Académique Documents
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PRELIMS:
Overview of Death and Dying
- Multiple Organ Dysfunction Syndrome - Incidence of Death - Death as a Natural Process
For Midterm
Second, open communication involving not only patients and family members but also include all relevant health professionals who will facilitate informed decision making.
Third, listen to patients own story (past & present life experiences) will assist the professional to understand the impact of symptoms from the patients perspective.
Symptoms are multidimensional = adopt a multiprofessional approach = Use interdisciplinary therapeutic model encompassing all dimEnsions of care. Allows members to share information through discussion and working together to formulate goals.
TAKE NOTE: one must be cautious when discussing symptom incidence and prevalence data because patient cohorts, symptom checklists and study methodologies differ. Core Symptoms related to Hospice admissions: Fatigue, Pain, Dyspnea, and Constipation.
EVALUATION
Establish cause of symptoms Effectiveness of interventions already implemented Physical examination Because of complexities, determine if the symptom is due to: the disease itself the treatment concurrent medical conditions or a combination of all three
EVALUATION
Regardless of the cause, a decision must be taken as to whether the symptom is reversible, treatable or a terminal event for the patient. A comprehensive explanation of the management plan should be given to the patient and family. If the patient is dying, appropriate terminal event symptom management should follow.
EVALUATION
Important: Patient-reported evaluation (mandatory) Assessment instruments Self-reporting instruments (most accurate and often over/ underestimated) Used to supplement professional judgment and aid assessment.
EVALUATION
Important: Issues: - problems in practical application (patient and staff burden) - although comprehensive, are cumbersome and requires time and effort from both patient and health professional. Benefit of using this tool must outweigh the burden of the patient.
EVALUATION
Important: Recommendations: - the simpler and briefer the tool, the more applicable. - Examples: Verbal Rating Scales and Visual Analogue Scale
EVALUATION
A plethora of general and disease-specific instruments exists, but what is important is that practitioners should choose a measurement tool that best suit the patient and measure the dimension of the symptom that is being assessed.
EXPLANATION
Explanation about the care and treatment options is vital to the delivery of effective care and empowers patients and caretakers to be involved as equal partners in the decision-making process. Information about the disease process and significance of symptoms should be provided to patients when they need it, and not at a time convenient for the caretakers.
EXPLANATION
Information should be provided in a sensitive manner. Poor communication skills in relation to information giving can have a detrimental effect on patient outcomes.
MANAGEMENT
Identify the cause and determine what is reversible or treatable Health professionals should work in partnership with the patient. Patients priorities must be considered, and realistic goals set in conjunction with the patient and then documented in the management plan..
MANAGEMENT
Treatment interventions should be tailored to meet the needs of the patient. Team cohesiveness is crucial to achieving successful outcomes. In order to achieve cohesiveness and be efficient, it may be useful for the interdisciplinary team to incorporate elements of collaborative practice.
MONITORING
Will not only determine the efficacy of interventions, but also facilitate regular reassessment of the severity of the symptoms and impact on the patient.
ATTENTION TO DETAIL
If done erroneously - will have significant consequences for the patient.
Throughout the process of symptom management, any missing detail by the health professionals can have significant consequences.
ATTENTION TO DETAIL
Crucial time can be wasted:
by not actively listening to the patient at the initial assessment stage by prescribing but not ascertaining the practical availability of medications and assessing side effects by failing to ask the right questions to elicit the correct information when monitoring interventions.
Key Points:
Meticulous assessment and multiprofessional input will increase the chances of getting it right first time. Involve the patient in decision-making partnership by exploring the symptom experience together.
Never give up hope or underestimate the effect that showing that you truly care about the patient will have on treatment outcomes.
