rural palliative care networking group meeting · 1/28/2014 · kazanowski m. symptom management...

Rural Palliative Care Networking Group MeetingJanuary 28, 2014

Staples, Minnesota

Agenda

• Welcome and Introductions

• Educational Session

– Symptom Management at End-of-Life Part II

– Presented by Laura Scherer, RN, Director,

Unity Family Home Care and Hospice

• Round-robin discussion

• Wrap-up and next steps

Clinical Review for the

Hospice and Palliative Nurse

Symptom Management

3

Anxiety, Delirium/Agitation. and Depression

Objectives

1. Define anxiety, delirium/agitation, and depression that is

present at the end of life.

2. Identify possible etiologies of anxiety, delirium/agitation, 2. Identify possible etiologies of anxiety, delirium/agitation,

and depression at the end of life.

3. Assess for the physical and psychosocial aspects of

anxiety, delirium/agitation, and depression that are

common at the end of life.

4

Objectives

4. Describe pharmacological and nonpharmacological

interventions for anxiety, delirium/agitation, and

depression that can be included in the plan of care at the

end of life.end of life.

5. Describe the patient and family instructions needed for

patients and families at the end of life.

5

Domains of

Quality Palliative Care

Clinical Practice Guidelines of Quality Palliative Care

� Domain 2: Physical Aspects of Care

� Guideline 2.1 Pain, other symptoms, and side

effects are managed based upon the best available effects are managed based upon the best available

evidence, with attention to disease-specific pain

and symptom, which is skillfully and systematically

applied.

6

Anxiety

� Feeling of deep sense of unease without an

identifiable cause

� Prevalence - varies

7

Causes of Anxiety

� Poorly controlled pain

� Altered physiologic states

� Medications

� Withdrawal from alcohol/medications� Withdrawal from alcohol/medications

� Medical conditions

� Physiological/Emotional/Spiritual distress

8

Assessment of

Anxiety

Physical symptoms

� Cognitive symptoms

� Pain

� Bowel/bladder � Bowel/bladder

� Familiarity with environment

� Interview questions

� Explore psychological and emotional dimensions

9

Pharmacological

Treatment of Anxiety

Antidepressants

� Blocks serotonin reuptake

Benzodiazepines

� acts on limbic-thalmic-hypothalmic area of the CNS � acts on limbic-thalmic-hypothalmic area of the CNS

producing anxiolytic, sedative, hypnotic, skeletal muscle

relaxation

� Neuroleptics

� blocks dopamine reuptake

10

Non-pharmacological

Treatment of Anxiety

� Coping skills

� Reassurance and support

� Manage stress and decrease stimulation

� Symptom management� Symptom management

� Complementary therapies

� Counseling

11

Anxiety

Patient & Family Education

� Review causes

� Monitor for signs and symptoms

� Avoid stimulation

� Patient safety� Patient safety

� Discuss unresolved issues

12

Anxiety

References

1. Kazanowski M. Symptom management in palliative care. In: Matzo ML,

Sherman D W, eds. Palliative care nursing: Quality Care to the End of

Life. New York, NY: Springer, 2006: 319-344.

2. Pasacreta JV, Minarik PA, Nield-Anderson L. Anxiety and depression.

In: Ferrell B R, Coyle N, eds. Textbook of Palliative Nursing. 2nd ed.

New York, NY: Oxford, 2006: 375-399. New York, NY: Oxford, 2006: 375-399.

3. Bednash G, Ferrell BR. End-of-Life Nursing Education Consortium

(ELNEC – Geriatric ). Washington, DC: Association of Colleges of

Nursing, 2007.

4. Breitbart W, Chochinov H, Passik S. Psychiatric aspects of palliative

care. In: Doyle D, Hanks G, MacDonald N, eds. Oxford Textbook of

Palliative Medicine. New York, NY: Oxford, 2003.

5. Berry PH, ed. Core Curriculum for the Hospice and Palliative Nurse

2nd ed. Dubuque, IA:Kendal/Hunt; 2005.

