PELAYANAN PERAWATAN PALIATIF DAN AKHIR MASA KEHIDUPAN

“Palliative sedation” is defined as the use of sedative medications to relieve refractory symptoms by a reduction in consciousness. Depending on the level of consciousness, three levels of sedation may be distinguished: mild, intermediate and deep. Depending on the duration, sedation is often described as intermittent or continuous.

Advance Care Planning is a process of reflection and communication. It is a time for you to reflect on your values and wishes, and to let people know what kind of health and personal care you would want in the future if you were unable to speak for yourself.

Recent studies suggest that medical care for patients with advanced illness is characterized by inadequately treated physical distress; fragmented care systems; poor communication between doctors, patients, and families; and enormous strains on family caregiver and support systems.

The following is a selection of tools for assessing pain and assessing and tracking the level of symptoms (some are patient reported).

"Any triage system that does not integrate palliative care principles is unethical. Patients who are not expected to survive should not be abandoned but must receive palliative care as a human right,"

Over 80% of patients receiving palliative care do not have severe symptoms at the time of death. Only a small proportion experience severe symptoms and evidence shows these symptoms either become absent or mild as death approaches. When patients are referred to palliative care 9% experience severe pain but this reduces to approximately 2% prior to death. Patients in their final days and hours receiving palliative care experience less pain, symptoms and problems than earlier in their illness.

Individualised care of people who are dying encompasses physical symptoms (such as pain, increasing fatigue and breathlessness), psychological symptoms (such as anxiety and depression), social and spiritual needs. Good communication and advance planning is necessary to ensure that people are appropriately involved in the decision-making process about the care they or their loved ones receive and that patients and families are treated with respect to maintain their dignity.

Palliative Care treats the symptoms that occur during a life-threatening condition or a serious illness, including physical, emotional, and psychological symptoms, as well as side effects of primary treatment. Whereas primary treatment focuses on curing the illness or extending life, this type of care is about improving the quality of life during treatment.
https://integracare.on.ca/palliative-care/

Your personal directive needs to be written, dated, signed by you, and witnessed by an adult. You do not need a lawyer to write a personal directive.

Antipsychotics can reduce distressing symptoms and shorten duration of delirium for all types of delirium:

• Haloperidol : orally 1.5mg - 3mg 4hourly & 3- 5mg nocte.
• Levomepromazine.
• Atypical antipsychotics : Olanzapine, Quetiapine.

At the end of life reassess daily underlying cause may have resolved. Review medications to ensure symptoms remain controlled. Provide extra support for family/carers.
https://ecancer.org/en/elearning/module/86-symptom-management-confusion-and-delirium/learn

Spiritual needs can include:

•     the need for meaning and purpose in our lives
•     the need to love and feel loved
•     the need to feel a sense of belonging
•     the need to feel hope, peace and gratitude.

Some people do things within their religion such as prayer or going to a religious meeting.   For other people, it could be being with friends and family, spending time in nature or doing work or hobbies.
What’s most important to someone can change over their life time.
Caring for people with a terminal illness can be very demanding. It might prompt you to ask questions about your own mortality, your beliefs, and look for meaning and purpose in your life.
https://www.mariecurie.org.uk/professionals/palliative-care-knowledge-zone/individual-needs/spirituality-end-life

It is important for your family and doctor to know that you have prepared a personal directive. Let them know where you keep your personal directive.

A personal directive does not include financial decisions.

The practice of hospice palliative care is relatively young. In Canada, it began in the 1970s and has evolved rapidly. The term “hospice palliative care” was coined to recognize the convergence of hospice and palliative care into one movement that has the same principles and norms of practice.

Clinician: “What are your most important goals if your health situation worsens?” 

Patient: “Just to spend time with the family. That’s about it. And be here as long as I can. I’m not looking for a miracle. I’m just looking for a little time.”

Every patient has the right to effective treatment and management for pain and symptoms. PCOC uses five clinical assessment tools to help identify and manage these common symptoms. The tools also allow the effectiveness of treatments to be evaluated and, importantly, they help patients, carers and families to communicate their experiences and preferences.

Psychological support services assess and help patients with psychological problems of all types and levels of severity, including:

A range of psychological interventions can be offered by both the statutory and voluntary sectors. Health and social care professionals offering day-to-day care provide much general psychological support to patients and carers and play a key role in psychological assessment and prevention and amelioration of distress. More specialised services include counselling, clinical and health psychology, liaison psychiatry and social work. These may be available as an integral part of local cancer services or may be part of generic mental health services, primary care services or hospice care. They can be located in GP practices, hospitals or hospices. The voluntary sector provides additional services, including telephone helplines and self-help and support groups.

Consider a trial of medicine to treat noisy respiratory secretions if they are causing distress to the dying person or their carers and conservative measures have not been successful. 

Consider the risks and benefits of the use of medications and tailor treatment to the dying person's individual needs or circumstances, using one of the following (off label indication) drugs:

The health care that people receive in the last years, months and weeks of their lives can help to minimise the distress and grief associated with death and dying for the individual, and for their family, friends and carers.

This free online training is designed for the Australian health context, and is available to participants by simply creating an account and logging in.

https://www.pallcaretraining.com.au/

TOP 10 THINGS PALLIATIVE CARE CLINICIANS WISHED EVERYONE KNEW ABOUT PALLIATIVE CARE

https://t.me/c/1305911983/58

Source: Jacob J. Strand, MD; Mihir M. Kamdar, MD; and Elise C. Carey, MD

https://www.mayoclinicproceedings.org/article/S0025-6196(13)00452-7/pdf

End-of-Life Prognostication
https://bit.ly/PrognosticationEOLC

The common Palliative Performance Score (PPS), for example, evaluates activity levels, ambulation, and mental status — and uses a chart to assign a PPS. The PPS paints a picture of the patient and provides an indicator of how he/she is doing compared to an otherwise well, functioning member of the population at that same age.

In addition to having an assigned PPS, dementia patients are scored in seven categories of increasing debility through a Functional Assessment Staging Test (FAST), which helps confirm that diagnosis.Other diseases have their own specific tests.
https://www.crossroadshospice.com/

Here are some signs that someone is actively dying.