THE SYMPTOMS
Causes
An increase in the respiratory effort required to overcome a certain load (often seen in obstructive or
restrictive lung disease, or pleural effusion) An increase in the proportion of respiratory muscle needed to maintain a normal workload (as demonstrated with neuromuscular weakness or cachexia) An increase in ventilatory requirements (as seen in hyperemia, hypercapnia, metabolic acidosis, or anemia). Patients may also experience a magnification of the intensity of dyspnea due to cultural background, surrounding environment, previous life experiences, and psychological or spiritual distress
Assessment of Dyspnea
Onset of symptom (acute vs chronic) Frequency (hourly, daily, a few times per
week, only when walking, etc) Severity (currently, at its least, and at its worst, using an appropriate scale such as the Visual Analog Scale (VAS) or Borg Any associated symptoms (eg, cough, dizziness
Assessment of Dyspnea
Exacerbating or alleviating factors (both
pharmacologic and nonpharmacologic) Impact on mood, activities of daily life, ability to sleep and eat Meaning of symptom Concerns about specific therapeutic interventions (ie, opioid analgesics and potential for substance abuse or respiratory depression)
Assessment of Dyspnea
Past and current treatments (including
primary treatments for malignancy, over-thecounter medications, herbal supplements, etc) as well as dosing schedule, patient adherence, and side effects
BREATHLESSNESS (DYSPNEA)
Management
Non Pharmacological: All communication should be clear. Any handling should be fully explained and carried out in a slow efficient manner, allowing for a rest between each stage of the procedure. Verbal responses should be limited. Use of close-ended questions be encouraged.
BREATHLESSNESS (DYSPNEA)
Management
Non Pharmacological: Platitudes should not be used, rather the distress that the patient is experiencing should be acknowledged. A fan reduces the sensation of breathlessness by affecting nerve receptors in the trigeminsl nerve distribution. Restful night sleep is of great importance.
BREATHLESSNESS (DYSPNEA)
Management
Non Pharmacological: Patient education in coping techniques. Breathing techniques and relaxation training. Aromatherapy. Therapeutic hypnotherapy. Acupuncture. Oxygen therapy Occupational therapy.
BREATHLESSNESS (DYSPNEA)
Management
Non Pharmacological: Agree realistic goals with patient. Positioning in bed Pacing activities that will be more strenuous using bronchodilator before strenuous activities. Pursed lip breathing Cool, smoke-free, dust-free environment.
BREATHLESSNESS (DYSPNEA)
Management
Non Pharmacological: Aids wheelchairs, commodes, portable oxygen etc for walking Relaxation, music and other therapies
BREATHLESSNESS (DYSPNEA)
Management
Pharmacological: Bronchodilators Steroids Nebulized Furosemide Cannabinoids Opiods (Morphine) Sedation Psychostimulants
BREATHLESSNESS (DYSPNEA)
Monitoring and Attention to Details
- Regular contact with the patient, including assessment of physical status, will facilitate monitoring of the symptoms.
COUGH
Contributing factors include immobility, aspiration, poor cough reflex and progressive weakness of the intercostals and diaphragmatic muscles. Caused by mechanical and/or chemical stimulation
COUGH
Management
Non Pharmacological: Proper coughing techniques Proper positioning Postural drainage Steam inhalation
COUGH
Management
Pharmacological, wet or productive cough: Nebulized saline Antibiotics Bronchodilators Expectorants Mucolytics
COUGH
Management
Pharmacological, dry cough: Antitussive Nebulized local anesthetics
PAIN
A complex phenomenon An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. If pain is unrelieved, the sufferer can be withdrawn, unable to focus and their whole personality can be changed as their quality of life diminishes.
PAIN
Types of Pain: Physiological Pain Neuropathic Pain Somatic Pain Visceral Pain
PAIN
Assessment of Pain:
PAIN
Assessment of Pain:
PAIN
Assessment of Pain:
PAIN
Factors Affecting Pain Experience:
PAIN MANAGEMENT
Address pain management at 2 levels: 1. Basic level palliative care for uncomplicated pain.