13

Delirium/Agitation

� Delirium – a global, potentially reversible

change in cognition and consciousness that is

relatively acute in onset

� Common in patient near death (approx 88%)

� Agitation - excessive restlessness accompanied

by increased mental and physical activity

14

Delirium/Agitation

Prevalence

� Almost half of patients experience

delirium/agitation in last 48 hours

� Experienced by 77-85% of terminally ill cancer � Experienced by 77-85% of terminally ill cancer

patients

15

Causes of

Delirium/Agitation

� Infection

� Malignancies / Tumor burden and secretions

� Renal or hepatic failure

� Metabolic abnormalities (low/hi Na, low K, hi Ca,

low/hi glucose, hypothyroid, renal/liver failure) low/hi glucose, hypothyroid, renal/liver failure)

� Hypoxemia

� Sensory deprivation

� Medications

� Fecal impaction / Urinary retention

� Vitamin deficiencies

16

Assessment of

Delirium/Agitation

� Distinguish from other related symptoms

� Physical assessment

� History

� Spiritual distress

� Consider medical etiologies

17

Assessment of

Delirium/Agitation

Established tools

� Mini-Mental Status Examination (MMSE)

www.chcr.brown.edu/MMSE.pdf

� Memorial Delirium Assessment Scale (MDAS) � Memorial Delirium Assessment Scale (MDAS)

www.painconsortium.gov

� Delirium Rating Scale (DRS)

18

Assessment of

Delirium/Agitation

Established tools

� Confusion Assessment Method (CAM)

www.hartfordign.org/publications/trythis/issue13.pdf

� Neecham Confusion Scale (NCS)

www.unc.edu/courses/2005fall/nurs/213/001/neuropsychiatricwww.unc.edu/courses/2005fall/nurs/213/001/neuropsychiatric

/neecham.html

19

Treatment of

Delirium/Agitation

� Correct underlying cause

� Consider symptomatic and supportive therapies

� At end of life, causes may not be reversible and

medications are indicatedmedications are indicated

20

Treatment of

Delirium/Agitation

Pharmacological interventions

� Neuroleptics

� blocks dopamine uptake; metabolized by the liver

� Haloperidol (Haldol)� Haloperidol (Haldol )

� Severe agiation

21

Treatment of

Delirium/Agitation

� Benzodiapines

� Midazolam (Versed)

� Anxiolytics

� Lorazepam (Ativan) � Lorazepam (Ativan)

� Atypical Antidepressants – blocks dopamine

uptake selectively, but with less anticholingeric

effects

� Risperidone

22

Non-pharmacological

Treatment of Delirium/Agitation

� Encourage presence of family

� Avoid excessive stimulation

� Reorient if indicated

� Familiar people and items� Familiar people and items

� Acknowledge visions


23

Delirium/Agitation


� Reassure patient and family

� Review symbolic language

� Review medications

� Sensory stimulation if indicated� Sensory stimulation if indicated

� Instruct how to reorient

24

Delirium/Agitation

References

1. Emanuel L, von Gunten C, Ferris F. The Education for Physicians on End of Life Care (EPEC) Curriculum. Washington, DC: American Medical Association, 2003.

2. Breitbart W, Chochinov H, Passik S. Psychiatric aspects of palliative care. In: Doyle D, Hanks G, MacDonald N, eds. Oxford textbook of palliative medicine. New York, NY: Oxford, 2005.palliative medicine. New York, NY: Oxford, 2005.

3. Lichter I, Hunt E. The last 48 hours of life. Journal of Palliative Care 1990;6:7-15.

4. Pereira J, Bruera E. The frequency and clinical course of cognitive impairment in patients with terminal cancer. Cancer 1997;79:835-842.

5. Caraceni A. Delirium in palliative medicine. European Journal of Palliative Care 1995;2:62-67.

6. Kuebler KK, Heidrich D, Vena C, English N. Delirium, confusion, and agitation. In: Ferrell BR, Coyle N, eds. Textbook of Palliative Nursing. 2nd ed. New York, NY: Oxford, 2006:401-420.

25

Delirium/Agitation

Additional References

Bednash G, Ferrell BR. End-of-Life Nursing Education Consortium

(ELNEC). Washington, DC: Association of Colleges of Nursing, 2009.