• Your loved one may not want food or drink. There may only be a need for enough liquid to keep the mouth from becoming dry. Do not force food, liquids, or medications.
• Your loved one may sleep a lot more and be in an unresponsive state without the ability to be aroused (coma/semi-coma). This is very natural and it’s important to let your loved one sleep. At this point, it’s important for you to be with them rather than do for them.
• As the oxygen supply to the brain decreases, they may experience severe agitation or hallucinations that are inconsistent with their normal manner or personality, such as pulling on bed linens or clothing. You can talk to them in a calm voice and reassure your loved one that you are there. You can play calm music or give them a back rub.
• Breathing may become irregular with periods of no breathing lasting for 20 to 30 seconds. Raising the head of your loved one’s bed will make breathing easier for them.
• Your loved one may pass less fluids. As bodily functions slowly decline and the intake of food and drink decrease, the output of fluids will also decrease. This is natural.

https://samaritannj.org/resources/what-is-active-dying/

General Principles of Symptom Management

• For any symptom an underlying cause when possible should be sought to aid cause-specific management.
• History, clinical examination and investigations should be tailored to individual patient need and circumstances.
• Treatment plans must be fully discussed with patients and carers.
• Continuous symptoms require continuous treatments (not just PRN medications).
• Review treatment plans within an appropriate timeframe for the individual patient need and circumstance. Consider review every 24 hours unless there is reason to do so more or less frequently.

https://gp-website-cdn-prod.s3.amazonaws.com/

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.

https://www.who.int/ncds/management/palliative-care/introduction/en/

PALLIATIVE APPROACH

An approach to care that does not attempt to lengthen or shorten the client's life. It acknowledges death is drawing near, although this may be many months or even years away. The approach also recognises that a range of symptoms may need to be addressed to improve overall comfort during life and around the time of death. (DoHA 2006)
https://www.pallcaretraining.com.au/mod/page/view.php?id=198

Approaching the End of Life When They are Likely to Die Within the Next 12 Months
https://bit.ly/Next12Months

Some people have more complex physical, psychological, social or spiritual problems. The severity and/or intractable nature of these complex palliative care problems may exceed the resources of the primary treating team and may require referral to the specialist palliative care service.

https://www.hse.ie/eng/services/publications/clinical-strategy-and-programmes/palliative-care-needs-assessment-guidance.pdf

Advance Care Directives
Since 1 July 2014 the Advance Care Directives Act 2013 (SA) has been in operation. This allows a person to:

• set out values and wishes to guide decisions about their future healthcare and other personal matters
• set out what, if any, particular healthcare they refuse and in what circumstances and
• appoint one or more substitute decision-makers.

https://www.lawhandbook.sa.gov.au/ch02s02.php

• Active opioid metabolites can accumulate in patients who are frail, debilitated or who have significant renal impairment. This can lead to opioid toxicity, characterised by myoclonic jerks, excessive sedation or confusion, restlessness and hallucinations. Hyperalgesia (increased sensitivity to pain) can also be a feature of opioids toxicity. Patients should be reviewed for features of toxicity of doses are being increased rapidly or to high levels. Switching to another opioid should be considered if opioid toxicity is unable to be managed with appropriate dose adjustment.
• The central nervous system effects of morphine may also be amplified when it is taken in combination with other centrally acting depressants, e.g. benzodiazepines, phenothiazines, tricyclic antidepressants or alcohol. Long-acting morphine may have a faster onset of action when taken with metoclopramide.

https://diigo.com/0hullz

Palliative Care for Life-Limiting Illnesses other than Cancer
https://bit.ly/Life-LimitingPC

Essential Drugs for Palliative Care
==========================

• Acetaminophen/paracetamol 
• Amitriptyline 
• Atropine 
• Bisacodyl 
• Carbamazepine 
• Carbocisteine 
• Chlorpromazine 
• Citalopram 
• Clonazepam 
• Codeine 
• Desipramine 
• Dexamethasone 
• Dextromethorpan 
• Diazepam 
• Diclofenac 
• Dimenhydrinate 
• Diphenhydramine 
• Docusate 
• Fentanyl transdermal patch 
• Gabapentin 
• Glycopyrronium/glycopyrrolate 
• Haloperidol 
• Hyoscine butyl bromide 
• Hyoscine hydrobromide 
• Ibuprofen 
• Imipramine 
• Levomepromazine (Methotrimeprazine) 
• Loperamide 
• Lorazepam 
• Megestrol Acetate 
• Methadone 
• Metoclopramide 
• Midazolam 
• Morphine 
• Naproxen 
• Octreotide 
• Olanzapine 
• Ondansetron 
• Oxycodone 
• Phenytoin 
• Phenobarbital 
• Prochlorperazine 
• Risperidone 
• Senokot 
• Tramadol 
• Tranexamic Acid 
• Trazodone 

http://www.inctr.org/fileadmin/user_upload/inctr-admin/Media/Palliative_Care_Complete.pdf

Olanzapine http://inctr-palliative-care-handbook.wikidot.com/olanzapine

Furosemide Used in Palliative Care
https://bit.ly/FurosemidePC

There are a number of broad classes of opioids:

• natural opiates, alkaloids contained in the resin of the opium poppy including morphine, codeine and thebaine, but not papaverine and noscapine which have a different mechanism of action;
• semi-synthetic opiates, created from the natural opioids, such as hydromorphone, hydrocodone, oxycodone, oxymorphone, desomorphine, diacetylmorphine (heroin), nicomorphine, dipropanoylmorphine, benzylmorphine and ethylmorphine;
• fully synthetic opioids, such as fentanyl, pethidine, methadone, tramadol and propoxyphene;
• endogenous opioid peptides, produced naturally in the body, such as endorphins, enkephalins, dynorphins, and endomorphins.

https://psychology.wikia.org/wiki/Opioids

Opioids
When to Use:

• Indicated for moderate to severe pain as a single agent or combined with acetaminophen or NSAIDs
• Effective across all 3 pain types (somatic, visceral, and neuropathic)
• Mainstay for treatment of moderate to severe cancer pain
• Oral, liquid, transbuccal, transdermal, rectal, subcutaneous, intravenous formulations
• Does not affect platelets, renal function, liver function, gastric mucosa

When to Avoid:

• Long-term use of opioids in persistent non-cancer pain without underlying serious illness (e.g. fibromyalgia, chronic low back pain) should only be considered under the supervision of a pain specialist

Key Provisos:

• Drug choice and dosing adjustments are necessary in patients with underlying organ dysfunction (kidney, liver)
• Side effects are manageable for most patients (constipation, nausea, sedation)
• Should be tapered when discontinued

https://www.capc.org/

The patient’s condition should be continually monitored in order to assess the patient’s needs and to give support to the relatives/carers.  Clinical experience has shown that in around 3% of cases, the patient’s condition can improve and the patient is no longer deemed to be in the dying phase. A full reassessment of the patient is then undertaken and an alternative management plan is put into place. The patient’s [sic] whose care is supported by the LCP must be assessed closely by the doctors and nurses at the bedside. LCP Version 12 also includes a formal process for reviewing decision making by the multidisciplinary team at least every 3 days over and above the ongoing assessments of the patient’s condition.
http://blog.practicalethics.ox.ac.uk/2012/11/the-liverpool-care-pathway-in-the-news-even-by-the-mails-standards-this-is-low/

This report highlights the fact that too many people are dying without dignity and more can be done to improve the experience of care in the last year and months of life for approximately 355,000 people in England.
https://www.ombudsman.org.uk/publications/dying-without-dignity-0

For example, the pathway recommends that in some circumstances doctors withdraw treatment, food and water from sedated patients in their final days. But Baroness Neuberger said that these guidelines had been misinterpreted to the extent that some patients’ families were even shouted at by nurses for giving them water.
https://www.channel4.com/news/death-dying-care-end-of-life-liverpool-care-pathway


Doctors hostile to the pathway say it is impossible to predict accurately when patients may die, that death on the pathway becomes a ‘self-fulfilling prophecy’, and that the method is used to get rid of difficult patients and to free hospital beds.
http://liverpool-care-pathway-a-national-sc.blogspot.com/2012/10/liverpool-care-pathway-justice-and.html

Commonly medications are prescribed to alleviate symptoms at th end of life often given by a syringe driver.