- said to be a core skill that every health care professional , in whatever setting should possess
PAIN MANAGEMENT
Address pain management at 2 levels: 2. Specialist level palliative care - led by clinicians with recognized, specialist palliative medicine training and deals with the more complex problems.
PAIN MANAGEMENT
Given: By Mouth By the Clock
By the Ladder
PAIN MANAGEMENT
Steps:
- Give examples of patients with successful outcomes related to the use of opioids.
- Offer to meet family members to minimize concerns. - Encourage questions at any time.
PAIN MANAGEMENT
Non-Drug Interventions:
Aromatherapy and massage Hypnosis and Relaxation therapy Spiritual Care Good communication and Counselling
GASTROINTESTINAL PROBLEMS
Nausea and Vomiting.
Vomiting is essentially a protective mechanism to rid the body of any ingested poison. Nausea is related to this process, being an unpleasant sensation that will stop further intake of the harmful substance.
GASTROINTESTINAL PROBLEMS
Evaluation / Assessment
A detailed hx, including tumor histology and spread and previous treatment.
Onset of Symptoms
P.E. Evaluation of biochemical status.
GASTROINTESTINAL PROBLEMS
Evaluation / Assessment
Factors that exacerbate or relieve symptoms
Management:
Anti-emetics
GASTROINTESTINAL PROBLEMS
Monitoring:
A key role is played by the nurse in the monitoring of the pattern and nature of the nausea and vomiting. Vomitus should be observed and its characteristics recorded. Amount, color, odor, presence of blood, undigested food or fecal fluid.
Communication Strategies for Advanced Care Planning Development of a trusting relationship with patients and families is integral to high-quality medical care, especially at end-oflife.
Rapport-Enhancing Verbal and Nonverbal Communication Strategies. Verbal Strategies Use open-ended questions to explore patient concerns Paraphrase the content of the patients communication using patients own words. Validate patients and family members feelings Summarize broad themes during the interaction. Nonverbal Strategies Give patient undivided attention. Avoid multi tasking. Directly face the [patient at eye level. Avoid distracting mannerisms. Maintain an open posture. Lean forward
Rapport-Enhancing Verbal and Nonverbal Communication Strategies. Verbal Strategies Deliver diagnostic and prognostic information sensitively end with empathy. Assess preferences for receiving medical information. Avoid the use of medical jargon. Nonverbal Strategies Maintain appropriate eye contact. Be sensitive to and aware of cultural differences in non verbal behaviour. Develop self-awareness about ones own nonverbal behaviours and what they communicate to others.
or her illness can help the health care professional better understand the patients knowledge base and suggest areas for further patient education. Better to assess how much the patient wants to know about the illness; although most patients want full information about their condition, not all patients do.
or her illness can help the health care professional better understand the patients knowledge base and suggest areas for further patient education. Better to assess how much the patient wants to know about the illness; although most patients want full information about their condition, not all patients do.
