Short Clinical Guidelines: Palliative Care

Short Clinical Guidelines: Palliative Care

Definition: Palliative care is provided to people who are facing serious illness and their families. This specialized care is aimed at relieving suffering and helping individuals and their families understand all possible treatment options, with special emphasis on managing the pain or symptoms that may accompany serious illness. The goal is to improve quality of life for both the patient and the family. It is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment. There is no time limit in terms of life expectancy ? patients may or may not be dying. All hospice is palliative care, but not all palliative care is hospice

Intensity of Care at End of Life Intensive care unit stays longer than a week in the last six months of life are increasing; 12.5% in 1996, 20.3% in 2007. Almost a third of Californians see 10 physicians in the last 6 months of life. 41% of Medicare patients with advanced directives entered palliative care/hospice care compared to 24% of those without advanced care planning. For certain terminally ill patients, those who choose hospice care live an average of 29 days longer than those who do not choose hospice. Hospice care reduced Medicare costs during the last year of life by an average of $2,309 per patient.

Care Goals: Vigorous treatment and relief from o Pain o Shortness of breath o Fatigue o Constipation o Nausea o Loss of appetite o Sleep difficulties o Worry, anxiety and depression Improved understanding of condition Clear, ongoing communication about what to expect and how to plan for current/future treatment(s) Support during medical treatments Support for family caregivers Practical support, i.e.: o Transportation o Accessing home health services o Nutrition support

The American College of Physicians (Annals of Internal Medicine, Vol. 148, Num. 2) makes the following recommendations:

1. In patients with serious illness at the end of life, clinicians should regularly assess patients for pain, dyspnea and depression

Adapted from the following resources by Riverside Physician Network Medical Practice Committee:

1

National Hospice and Palliative Care Organization

Center to Advance Palliative Care

National Palliative Care Research Center

Review Date: 9/2015 Effective Date: March, 2013

Short Clinical Guidelines: Palliative Care

2. In patients with serious illness at the end of life, clinicians should use therapies of proven effectiveness to manage pain.

3. In patients with serious illness at the end of life, clinicians should use therapies of proven effectiveness to manage dyspnea.

4. In patients with serious illness at the end of life, clinicians should use therapies of proven effectiveness to manage depression.

5. Clinicians should ensure that advance care planning, including completion of advance directives, occurs for all patients with serious illness

Palliative Care "Triggers" General considerations clinicians should use to identify patients who would benefit from palliative care include:

1. Disease progression, especially with functional decline 2. Pain and/or other symptoms not responding to optimal medical treatment 3. Need for advanced care planning 4. Not surprised if the patient were to die within 12 to 24 months

Conditions that may prompt the initiation of palliative care include, but are not limited to:

Debility/Failure to Thrive Dementia Complex care requirements Cancer

o Metastatic/recurrent o Patient desires continued curative treatment(s) Advanced COPD Advanced congestive heart failure Stroke o Decreased function by at least 50% End stage renal disease Ventilator dependent Chronic disease that is now life-limiting Catastrophic illness/injury Concomitant disease process o Liver disease o Diabetes o Moderate renal disease o Moderate COPD o Moderate congestive heart failure

Adapted from the following resources by Riverside Physician Network Medical Practice Committee:

2

National Hospice and Palliative Care Organization

Center to Advance Palliative Care

National Palliative Care Research Center

Review Date: 9/2015 Effective Date: March, 2013

Short Clinical Guidelines: Palliative Care

Common Symptoms Across Life-limiting Disease Settings:

Overall

o Fatigue

o Pain

o Dyspnea

o Delirium

o Anorexia

Cancer

o Pain o Fatigue o Anorexia o Anxiety o Depression

Heart Failure

o Dyspnea o Fatigue o Pain o Anxiety o Sleep disturbances

COPD

o Dyspnea o Fatigue o Xerotomia o Coughing o Anxiety

Renal Disease

o Fatigue o Sleep disturbances o Pain o Anxiety o Constipation

End-stage Liver Disease

o Depression o Sleep disturbances o Fatigue o Muscle cramps o Cachexia

HIV/AIDS

o Diarrhea o Fatigue o Depression o Pain o Delirium

Adapted from the following resources by Riverside Physician Network Medical Practice Committee:

3

National Hospice and Palliative Care Organization

Center to Advance Palliative Care

National Palliative Care Research Center

Review Date: 9/2015 Effective Date: March, 2013

Short Clinical Guidelines: Palliative Care

Initiation of Palliative Care There is no definitive tool to predict when to initiate palliative care. The decision to initiate palliative care is made jointly by the provider, the patient and the patient's caregiver(s). Factors that influence this decision may include cultural beliefs/barriers, and religious/spiritual beliefs. The attached tools may be helpful as a way to assess your patient's physical and emotional status. This in turn may make the discussion of care planning easier to initiate.

If the determination is made that palliative care would be appropriate, please submit a referral with supporting documentation to the Riverside Physician Network Referral Department for processing to the contracted agency. If you would like additional coordination of care assistance, please contact the outpatient Case Manager at (951) 7889800.

Adapted from the following resources by Riverside Physician Network Medical Practice Committee:

4

National Hospice and Palliative Care Organization

Center to Advance Palliative Care

National Palliative Care Research Center

Review Date: 9/2015 Effective Date: March, 2013

Short Clinical Guidelines: Palliative Care

NEW EDMONTON FUNCTIONAL ASSESSSMENT TOOL

Communication

0 Functional

Independent with all aspects of communication

Mental Status Oriented x3, memory intact

Pain None or occ. pain. Pain does not impact function

Dyspnea No dysfunction

Balance Sit

Stand Mobility

Normal balance

Controls/moves all limbs at will. Performs safely and independently

Locomotion Walks unassisted or Walk independently in lead up and

Wheelchair propelling

Fatigue Motivation

ADL

Rarely needs to rest

Wants to participate despite limitations Independent

Performance Independent in room or unit Status

1 Min Dysfunction

Requires glasses, hearing aids(s) or communication devices Impaired 2/6 orientation/ memory. Follow simple commands

Pain limits some activity. Inhibits function minimally Urgency ? counting or SOBOE or intermittent balance. Attain/maintain position with equipment or 1 person. Min safety risk

Controls/moves all limbs but degree of limitation. 1 assist to move safely

Walks with 1 person assist/+ walk aid or supervision with lead up

Rest 50% of time Independent using adaptive equipment

Independent with minimal assist of 1

2 Mod Dysfunction

Communicates effectively 50% of day

Active/passive participant ................
................

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