• Pain ,codeine, Paracetamol, morphine.
• Nausea , cyclizine, ondansetron
• Resp secretions hyoscine
• Anxiety midazolam .

Fluids are not  withheld at the end of life . Mouth toilet is given to moisten the mouth
https://rickolddoc.wordpress.com/2014/03/10/the-liverpool-care-pathway/

• "A dying loved one may become delirious, which also can be a frightening experience for everyone involved. Delirium occurs in many of those who are near the end of life. It may have a single cause, or it may result from a combination of several factors such as medicines or changes in the body's metabolism.
• Symptoms of delirium include agitation, hallucinations, and consciousness that comes and goes. These symptoms can usually be managed with medicines."

https://diigo.com/0hufga

Hypodermoclysis Guidelines in Palliative Care
https://bit.ly/HypodermoclysisPC

End of life symptoms are generally well controlled
by use of nine commonly used medications:

1. morphine sulphate/tartrate
2. hydromorphone
3. haloperidol
4. midazolam
5. metoclopramide
6. hyoscine hydrobromide
7. clonazepam
8. hyoscine butylbromide
9. fentanyl

Medications contraindicated for use via subcutaneous infusion
due to severe localised reactions:

• prochlorperazine
• diazepam
• chlorpromazine

Medications linked to abscess formation
when used in subcutaneous infusions:

• pethidine hydrochloride
• prochlorperazine
• chlorpromazine

https://www.health.qld.gov.au/cpcre/subcutaneous/section4

The Guidelines for Subcutaneous Infusion Device Management in Palliative Care provide clinicians and palliative care services with guidelines to inform practice, development of policy and procedures, and education for subcutaneous infusion device management.
https://www.health.qld.gov.au/cpcre/subcutaneous/guidelines

Subcutaneous medication administration is a common route of administration of medications in both the hospital and community settings. Subcutaneous infusion of medications can be used in a variety of scenarios; one such situation is in palliative care, to optimise the delivery of medications to provide appropriate symptom management. It is often used in patients who are unable to take medication by mouth, those that have poor gut absorption, nausea and vomiting or those that require a continuous infusion in the community. Indwelling subcutaneous catheter devices may assist in medication delivery and decrease trauma, distress and discomfort for the patient.
https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Subcutaneous_catheter_devices_management_of_insuflon_and_BD_safTIntima_devices/

The use of analgesic drugs is based on the analgesic ladder developed by the World Health Organisation (WHO), which divides analgesic drugs into three groups:

1. Step I — non-opioid analgesics (NSAIDs, non-ste- roid anti-inflammatory drugs) or paracetamol or metamizole;
2. Step II — so-called “weak” opioids (tramadol, codeine, and dihydrocodeine);
3. Step III — so-called “strong” opioids (morphine, oxycodone, oxycodone/naloxone, fentanyl, buprenorphine, tapentadol, methadone, hydromorphone).

https://journals.viamedica.pl/palliative_medicine_in_practice/article/download/58273/43946

Naloxone
Antidote for opioid sensitivity or overdose induced respiratory depression is Naloxone.
Dilute 400micgrograms in 10ml 0.9% sodium chloride to give a concentration of 40 micgrograms /ml. Administer 40-80microgram naloxone hydrochloride IV bolus every 2-3 minutes up to a maximum of 10mg, until the patient’s breathing and the level of consciousness has improved (if in extremis can use a higher starting bolus such as 200 micrograms). If IV route is not available, naloxone may be administered as IM injection. Dose is always titrated to individual patients condition and rate of reversal.
https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0011/306389/liverpoolMorphine.pdf

Prescribing in Palliative Care

https://patient.info/doctor/prescribing-in-palliative-care

Palliative care enhances the quality of life of people with a life-limiting illness.
https://library.nshealth.ca/PalliativeCare

Palliative and End of Life Care Toolkit
https://sites.google.com/view/pc-eolcare-toolkit/home

Palliative and care at end of life resources
https://www.health.qld.gov.au/clinical-practice/guidelines-procedures/patient-safety/end-of-life/resources/palliative-and-care-at-end-of-life-resources

Effects on patient and family if diagnosis of dying is not made

1. Patient and family are unaware that death is imminent
2. Patient loses trust in doctor as his or her condition deteriorates without acknowledgment that this is happening
3. Patient and relatives get conflicting messages from the multiprofessional team
4. Patient dies with uncontrolled symptoms, leading to a distressing and undignified death
5. Patient and family feel dissatisfied
6. At death, cardiopulmonary resuscitation may be inappropriately initiated
7. Cultural and spiritual needs not met 

All the above can lead to complex bereavement problems and formal complaints about care
http://palcare.streamliners.co.nz/Care of the dying patient the last days or hours.pdf

Morphine has been proven to reduce dyspnoea - the mechanism is not clear.
Usually lower doses are required than those for pain, e.g. 2.5 - 10 mg of elixir 4 hourly or PRN. The dose can be gradually titrated as for pain, but comfort rather than resolution of dyspnoea is generally the desired end point.
http://cdhb.palliativecare.org.nz/index.htm

B.C. INTER-PROFESSIONAL PALLIATIVE SYMPTOM MANAGEMENT GUIDELINES

https://t.me/c/1305911983/65

OVERDOSE OPIOID PREVENTION

https://t.me/c/1305911983/79

Palliative Performance Scale (PPS, version 2) is an 11-point scale designed to measure patients’ performance status in 10% decrements from 100% (healthy) to 0% (death) based on five observable parameters: ambulation, ability to do activities, self-care, food/fluid intake, and consciousness level.

https://victoriahospice.org/how-we-can-help/clinical-tools/

Module 6 Recognising Deteriorating Clients

https://www.pallcaretraining.com.au/course/view.php?id=9

NECN - PALLIATIVE-CARE-GUIDELINES

https://t.me/c/1305911983/63

Below you'll find links to CCPs developed by CCO for the stable, transitional, and end of life stages. Palliative Care Collaborative CCPs