26

Depression

� Intense and often prolonged feelings of sadness,

hopelessness and despair

27

Depression

Prevalence

� 25–77% terminally ill population

� 22% of nursing home residents

� Often not recognized at end-of-life� Often not recognized at end-of-life

28

Causes of Depression

� Medical conditions

� Pain

� Treatment-related factors

� Medications� Medications

� Psychological factors

� Financial issues

29

Assessment of Depression

� Symptoms associated with medically ill

� Enduring sad mood

� Hopelessness

Fatigue� Fatigue

� Diminished ability to make decisions

30


� Risk factors

� Medical co morbidity

� Male > age 45

� Stressful life events

� Uncontrolled pain

31


� Screening tools

� Mini-Mental Status Examination (MMSE)

� Beck Depression Inventory

� Geriatric Depression Scale

� Cultural influences

� Cultures may judge severity of depressive symptoms

differently

� Symptoms should not be dismissed because it is seen as a

characteristic of a particular culture

� Chinese may use the term ‘imbalance’

� Latino/Mediterrean may say ‘nerves’, ‘headaches’

32


� Ask questions regarding

� Mood

� Behavior

� Cognition� Cognition

� Suicide assessment risk factors

� Psychiatric disorder

� Depression

� Alcohol abuse

33

Treatment of Depression

� Optimal

� Pharmacological

� Non-pharmacological

� Interpersonal interventions� Interpersonal interventions

� Complementary

34

PharmacologicalTreatment of Depression

� Antidepressants

� Blocks serotonin, (5HT) reuptake

� SSRIs

� Considered as first line treatment� Considered as first line treatment

� For debilitated patients start at 1/3 dose

35


� Tricyclics

� Blocks reuptake of various neurotransmitters at the

neuronal membrane

� Improves sleep

� Effective on 70% of patients treated

36


� Stimulants

� Stimulates CNS and respiratory centers

� Increases appetite and energy levels

� Improves mood� Improves mood

� Reduces sedation

37


� Other

� Steroids

� Improves appetite

� Elevates moodElevates mood

� Non-benzodiazepines

� Useful in patients wit mixed anxiety/depressive

symptoms

38

Non-pharmacological


� Counseling

� reinforce goals and interventions of care plan established by

interdisciplinary team

� Behavioral interventions

� Provide directed / structured activities

� Focus on goal attainment / prepare for future adaptive coping

39

Non-pharmacological


� Cognitive interventions

� Assist patient to reframe negative thoughts into positive

thoughts

� Interpersonal interventions

Build rapport with frequent, short visits� Build rapport with frequent, short visits

� Mobilize family and social support systems


� Guided imagery

� Art and music therapy

40

Non-pharmacological


Specific Behavioral Strategies

� Negotiate structured schedule

� Realistic goals

� Positively reinforce� Positively reinforce

41

Depression


� Review signs and symptoms

� Instruct on prevalence

� Review medications

� Review non-pharmacological interventions� Review non-pharmacological interventions

� Provide private opportunity to talk

42

Depression

References

1. Bednash G, Ferrell BR. End-of-Life Nursing Education

Consortium (ELNEC ). Washington, DC: Association of Colleges

of Nursing, 2009.

2. Pasacreta JV, Minarik PA, Nield-Anderson L. Anxiety and

depression. In: Ferrell BR, Coyle N, eds. Textbook of Palliative

Nursing. 2nd ed. New York, NY: Oxford, 2006:375-399.Nursing. 2nd ed. New York, NY: Oxford, 2006:375-399.

3. Breitbart W, Chochinov H, Passik S. Psychiatric aspects of

palliative care. In: Doyle D, Hanks G, MacDonald N, eds.

Oxford Textbook of Palliative Medicine. New York, NY: Oxford,

2005.

4. Wrede-Seaman L. Symptom management algorithms: A

handbook for palliative care. Yakima, WA: Intellicard, 1999.

43

Questions?

Please join us on May 6 for Part 3 or 3

Symptom Management – Respiratory ,

Fatigue, & pressure ulcers

Laura Scherer RN, CHPN

Director at Unity Family Home Care and Hospice

[email protected]

320-631-5595 44

Round-Robin Discussion

Wrap-Up and Next Steps

• Next meeting

– Tuesday, May 6, 2014, 10 am – noon

– Knute Nelson Grand Arbor hosting

• 4403 Pioneer Road SE

Alexandria, MN 56308

– Educational Session: Symptom

Management Part III– Respiratory,

Fatigue, & pressure ulcers

• Presented by Laura Scherer

Questions?

Janelle Shearer, MA, RN, BSN

� 952-853-8553 or 877-787-2847

[email protected]

www.stratishealth.org

Stratis Health is a nonprofit organization based in Minnesota that leads collaboration

and innovation in health care quality and safety, and serves as a trusted expert in

facilitating improvement for people and communities.

This effort is sponsored by UCare and supported by Stratis Health.

rural palliative care networking group meeting · 1/28/2014 · kazanowski m. symptom management...

Documents