PELAYANAN PERAWATAN PALIATIF DAN AKHIR MASA KEHIDUPAN

• Perform a needs assessment to evaluate the wisdom of a palliative team e.g. if your hospital is a Maternity Hospital it makes no sense.  However if it is a general hospital with an oncology service and possibly other specialists it makes good sense.
• Enrol nursing, medical, social work, pastoral and other colleagues in a working group to develop a proposal for formal presentation to your institution
• Find a sympathetic administrator / planner who will support your thinking and proposal
• Meet with Hospital Administration and present your idea/proposal/costings
• Get advanced training in palliative care, read and surf the many good palliative sites on the internet if available
• Meet with colleagues in other disciplines, oncology, surgery, medicine to introduce yourself and the concept of palliative care.  Their understanding and collaboration is essential
• Meet with pharmacy administration to enrol their support and inform them of the principles, practice and pharmacopoeia of palliative care. You must be sympathetic to there concerns re: increased workload, overtime budget etc.

• • Pain
• • Dyspnea
• • Nausea/vomiting
• • Weakness & fatigue
• • Insomnia
• • Anorexia +/-cachexia
• • Incontinence
• • Constipation
• • Agitation/Delirium
• • Anxiety
• • Depression
• • Sense of well-being
• • Uncertainty about future
• • Fear of disability
• • Fear of death
• • Hopelessness
• • Remorse
• • Loneliness
• • Loss of
•     – Meaning/Role
•     – Control
•     – Dignity
•     – Autonomy

Hospital Palliative Care Unit
https://bit.ly/HospitalPCU

• Every person is different and symptoms experienced at end of life vary. Some common symptoms are pain, constipation, nausea, tiredness, breathlessness, fatigue and delirium.
  In most cases symptoms can be controlled to a comfortable level, but some symptoms may not disappear completely.
• Relief of symptoms is one of the major aims of the palliative care team.
• As a carer, you can help the person you are caring for by assisting them in recognising and managing their symptoms. Only do this if you feel comfortable doing so and if your relative is happy for you to do so. Otherwise, contact your GP or a palliative care team member if you are concerned about symptom management.
  https://www.betterhealth.vic.gov.au/health/ServicesAndSupport/Palliative-care-dealing-with-common-symptoms?viewAsPdf=true

• It can often be difficult to be certain that a person is dying, but it is essential to recognize the signs of dying in order to appropriately care for people at the end of life.
• An individualised care plan including the areas of symptom control and anticipatory prescribing should be created.
• Follow the principles of pain management used at other times when caring for people in the last days of life, for example, matching the medicine to the severity of pain and, when possible, using the dying person's preferences for how it is given. Consider non-pharmacological management of pain in a person in the last days of life.

• MYTH: I can only get palliative care in hospital 

• MYTH: Palliative care manages pain through the use of addictive narcotics. 

• MYTH: Hospice and palliative care accelerates death. 

• MYTH: Hospice and palliative care is just for people with cancer 

• MYTH: Hospices are generally just for old people 

• MYTH: Everyone has access to hospice and palliative care 

• MYTH: Having hospice and palliative care means you will die soon. 

• Venous thromboembolism (VTE) is a common complication of malignancy which carries a poor prognosis.  This Fast Fact discusses the approach to VTE in patients with advanced cancer.
• The patient’s prognosis and preferences should be considered prior to starting anticoagulation therapy.  Clinicians should work with hospice agencies to determine an affordable plan to safely administer and monitor anticoagulation for acute VTE in hospice patients.  Clinicians should prepare patients who decide to initiate anticoagulation for discontinuing it once expected survival is short or worsening risks such as uncontrolled INR become apparent.
• *Major bleeding includes any bleeding associated with death, located at a critical site (intracranial, intraspinal, intraocular, retroperitoneal or pericardial area), resulting in the need for a transfusion of at least two units of blood or leading to a drop in hemoglobin of at least 2.0 g per deciliter.

• Assess whether patient is at risk of VTE. If so, take into account any risk of bleeding and expected prognosis; and then discuss with the patient whether they wish to have active prophylaxis with anti-embolism stockings and low molecular weight (LMW) heparin as appropriate, balancing risks and benefits to optimise quality of life. If the patient is in the last few days or weeks of life then thromboprophylaxis is often not appropriate, and is not routine. The best evidence in favour of thromboprophylaxis is in potentially reversible co-existing acute conditions e.g. patient admitted to hospital for intravenous antibiotics for community acquired pneumonia.