- Stable Stage Palliative Care Collaborative CCPs
- Transitional Stage Palliative Care Collaborative CCPs
- End-of-Life Stage Palliative Care Collaborative CCPs
- Booklet Palliative Care Collaborative CCPs
- Condensed Version

http://www.torontocentrallhin.on.ca/PalliativeCareNetwork/HealthCareProviders.aspx

The Palliative Performance Scale (PPS) has been shown to be both valid and useful for a broad range of palliative care patients: those with advanced cancer diagnoses or life-threatening non-cancer diagnoses in clinics, hospitals, or hospices.

https://eprognosis.ucsf.edu/pps.php?p=palliative

Levels of Palliative Care

https://hospicefoundation.ie/aboutus/hospice-palliative-and-end-of-life-care/what-is-palliative-care/

Key points to consider in the pharmacological management of end-of-life (terminal) symptoms include:

• Confirm the patient and/or their Substitute Decision Maker (SDM) are aware that the patient is dying and support the use of medicines to manage end-of-life (terminal) symptoms.
• Prescribe medicines based on careful assessment of the dying patient's condition and symptoms.
• Regularly reassess treatment so the doses are proportionate to the severity of symptoms.
• Cease any medications that have minimal therapeutic benefit in the terminal phase of life.
• Consider the burden associated with how medicines are given, minimising the potential for side effects.
• Consider administering medicines via the subcutaneous route - the least invasive and most reliable route in the dying.
• Write up PRN orders for intermittent symptoms and to cover possible breakthrough events for persistent symptoms.
• Ensure that medicines are easily accessible when needed by writing up the medicines in advance (see Anticipatory prescribing).
• Identify the cause of problems and then manage in the context of the patient's preferences: remembering some things are irreversible and are a part of the dying process.

https://apps.caresearch.com.au/palliAGED/Prescribing-guidance

Hypodermoclysis, the subcutaneous infusion of fluids, is a useful and easy hydration technique suitable for mildly to moderately dehydrated adult patients, especially the elderly. The method is considered safe and does not pose any serious complications.

https://www.aafp.org/afp/2001/1101/p1575.html

B.C. INTER-PROFESSIONAL PALLIATIVE SYMPTOM MANAGEMENT GUIDELINES

https://www.bc-cpc.ca/cpc/wp-content/uploads/2018/09/SMGs-interactive-final-Nov-30-compressed.pdf

END OF LIFE SYMPTOM MANAGEMENT ALGORITHM

https://t.me/c/1305911983/47

WHO - ESSENTIAL MEDICINES IN PALLIATIVE CARE

https://t.me/c/1305911983/59

APPROACHING THE END OF LIFE

Patients are ‘approaching the end of life’ when they are likely to die within the next 12 months.

This includes patients whose death is imminent (expected within a few hours or days) and those with:

Also applies to those extremely premature neonates whose prospects for survival are known to be very poor, and to patients who are diagnosed as being in a persistent vegetative state (PVS), for whom a decision to withdraw treatment may lead to their death. (Download)

https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/treatment-and-care-towards-the-end-of-life/guidance

PALLIATIVE CARE RESOURCES

https://sites.google.com/view/palliative-care-resources/home

Analysis of available evidence suggested 11 symptoms occurring in the advanced stages and end of life stage for the mortality conditions identified which are priorities in palliative care:

• Anorexia
• Anxiety
• Constipation
• Delirium
• Depression
• Diarrhoea
• Dyspnea
• Fatigue
• Nausea and vomiting
• Pain
• Respiratory tract secretions

Fifteen medications were identified as essential for the treatments of these symptoms.

https://www.who.int/selection_medicines/committees/expert/19/applications/PalliativeCare_8_A_R.pdf

Family and friends often ask if the person can have artificial hydration and nutrition, for example tube feeding or subcutaneous fluids. For some conditions, this is an option. But for other conditions, and often when people are in their days, there is no evidence that it helps people to live longer or improves their quality of life.

https://www.mariecurie.org.uk/professionals/palliative-care-knowledge-zone/symptom-control/hydration-nutrition

Palliative care is required for a wide range of diseases. The majority of adults in need of palliative care have chronic diseases such as cardiovascular diseases (38.5%), cancer (34%), chronic respiratory diseases (10.3%), AIDS (5.7%) and diabetes (4.6%). Many other conditions may require palliative care, including kidney failure, chronic liver disease, multiple sclerosis, Parkinson’s disease, rheumatoid arthritis, neurological disease, dementia, congenital anomalies and drug-resistant tuberculosis.

https://www.who.int/news-room/fact-sheets/detail/palliative-care

These guidelines are one of many resources available to health care professionals in Fraser Health to improve health care outcomes in hospice palliative/end-of-life care.

https://www.fraserhealth.ca/employees/clinical-resources/hospice-palliative-care#.Xh0ZR4gxXZ5

Fentanyl is a potent opioid analgesic; check the dose conversion carefully. 100 to 150times more potent than oral morphine. • A 25 microgram/hour fentanyl patch is equivalent to about 60mg to 90mg of oralmorphine in 24 hours.

https://www.palliativecareguidelines.scot.nhs.uk/media/71357/20-2019-fentanyl-patches.pdf

Palliative and End of Life Care Toolkit

https://www.rcgp.org.uk/clinical-and-research/resources/toolkits/palliative-and-end-of-life-care-toolkit.aspx

There is a lack of any strong evidence, therefore decisions to initiate subcutaneous (SC) hydration rests with the multidisciplinary team in discussion with the patient and family, and will vary from patient to patient depending on the estimated burden to benefit balance.

https://www.palliativecareguidelines.scot.nhs.uk/media/71354/20-2019-subcutaneous-fluids.pdf

TEN STEPS TO BETTER PROGNOSTICATION

https://t.me/c/1305911983/42

Anticipatory end of life care medication for the symptoms of terminal restlessness, pain and excessive secretions in frail older people in care homes. End of Life Journal Vol. 3, No. 3, pages 1-6)

https://www.stchristophers.org.uk/wp-content/uploads/2015/11/steps_stepthree_Anticipatory-guidelines.pdf

As NICE highlights in its new guidelines, there were three main areas of concern:

https://www.nhs.uk/news/medical-practice/new-guidelines-on-end-of-life-care-published-by-nice/

These guidelines are one of many resources available to health care professionals in Fraser Health to improve health care outcomes in hospice palliative/end-of-life care. These guidelines provide recommendations based on scientific evidence and expert clinical opinion.

https://www.fraserhealth.ca/employees/clinical-resources/hospice-palliative-care#.Xgp5-hsxXZ6

STROKE AND PALLIATIVE CARE
https://sites.google.com/view/stroke-and-palliative-care/home

Stroke symptoms can include:

