

• Care is Patient-Focused – Palliative cares strives to meet the physical, psychological, spiritual and social needs of patients and families.

• It is sensitive to personal, cultural and religious values, beliefs and practices, developmental state,and readiness to deal with the dying process

Philosophy……

• People Have the Right To Choice - Each person is an autonomous and unique individual with the right to participate in informed discussion related to care and to choose the best possible options and outcomes based on that information.

• Dying is Part of Life – Palliative care affirms life. Euthanasia and physician assisted suicide are not considered options. Palliative care never intentionally hastens death.

• Quality of Life Guides Decisions – Care choices should be guided by quality of life as defined by the patient.

Philosophy…….

• Team Work Is Essential – Palliative care is a network of services most effectively delivered by an interdisciplinary team who rely on shared knowledge, expertise and effective interactions.

• Service is Coordinated – A palliative care program should promote continuity of care across settings and coordination amongst all involved caregivers and programs/services.

Philosophy…..

• Confidentiality is Central – Patient information is treated with the utmost respect. Team members must adhere to this principle.

• Care Setting Is Important – Palliative care is provided in a patient and family focused environment in the most appropriate care setting. The needs and preferences of the patient and family, as well as the resources available, are taken into consideration.

Philosophy……

• Caregiver Well-Being Is Fundamental – The provision of ongoing support to enhance formal and informal caregivers‛ well-being is integral to a successful palliative care program.

• On-going Education is Essential – Patient, family, caregiver and public education is important to the maintenance and enhancement of the quality of palliative care.

SCOPE

• Palliative care is the specialized medical care for people with serious illness.

• provides relief from pain, shortness of breath, nausea and other distressing symptoms;

• affirms life and regards dying as a normal process;

• intends neither to hasten nor to postpone death;

• integrates the psychological and spiritual aspects of patient care;

SCOPE

• offers a support system to help patients live as actively as possible;

• offers a support system to help the family cope;

• uses a team approach to address the needs of patients and their families;

• will enhance quality of life;• is applicable early in the course of

illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy.

Palliative Care Patient Support Services

Three categories of support:

1. Pain management is vital for comfort and to reduce patients’ distress. Health care professionals and families can collaborate to identify the sources of pain and relieve them with drugs and other forms of therapy.

Palliative Care Patient Support Services

2. Symptom management involves treating symptoms other than pain such as nausea, weakness, bowel and bladder problems, mental confusion, fatigue, and difficulty breathing

Palliative Care Patient Support Services

3. Emotional and spiritual support is important for both the patient and family in dealing with the emotional demands of critical illness.

Cure/Life-prolongingIntent

Palliative/Comfort Intent

DEATH

“Active Treatment”

PalliativeCare

DEATH

EVOLVING MODEL OF PALLIATIVE CARE

Curative Treatment(Cancer, CHF, COPD, AIDS,

Dementia debilitating Neurological diseases …)

Palliative Treatment

Bereavement CareHospice

DeathDiagnosis

Most Recent MODEL OF CARE

Continuum of Care

How could we assess the patient needs?

• Holistic : Physical. Psychological. Spiritual. Social.

Example of a suggested essential drug list for palliative care

Analgesics

Non-opioids (mild pain)• Acetylsalicylic acid• Paracetamol• IbuprofenOpioids (mild to moderate pain) CodeineOpioids (moderate to severe pain)• Morphine• MethadoneOpioid antagonist • Naloxone

Corticosteroids • Dexametasone• PrednisoneLaxatives• Senna• Sodium ducosate• Mineral oil• Lactulose• Magnesium

hydroxideAppetite • PrednisoleBowel obstruction (when surgery not indicated) DimenhydrinateHaloperidolHyoscine butylbromideMetoclopramide

Anxiety, depression, insomnia, psychosis, Amitryptiline• epileptic seizures

Diazepam• Lorazepam• Chlorpromazine• Haloperidol• Phenytoin• Sodium valproate

Diarrhoea • Codeine phosphate• Loperamide

essential drug list….Gastric protection• Omeprazol

Fluid retention• Furosemide• SpironolactoneOral candidiasis • Cotrimoxazole• Ketoconazole• NystatinNausea and vomiting• Dimenhydrinate• Holoperidol• Metoclopramide• Prednisolone• Prochlorperazine

Morphine consumption as indicator of effective palliative service:• Morphine consumption can be used as an

approximate measure of the availability of pain control and hence availability of this form of palliative care.

• Developing countries consumed only 6% of global consumption of morphine. ( almost 80 percent of the world's population)

• While 10 countries together accounted for 87% of total world consumption of morphine.

International Observatory on End of Life Care