Signs and Symptoms at the End of Life
https://bit.ly/SignsandSymptomsattheEndofLife

• you are at the centre of
  planning and decision-making around your end of life and palliative care
• your individual, cultural and religious needs are considered when care is planned
• you are treated in the way you want to be treated
• your preferences and values are recognised and respected
• you are treated with respect and dignity whatever your age, cultural background, religion or sexual orientation. 

By responding to your needs and those of your family in this way, your palliative care team can help you make the most of each day.

https://www.betterhealth.vic.gov.au/

• In 1987, Ventafridda and colleagues demonstrated, in a retrospective study, that the use of the WHO analgesic ladder for all cancer pain led to a reduction in pain intensity in 71% of patients.
• Therefore, nearly a third of patients may need additional pharmacological and psychological management. This often requires the use of adjuvant analgesics.
• Anti-depressants may be useful; older less specific drugs such as amitriptyline are more effective than the newer drugs that target fewer receptor sites (e.g. fluoxetine).

https://bjaed.org/article/S1743-1816(17)30528-0/fulltext

1. The time to start palliative care is as soon as a patient's cancer becomes advanced
2. For newly diagnosed patients with advanced cancer, the Expert Panel suggests early palliative care involvement within 8 weeks after diagnosis
3. Inpatients and outpatients with advanced cancer should receive dedicated palliative care services early in the disease course concurrent with active treatment.

1. Thinking and talking about death
2. The warning shot
3. Choosing where and how you would like to be cared for in your final illness
4. How should your funeral be conducted?
5. Where should you be buried?
6. How should your estate be divided after death?

Managing Comorbidities and Deprescribing in Palliative Care
https://bit.ly/ComorbiditiesPC

• Respect patients’ perspectives and do not infringe privacy;
• Involve all members of the interdisciplinary team to the extent that they are able and willing to contribute;
• Permit clear documentation of needs, strategic responses to these needs, resources required, and outcomes;
• Integrate strategies into an overall care plan in ways that are readily understood by all members of the interdisciplinary team;
• Provide a shared framework for continuity of care between community agencies and inpatient services; and
• Provide a place for religious care but do not conflate spiritual issues with religious practice. While spiritual care in general may be provided by a team, specific religious care is best provided by a person from the same faith community, preferably one willing to participate in the team.

•     Pain
•     Constipation
•     Nausea and vomiting
•     Diarrhea
•     Bowel or bladder problems
•     Loss of appetite, weight loss, or wasting
•     Shortness of breath or labored breathing
•     Coughing
•     Depression
•     Delirium or mental confusion
•     Weakness
•     Difficulty sleeping

West Midlands Palliative Guidelines for Medicine:

These guidelines are a summary of the current practice of specialists working in palliative care in the West Midlands Region and can be used for patients who are receiving care at home or in hospitals.

http://www.wmcares.org.uk/wmpcp/guide/



Medical Goals of Care and Limitation of Treatment

The aim of the Medical Goals of Care Plan is to ensure that patients who are unlikely to benefit from medical treatment aimed at cure, receive care appropriate to their condition and are not subjected to burdensome or futile treatments. In particular, this concerns cardiopulmonary resuscitation and Medical Emergency Team (MET) calls, which may otherwise occur if the patient’s condition deteriorates. A set of Principles – Medical Goals of Care (GOC) Plan underlines this aim.

https://www.pallcaretas.org.au/medical-goals-of-care-and-limitations-of-treatment/

Calm Together have put together a collection of meditations, sleep stories, exercises and music to aid relaxation and alleviate anxiety

 https://www.calm.com/blog/take-a-deep-breath

Please select the palliative care team members involved in the care of the patient. Select all that apply. The discipline must be a regular and specifically recognized member of the palliative care team and must have contact with the patient/family. The person of that discipline may have other responsibilities but is clearly identified and identifies as a member of the palliative care team. For example, a visit by a chaplain that sees all patients in the hospital but who does not participate as a member of the palliative care team would not be included. If that chaplain did attend palliative care team meetings (clinical and administrative), then the chaplain would be considered a member of the palliative care team, and the visit would be recorded here.
Check all that apply

• Physician
• Licensed Practical Nurse (LPN)
• Chaplain/ Spiritual Care
• Dietitian/ Nutritionist
• Advanced Practice Nurse
• Psychologist
• Physical/ Occupational Therapist
• Pharmacist
• Physician Assistant (PA)
• Psychiatrist
• Other Therapist (e.g., massage, music/art)
• Community Health Worker
• Registered Nurse (RN)
• Social Worker
• Child Life Specialist
• Other: _____________________

Please select the reason(s) for the palliative care consultation at the time of the initial request (check all that apply)