• paralysis
• numbness or weakness in the arm, face, and leg, especially on one side of the body
• trouble speaking or understanding speech
• confusion
• slurring speech
• vision problems, such as trouble seeing in one or both eyes with vision blackened or blurred, or double vision
• trouble walking
• loss of balance or coordination
• dizziness
• severe, sudden headache with an unknown cause
• nausea or vomiting
• hallucination
• pain
• general weakness
• shortness of breath or trouble breathing
• fainting or losing consciousness
• seizures
• confusion, disorientation, or lack of responsiveness
• sudden behavioral changes, especially increased agitation

https://www.healthline.com/health/stroke#symptoms-in-women

All people admitted to hospital with Acute stroke should receive:

• Swallow screen

modification of diet or institution of NG feeding as appropriate within 48 hours

• Hydration Status: Maintain euvolemia.
• Assessment of continence
• Evaluation of pressure risk
• Early mobilisation where appropriate
• Occupational therapy and seating assessment
• Multidisciplinary assessment and discussion
• Assessment of mood
• Information meeting with relatives and patient

Source:
https://www.hse.ie/eng/services/publications/clinical-strategy-and-programmes/stroke-unit-management-care-bundle.pdf

Care of dying adults in the last days of life NICE guideline [NG31] Published date: December 2015

https://www.nice.org.uk/guidance/ng31

PALLIATIVE CARE IN HOSPITALS - AN OVERVIEW

https://t.me/c/1305911983/34

Baca dulu!

SG Pall Ebook

https://www.duke-nus.edu.sg/lcpc/resources/sg-pall-ebook-disclaimer

Opioid use in palliative care: new developments and guidelines
https://www.prescriber.co.uk/article/opioid-use-in-palliative-care-new-developments-and-guidelines/

ESMO guidelines note that although oral administration is advocated, patients presenting with severe pain that needs urgent relief should be treated and titrated with parenteral opioids, usually subcutaneous or intravenous.
https://emedicine.medscape.com/article/2500043-overview#showall

Emergencies in Palliative Care
https://bit.ly/EmergenciesinPalliativeCare

Guideline PC

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. Your local Specialist Palliative Care Team are available for further advice. The production of these guidelines is independent, funded by the sales of previous editions
http://www.wmcares.org.uk/wmpcp/guide/

INCTR Palliative Care Handbook:

This site is an electronic version of the INCTR Palliative Care Handbook. It is freely available in this format, and can be purchased as a robust hard copy pocket version for all who need information on symptom control in patients with serious diseases.
http://inctr-palliative-care-handbook.wikidot.com/table-of-contents

Scottish Palliative Care Guidelines

The Scottish Palliative Care Guidelines reflect a consensus of opinion about good practice in the management of adult patients with life-limiting illness. They are designed for healthcare professionals from any care setting who are involved in supporting people with a palliative life-limiting condition.
https://www.palliativecareguidelines.scot.nhs.uk/guidelines/symptom-control.aspx

iPal

Access to key information about palliative care:

• Assess: screening tool to assess need for palliative care and symptom assessment scale and tips.
• Manage: drugs and other therapies for common symptoms
• Plan: aids for planning future care and decision-making
• Communicate: make communication therapeutic by using talking tips for breaking bad news, CPR, prognosis, goals of care, end-of-life and specific situations

 https://ipalapp.com/manage/

BERKSHIRE ADULT PALLIATIVE CARE GUIDELINES - END OF LIFE CARE – GL110

https://t.me/c/1305911983/35

Palliative care helps people live as fully and as comfortably as possible with a life-limiting illness. Palliative care is for people of any age. It can be provided in your home, a hospital, a hospice or an aged care (nursing) home.

https://www.health.gov.au/health-topics/palliative-care

Palliative Performance Scale Population: https://eprognosis.ucsf.edu/pps.php

PALLIATIVE CARE IN DEVELOPING COUNTRIES - PRINCIPLES AND PRACTICE

https://t.me/c/1305911983/16

From our experience at the hospice we know that organ/tissue donation can help patients and families feel comforted by knowing that they have given hope to others, and that some good has come out of their loss. However, we also realise that not everyone feels comfortable with taking such a step.

https://www.stchristophers.org.uk/wp-content/uploads/2015/11/CORNEA_and_TISSUE.pdf

THE IAHPC MANUAL OF PALLIATIVE CARE 3RD EDITION

https://t.me/c/1305911983/29

IAHPC List of Essential Practices in Palliative Care

https://t.me/c/1305911983/22

Evidence-based resources for assessing pain, symptom burden, psychological and social needs, caregiver burden, and spiritual distress.

https://www.capc.org/toolkits/patient-identification-and-assessment/

Access to key information about palliative care:

https://ipalapp.com/

Hospice patients can experience many kinds of symptoms such as: pain, restlessness/agitation, confusion/delirium, lethargy/weakness, shortness of breath, and nausea/vomiting.

https://www.hopewestco.org/managing-common-symptoms/

YAPALINDO

https://t.me/joinchat/AAAAAE3Woq8i2RLS0sQ-sQ

Subcutaneous hydration (previously known as hypodermoclysis) is a technique used for the subcutaneous administration of large volumes of fluids and electrolytes in order to achieve fluid maintenance or replacement. It is used in patients who are unable to tolerate sufficient oral intake and where intravenous access may be difficult to obtain or sustain, or is inappropriate.

http://www.wmcares.org.uk/wp-content/uploads/Subcutaneous-hydration-in-palliative-care-v2.4-Final.pdf

This free online training is designed for the Australian health context, and is available to participants by simply creating an account and logging in. This project is funded by the Australian Government Department of Health and is developed by the Australian Healthcare and Hospitals Association (AHHA), with input from industry and other specialists.

https://www.pallcaretraining.com.au/

In the PPS, physical performance is measured in 10% decremental levels from fully ambulatory and healthy (100%) to death (0%). These levels are further differentiated by five observable parameters: the degree of ambulation ability to do activities/extent of disease ability to do self care food/fluid intake level of consciousness

http://www.collaborativecurriculum.ca/en/modules/PPS/PPS-thepalliativeperformancescale-01.jsp

End of life is when a person is living with, and impaired by, a fatal condition, even if the trajectory is ambiguous or unknown.

https://www.eldac.com.au/tabid/4920/Default.aspx

Guidelines Schedule

https://www.palliativecareguidelines.scot.nhs.uk/guidelines/about-the-guidelines/guidelines-schedule.aspx

Worldwide, a number of significant barriers must be overcome to address the unmet need for palliative care:

https://www.who.int/news-room/fact-sheets/detail/palliative-care

Pain is one of the most frequent and serious symptoms experienced by patients in need of palliative care. Opioid analgesics are essential for treating the pain associated with many advanced progressive conditions. For example, 80% of patients with AIDS or cancer, and 67% of patients with cardiovascular disease or chronic obstructive pulmonary disease will experience moderate to severe pain at the end of their lives.

https://www.who.int/news-room/fact-sheets/detail/palliative-care

Guidelines for the Management at the End of Life
https://sites.google.com/view/management-at-the-end-of-life/home

The aim of this guidance document and supporting tools is to facilitate the rapid discharge of persons from hospital who wish to die at home. Below you will find a guidance document, presentation, summary steps and useful documents to allow healthcare teams to plan and enable discharge where possible.

http://www.professionalpalliativehub.com/guidelines/republic-ireland-palliative-care-tools-guidance/rapid-discharge-guidance

INSPIRE SELF-CARE

https://palliativecareindonesia.blogspot.com/p/blog-page_14.html

Palliative and End-of-Life Care in Stroke
https://sites.google.com/view/palliativecareinstroke/home

STROKE AND PALLIATIVE CARE
https://sites.google.com/view/stroke-and-palliative-care/home

Many people living with cancer experience nausea, diarrhea, and other symptoms and side effects from their treatment or disease. For healthcare providers, we offer tools for assessing and managing patients’ symptoms and side effects.

https://www.cancercareontario.ca/en/symptom-management

Palliative care is more than just pain relief. It includes addressing the physical, psychosocial and emotional suffering of patients with serious advanced illnesses and supporting family members providing care to a loved one.

https://www.who.int/mediacentre/news/releases/2014/palliative-care-20140128/en/

Codeine is not generally given as a single agent when used orally as an analgesic, but is usually combined with a non-opioid and recent systematic reviews confirm that the combination of codeine and paracetamol is more effective that paracetamol alone.
http://www.geocities.ws/kaqu/simanpc/8.2%20-%20The%20management%20of%20Pain/8.2.3%20-%20Opioid%20analgesic%20therapy.htm

 

Your Symptoms Matter is a set of tools to help healthcare providers monitor and manage their patients’ symptoms more effectively. These tools can be used regardless of where patients are in the cancer continuum.

https://www.cancercareontario.ca/en/guidelines-advice/symptom-side-effect-management/symptom-assessment-tool

MANAGING SYMPTOMS FOR AN ADULT IN THE LAST DAYS OF LIFE

https://t.me/c/1305911983/5

Management of hiccups in palliative care patients
If a patient is in the last few days of life, consideration should be given to using midazolam by subcutaneous infusion to relieve intractable hiccups. Midazolam may also be used while trialling the efficacy of other treatments. Midazolam is commonly used in the terminal phase of patient care—for management of agitation and distress. This general sedation effect was also found to be useful to suppress hiccup reflexes through case reports.
https://spcare.bmj.com/content/bmjspcare/8/1/1.full.pdf

All nursing staff who care for dying patients have a responsibility to ensure they have enough knowledge and skills to manage the key symptoms that may occur in the last few days of life.

http://rcnendoflife.org.uk/symptom-management/

THE PALLIATIVE CARE HANDBOOK - 2019

https://t.me/c/1305911983/14

Radiotherapy for the Palliation of Advanced Sarcomas—The Effectiveness of Radiotherapy in Providing Symptomatic Improvement for Advanced Sarcomas in a Single Centre Cohort

https://www.mdpi.com/2227-9032/7/4/120

Principles of Palliative Care

• Palliative care incorporates the whole spectrum of care — medical, nursing, psychological, social, cultural and spiritual. A holistic approach, incorporating these wider aspects of care, is good medical practice and in palliative care it is essential.
• The principles of palliative care might simply be regarded as those of good clinical practice, whatever the patient’s illness, wherever the patient is under care, whatever his / her social status, creed, culture or education.

https://hospicecare.com/what-we-do/publications/getting-started/6-principles-of-palliative-care

This resource has been developed for you by the Royal College of Nursing (RCN) and is designed to offer you support in your delivery of appropriate end of life care alongside your existing training.

https://rcni.com/hosted-content/rcn/fundamentals-of-end-of-life-care/end-of-life-care-%E2%80%93-fundamentals-of-nursing-care-end-of-life

Patients with palliative performance scale (PPS) levels of 10%, 20%, and 30%
(ie bed bound, needing all care, reduced oral intake and drowsy) have a median survival of 2, 4 and 13 days, respectively,
thus probably making the PPS the most suitable prognostic tool for identifying patients at risk of imminent death.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6752241/

The Palliative Performance Scale (PPS), a modification of the Karnofsky Performance Scale, is presented as a new tool for measurement of physical status in palliative care. Its initial uses in Victoria include communication, analysis of home nursing care workload, profiling admissions and discharges to the hospice unit, and, possibly, prognostication. Palliative Performance Scale (PPS): A new tool (PDF Download Available).
Available from: https://www.researchgate.net/

The Hospice and Palliative Nurses Association provides educational opportunities not only to our members, but to all hospice and palliative nurses and members of the nursing team.

https://advancingexpertcare.org/HPNA/Education/HPNA/Education_Home.aspx?hkey=8e4324bc-77c5-4cbc-93d7-a24c1428702b

PALLIA 10

https://www.scribd.com/document/441045275/PALLIA-10

Through early integration into the care plan of seriously ill people, palliative care improves quality of life for both the patient and the family.

https://lmhpco.org/healthcare-professionals/pediatric-palliative-care/

𝑨 𝑮𝑶𝑶𝑫 𝑫𝑬𝑨𝑻𝑯 - 𝑷𝑬𝑹𝑺𝑷𝑬𝑪𝑻𝑰𝑽𝑬𝑺 𝑶𝑭 𝑴𝑼𝑺𝑳𝑰𝑴 𝑷𝑨𝑻𝑰𝑬𝑵𝑻𝑺 𝑨𝑵𝑫 𝑯𝑬𝑨𝑳𝑻𝑯 𝑪𝑨𝑹𝑬 𝑷𝑹𝑶𝑽𝑰𝑫𝑬𝑹𝑺

https://t.me/c/1305911983/18

Our goal is to improve the quality of life for patients and families facing serious illnesses through education of multi-disciplinary doctors, nurses,psychologists, social workers and other allied health personnel. Developed by Stanford eCampus this FREE training portal features learning modules, resources and training materials from internationally recognized leaders in the field of Hospice and Palliative Medicine.

https://palliative.stanford.edu/

Each year, 40 million people are in need of palliative care. Only 14% of people needing palliative care at the end of life currently receive it. Palliative care is an essential component of comprehensive health services for NCDs.

https://www.who.int/ncds/management/palliative-care/en/

The Dana-Farber Cancer Institute/ Brigham and Women’s Hospital Pain Management Tables and Guidelines (Pink Book) has been in use by DFCI/BWH clinicians since 1998. Widely used by the Harvard Interprofessional Palliative Care fellows and internal medicine house staff at Brigham and Women’s Hospital, the Pink Book contains useful opioid conversion tables, medication charts, and clinical pearls in the clinical management of pain.