• Symptom Management
• Decision Making (includes Goals of Care)
• Appoint health care proxy
• Providing support to patient/family
• Providing support to colleagues/staff
• Other: ____________________

https://www.palliativequality.org/images/participate/COVID-19-Case-Report-Hospital-Based-final2.pdf

Competency in Palliative Care
https://bit.ly/CompetencyinPalliativeCare

Palliative care may last for weeks, months, or years, and the relief of moderate to severe pain during that time can greatly improve quality of life. The biggest problem with palliative care is that many people are referred for care too late. By starting this type of care early, and by using the right type of pain management, nearly all pain problems can be relieved or reduced.
https://www.hopkinsmedicine.org/health/wellness-and-prevention/palliative-care-methods-for-controlling-pain

ABBEY PAIN SCALE - FOR MEASUREMENT OF PAIN IN PATIENTS WHO CANNOT VERBALISE

The route to success in end of life care – achieving quality in acute hospitals (2010) highlighted best practice models developed by acute hospital trusts and supported by The National End of Life Care Programme (now part of NHS Improving Quality). It provided a comprehensive framework to enable acute hospitals to deliver high quality person centred care at the end of life.
https://www.england.nhs.uk/wp-content/uploads/2016/01/transforming-end-of-life-care-acute-hospitals.pdf

• Level one – Palliative Care Approach: Palliative care principles should be appropriately applied by all health care professionals.
• Level two – General Palliative Care: At an intermediate level, a proportion of patients and families will benefit from the expertise of health care professionals who, although not engaged full time in palliative care, have had some additional training and experience in palliative care.
• Level three – Specialist Palliative Care: SPC services are those services whose core activity is limited to the provisional of palliative care.

Specialist Palliative Care is delivered by a multi-disciplinary team of health professionals who work together to provide care and support to the patient and family, depending on their needs and the available resources.

 https://diigo.com/0hueob

1. • 0.9% Sodium Chloride (normal saline)
2. • 0.45% Sodium Chloride (half normal saline)
3. • Dextrose 5% and 0.9% Sodium Chloride (D5NS)
4. • Dextrose 5% and 0.45% Sodium Chloride (D5 1/2NS)
5. • Dextrose 3.33% and 0.3% Sodium Chloride (2/3 & 1/3)
6. • Lactated Ringers
7. • Solutions containing potassium (maximum concentration 40 mEq/litre)

Subcutaneous Hydration in Palliative Care
https://bit.ly/SubcutaneousHydrationPC

• 1. Subcutaneous insertion sites used for medication administration should be rotated every 2-7 days and as clinically indicated.
• 2. Subcutaneous insertion sites used for hydration fluids should be rotated every 24-48 hours or after 1.5 - 2 litres of fluid and as clinically indicated.

• a. anterior chest, upper abdomen, anterior or lateral aspects of the thigh, on the back above the scapula, and outer-upper arm;
• b. ambulatory patients – the upper chest area (subclavicular) is recommended because it allows full range of motion;
• c. patients with little subcutaneous tissue – use the upper abdomen away from the waistline. Avoid areas of constriction and areas over large underlying muscles or nerves. Low abdominal sites may cause scrotal edema. Insulin is absorbed most consistently in this site so is preferred for continuous insulin infusion;
• d. sites in the thighs may cause scrotal edema;
• e. confused patients – upper back can be useful to prevent accidental removal;
• f. skin should be intact, site located away from bony prominences and umbilical area to ensure adequate adipose tissue.

The following guidance must be adhered to when prescribing, dispensing or administering opioid medicines:
☛ Confirm any recent opioid dose, formulation, frequency of administration and any other analgesic prescribed for the patient.
☛ Ensure where a dose increase is intended, that the calculated dose is safe for the patient. Not normally more than 50% higher than the previous dose.
☛ Check the usual starting dose, frequency of administration, standard dosing increments, symptoms of overdose, and common side effects of that medicine and formulation.
☛ Ensure that naloxone (the antidote to opioid medicines) is available in the clinical area, to treat overdose and reverse unwanted, severe adverse effects.
☛ In palliative care and chronic opioid use give lower doses of naloxone to carefully manage opioid-induced respiratory depression and sedation, while maintaining adequate analgesia:
– 100 to 200 micrograms IV stat. If respiratory response is inadequate, give 100 micrograms every 2 minutes.
– Further doses may be necessary at one to two hour intervals especially when the opioid causing the toxicity has a long half life.
https://web.archive.org/web/20200811153615/https://mm.wirral.nhs.uk/document_uploads/guidelines/CareoftheDying-non-renal-v14_67703.pdf