http://pinkbook.dfci.org/

Palliative care education and training collaborative

http://www.pcc4u.org/about-pcc4u/palliative-care-education-and-training-collaborative/

The Guide to Children’s Palliative Care is an essential resource for all those with an interest in planning, commissioning and delivering services and care for babies, children and young people with life-limiting and life-threatening conditions, and their families.

https://www.togetherforshortlives.org.uk/resource/a-guide-to-childrens-palliative-care/

• The General Medical Council defines approaching the end of life as when a person is likely to die within the next 12 months. This timeframe provides a guide as to when people might be identified as approaching the end of life. 
• For some conditions, the trajectory may require identification and subsequent planning to happen earlier. 
• For other conditions, it may not be possible to identify people until nearer the time of death. Identification should take place with sufficient time to enable provision of high-quality end of life planning, care and support in accordance with the person's needs and preferences. 
• Identification will need to be considered on an individual basis.

https://www.nice.org.uk/guidance/qs13/chapter/Quality-statement-1-Identification

Among the most important projects is “3.g.i.”, which aims to integrate palliative care into the Patient-Centered Medical Home Model. CCB believes that improvement in the practice of primary palliative care—interventions delivered through primary care that aim to reduce the burden of illness associated with any type of serious chronic illness—is essential to advancing the PPS transformational agenda.

https://www.mjhspalliativeinstitute.org/ccb/

PENNINE LANCASHIRE PALLIATIVE AND END OF LIFE CARE MODEL

https://t.me/c/1305911983/11

Clinical Practice Guidelines for Quality Palliative Care, 4th edition, create a blueprint for excellence by establishing a comprehensive foundation for gold-standard palliative care for all people living with serious illness, regardless of their diagnosis, prognosis, age or setting.

https://www.nationalcoalitionhpc.org/ncp/

Palliative care focuses on the person and their family, and on enhancing their quality of life throughout their illness, not just at the end of life. The initiation of palliative care should not be delayed for people with a progressive, life-limiting illness if they have physical, psychological, social, or spiritual needs during treatment.

https://www.hqontario.ca/Evidence-to-Improve-Care/Quality-Standards/View-all-Quality-Standards/Palliative-Care/Quality-Statement-1-Identification-and-Assessment-of-Needs

PANG Clinical Guidelines book.pallcare.info provides alternative access to the PANG guidelines 2016 (version 4). The screen layout is designed for a desktop PC, and will not work well on a small screen e.g. mobile phone. No site registration is required.

https://www.pallcare.info/

Berdoa Menutup Sedih Tanpa Biaya

https://palliativecareindonesia.blogspot.com/p/blog-page_29.html

Pediatric Hospice and Palliative Medicine (PHPM) is both a philosophy and an organized method for delivering competent, compassionate, and consistent care to children with chronic, complex and/or life-threatening conditions, as well as to their families.

https://services.aap.org/en/community/aap-sections/hospice-and-palliative-medicine/pediatric-hospice-and-palliative-medicine-career-guide/

PALLIATIVE CARE CARE FOR ADULTS WITH A PROGRESSIVE, LIFE-LIMITING ILLNESS

https://t.me/c/1305911983/20

Demonstrate the value of your pediatric palliative care service to program stakeholders.

https://www.capc.org/toolkits/designing-a-pediatric-palliative-care-program/

Morphine Sulfate 10mg/ml Injection BP

• Morphine Sulfate may be given by the subcutaneous, intramuscular or intravenous route. The subcutaneous route is not suitable for oedematous patients. The dosage should be based on the severity of the pain and the response and tolerance of the individual patient. The epidural or intrathecal routes must not be used as the product contains a preservative.

• Prior to starting treatment with opioids, a discussion should be held with patients to put in place a strategy for ending treatment with morphine sulphate in order to minimise the risk of addiction and drug withdrawal syndrome

 https://www.medicines.org.uk/emc/product/2244/smpc

Palliative Sedation: Myth vs. Fact

Patients with poorly controlled pain, shortness of breath, and agitation actually die sooner because of the stress caused by this suffering. Studies clearly demonstrate that palliative sedation does not hasten death.
https://www.capc.org/about/press-media/press-releases/2010-1-6/palliative-sedation-myth-vs-fact/

The more common side effects that can occur with dexamethasone oral tablets include:

• nausea
• vomiting
• stomach upset
• swelling (edema)
• headache
• dizziness
• mood changes, such as depression, mood swings, or personality changes
• trouble falling asleep
• anxiety
• low potassium levels (causing symptoms such as tiredness)
• high blood glucose
• high blood pressure

If these effects are mild, they may go away within a few days or a couple of weeks. If they’re more severe or don’t go away, talk to your doctor or pharmacist.

https://www.healthline.com/health/dexamethasone-oral-tablet#side-effects

The mission of LMHPCO is to improve the quality of hospice & palliative care in Louisiana & Mississippi.

https://lmhpco.org/healthcare-professionals/pediatric-palliative-care/

IAN ANDERSON CONTINUING EDUCATION PROGRAM IN END-OF-LIFE CARE

https://t.me/c/1305911983/8

New York State Palliative Care Education and Training Council

https://www.health.ny.gov/professionals/palliative_care/

How people die remains in the memory of those who live on

https://www.bmj.com/content/341/bmj.c4861

Guidance At End of Life (GAEL) for Health Care Professionals
https://palliativecareindonesia.blogspot.com/p/guidance-at-end-of-life-gael-for-health.html

Hospice and palliative medicine core competencies The American Academy of Hospice and Palliative Care Medicine (AAHPM) has developed a list of core competencies for palliative care specialists (pdf).

https://palliativemedicine.wustl.edu/hospice-palliative-medicine-fellowship/curriculum/

Download: http://aahpm.org/uploads/education/competencies/Competencies%20v.%202.3.pdf

PALLIATIVE CANCER CARE GUIDELINES

https://t.me/c/1305911983/23

The framework describes core competences and discipline specific competences for twelve health and social care disciplines.

https://www.hse.ie/eng/about/who/cspd/ncps/palliative-care/resources/competence-framework/

• fatigue,
• anorexia,
• cachexia,
• dry mouth,
• cough,
• hyperhidrosis,
• pruritus.

Needs assessment forms an important part of palliative care in all settings and can improve their quality of life of adults with dementia or those who are at end-of-life.

https://www.palliaged.com.au/tabid/4880/Default.aspx

A multi-dimensional screening questionnaire providing a profile of needs to identify patients who could benefit from additional supportive or palliative care.

https://www.aci.health.nsw.gov.au/palliative-care-blueprint/the-blueprint/essential-components/essential-component-7#resource-291991

Download: https://www.gem-measures.org/Public/DownloadMeasure.aspx?mid=1595

Specialist palliative care services have a role in research and in knowledge generation and dissemination (NSW Health, 2007) and require funding and support to make this contribution to support overall improvement in the quality of service delivery and outcomes.

https://www.aci.health.nsw.gov.au/palliative-care-blueprint/the-blueprint/essential-components/essential-component-7

Hospice and palliative care is about having the best quality of life for however long life remains. Palliative care patients have serious illnesses that eventually bring about the end-of-life but up until then it is important to be free from pain, symptoms, and suffering. Recent studies show that many patients who receive palliative care may live longer than those receiving standard care based on a more curative model.
http://www.adultpalliativehub.com/who-we-are/about-adult-palliative/palliative-care-myths

10 MYTHS ABOUT PALLIATIVE CARE

https://t.me/c/1305911983/31

The aims of the LCP are;

• To recognise when death is approaching, and when ongoing medical treatment is futile. This is sometimes difficult to do, but the pathway specifies that the team caring for the patient, including at least one senior doctor, should be in agreement that this is the case.
• To assess the patient for common symptoms at the end of life, and to treat these appropriately.
• To communicate effectively with the patient and their friends and family, to ensure that their wishes are respected as far as possible.
• To respect a patient’s spiritual needs.
• To review whether current interventions are in the patient’s best interests, for example continuing with blood testing, intravenous drugs and oxygen therapy.

https://rickolddoc.wordpress.com/2014/03/10/the-liverpool-care-pathway/

Avoid undertaking investigations that are unlikely to affect care in the last few days of life unless there is a clinical need to do so, for example, when a blood count could guide the use of platelet transfusion to avoid catastrophic bleeding.
https://www.ncbi.nlm.nih.gov/books/NBK356023/#ch1.s1

HARI PERTAMA:

https://drive.google.com/drive/folders/11YXiOd1kR7_wyKv0gsa9MxB9oG46T-Me?usp=sharing

HARI KEDUA :

https://drive.google.com/drive/folders/1zITY3gqakqvr7X8jVK8xRvn6V6vbclDh?usp=sharing

HARI KETIGA :

https://drive.google.com/drive/folders/1OErt9KMQ3HQgXUpPrVw2tgcvEH5CyYw7?usp=sharing

WORKSHOP:

https://drive.google.com/drive/folders/1nf8_M1iUIyMHdNsmx--lODT5AaPRfTSX?usp=sharing

CLINICAL PRACTICE GUIDELINES FOR QUALITY PALLIATIVE CARE

https://t.me/c/1305911983/15

In specialist settings (eg specialist palliative care services), the NAT: PD can assist in determining when complex needs have been met and act as a discharge planning tool, or to identify the need for ongoing support.

http://media.pcc4u.org/Documents/NeedsAssessmentTool_20140930.pdf

APPM Master Formulary 2020 (5th edition)
https://www.appm.org.uk/_webedit/uploaded-files/All%20Files/Event%20Resources/2020%20APPM%20Master%20Formulary%202020%20protected.pdf

Pelatihan Perawatan Paliatif pada Pasien Stroke
https://drive.google.com/file/d/1Qvju5kkbNoWqyUL12tmI2WY0rnixduRv/view?usp=sharing

There are many reliable and validated tools available to guide health professionals with symptom assessment.

http://www.pcc4u.org/learning-modules/core-modules/module-3-assessment/2-common-symptoms/activity-6-assessment-tools/

Getting it right every time

https://www.rcn.org.uk/professional-development/publications/pub-004871

A palliative care approach is more than easing the approaching death of an individual. It aims to improve the quality of life of a cared-for person who faces life-threatening illness, as well as that of their family. It does this by providing pain and symptom relief as well as spiritual and psychosocial support, from diagnosis to the end-of-life and bereavement.

https://www.open.edu/openlearncreate/mod/oucontent/view.php?id=81112&section=2

Edmonton Symptom Assessment System (ESAS-r)

1. Pain – grimacing, guarding against painful maneuver
2. Tiredness – increased amount of time spent
3. Drowsiness – decreased level of alertness
4. Nausea – retching or vomiting
5. Appetite – quantity of food intake
6. Shortness of breath – increased respiratory rate or effort that appears to causing distress to the patient
7. Depression – tearfulness, flat affect, withdrawal from social interactions, irritability, decreased concentration and/or memory, disturbed sleep pattern
8. Anxiety – agitation, flushing, restlessness, sweating, increased heart rate (intermittent), shortness of breath
9. Wellbeing – how the patient appears overall

• https://web.archive.org/web/20170203224559if_/https://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=351493

• https://web.archive.org/web/20171009233613if_/http://www.palliative.org/NewPC/_pdfs/tools/ESAS-r.pdf

• https://web.archive.org/web/20181008214941if_/http://palliative.org:80/NewPC/_pdfs/tools/ESAS-r%20Graph.pdf

• https://web.archive.org/web/20130626224515if_/http://www.palliative.org:80/newpc/_pdfs/tools/ESAS-r%20guidelines.pdf

Effective ways to communicate with the patient are:

• Make eye contact
• Take time
• Listen
• Ask open-ended questions such as, "How are you feeling?"
• Avoid asking closed-ended (yes or no) questions or interrupting the patient

https://www.capc.org/training/symptom-management/depression/launch/

Consider using the deltoid areas (right) or the scapula in confused patients, to reduce the risk that they will pull the needle out. Avoid bony areas where subcutaneous tissue is poor, areas where movement could dislodge the needle, broken skin, and areas of ascites, lymphoedema and previously irradiated skin where absorption may be impaired (Radcliffe, 2017).
https://www.gmmh.nhs.uk/download.cfm?doc=docm93jijm4n7159.pdf&ver=9697

Medications Used for Subcutaneous Infusion
https://bit.ly/MedicationsSubcutaneous

Pain can be divided into nociceptive and neuropathic types of pain.
Pain can be a mixture of these two types.

 

Nociceptive pain:

☛ Caused by invasion and destruction of or pressure on superficial somatic structures like skin, deeper skeletal structures such as bone and muscle and visceral structures and organs.
☛ Types: superficial, deep, visceral
☛ Superficial and deep nociceptive pain is usually localized and non-radiating.
☛ Visceral pain is more diffuse over the viscera involved.

 

Neuropathic pain:

☛ Caused by pressure on or destruction of peripheral, autonomic or central nervous system structures.
☛ Radiation of pain along dermatomal or peripheral nerve distributions
☛ Often described as burning and/or deep aching.
☛ May be associated with dysesthesia, hypesthesia, hyperesthesia and allodynia. 

☛May also be accompanied by lightning like jabs of brief sharp pain (lancinating pain).

 

https://web.archive.org/web/20200811025450/https://www.cpd.utoronto.ca/endoflife/Modules/PAIN%20MANAGEMENT%20MODULE.pdf

 

Okay kan, Bro!