values, or the principles, ideas or qualities deemed worthwhile, can help clinicians deliver appropriate patient-centered care. Patients can be asked to elaborate on what makes life worthwhile and to explain what the term quality of life mean
Psychological morbidity
9 to 58 % cancer patients develop an affective disorder requiring intervention Review article, Massie et al 2004 Oncologists did not identify majority (60 to100%) patients with
3 Main Ways:Identification of Concerns The Significance of Information Giving The Importance of Negotiated Decision Making
Harrison et al 1994
Information giving
Patients who feel they are given inadequate information (too little or too much) at time of diagnosis are at greater risk of affective disorders
Stress
in health professionals
High emotional exhaustion High depersonalisation Low personal accomplishment
30% senior oncologists had high scores on the Maslach burnout inventory
distress
NB: Consider barriers from both the health care professionals and patients perspective
Barriers
Fears
Unleashing strong emotions Upsetting patients/relatives
Beliefs
Emotional problems are inevitable Not my role Talking raises expectations Patient will fall apart Will take too long
Barriers
Lack of skills
Assessing knowledge and perceptions Integrating medical and psychosocial modes of enquiry Handling difficult reactions
Working environment
No support or supervision No referral pathway Staff conflict Lack of time Lack of privacy
Patient Barriers
Fears Of being stigmatised Being judged as ungrateful Of crying/breaking down Of burdening health professional Of causing distress to the health professional
Other reasons
Patient cannot find the right words Does not have command of the language Relevant questions were not asked Patient cues met by distancing
Maguire, 1999; Heaven & Maguire 1998
(Identify patients
history/agenda/needs/concerns)
Acknowledge patients agenda/concerns Negotiate decision-making
Open questions Open directive questions Psychological focus Pauses Screening questions
Picking up cues
Reflection (acknowledgment)
Summary
Minimal prompts
needed
Give information in small
Pause - allow information to sink in Wait for a response BEFORE continuing Check understanding Check impact
chunks
Use clear and simple terms Avoid detail unless requested
Silence or minimal prompts most likely immediately to precede disclosure Eide H et al 2004 Giving information reduces likelihood of further
Types of Cues
Psychological symptoms Words/phrases which describe physiological correlates of unpleasant emotional states Words/phrases suggesting vague or undefined
emotions
Verbal hints to hidden concerns Mention of a life event/repeated or emphasised
Non-verbal cues
Clear expression of a negative or
Importance of cues
Facilitative questions linked to cues increase the probability of further cues and are key to a patientcentred consultation Zimmerman et al 2003 Open questions linked to a cue are 4.5 times more likely to lead to further significant disclosure than unlinked open questions Facilitating the first patient cue appears to be important 20% drop in cues during consultation if first cue is not facilitated Fletcher PhD thesis 2006
Levinson et al 2000
times by 10-12%.
Butow et al 2002
Blocking behaviours
Blocking behaviours can:
Inhibit patient disclosure of feelings and concerns
Maguire et al 1996; Wilkinson et al 2008
Blocking behaviours
Physical questions Inappropriate information Premature reassurance Premature advice Normalising Minimising Jollying along Passing the buck Chit chat
Closed questions
Multiple questions Leading questions Defending/justifying
Blocking behaviours
Wilkinson 1991; Wilkinson et al 2008; Maguire et al 1996
Distancing strategies - more subtle Change of time frame - Are you upset now? Change of person - and was your wife upset? Removal of emotion - How long were you ill for?
Structuring a consultation
Initiating the session Gathering information Physical examination Explanation and planning Closing the session
Gathering information
Explore patients problems / concerns from beginning and identify current concerns: Biomedical perspective Patients perspective Physical, social, spiritual and psychological
Physical examination
Structuring a History/Assessment/Consultation
Initiating the session
Preparation Establishing initial rapport (Name & role) Identifying the reasons for the consultation Providing Structure Building the relationship
Gathering information
Exploration of the patients problems to discover Patients perspective Biomedical perspective physical social spiritual psychological
Summary
Facilitative skills used in context are fundamental to
good practice Blocking behaviours will inhibit patient disclosure Structuring a consultation will help maximise patient information gathered and aid the tailoring of appropriate information There are many negative consequences of ineffective communication with patients Our fears, attitudes, confidence, beliefs and training all impact on our ability to communicate well
Discussing prognosis
Discussing prognosis
Identify any concerns that the patient
Am I going to die?
proposed treatments
Discussing prognosis
Avoid giving specific time frames
How long have I got? Well, it may be months rather than years, but it is unlikely to be a few weeks
If the patient will ultimately die of the
disease, offer to explain signs and symptoms of deteriotation but avoid frightening details
You may notice that you are more short of breath or more easily tired
Common Pitfalls
Inadequate time or information Failure to elicit the patients
Common Pitfalls
Platitudes and false re-assurance
unchallenged when it is causing difficulties for the patient and their relatives
Removing all hopes
Principles
Assure the patient that you will not
abandon him/her
Explain the patients physical and
Procedures
Show empathy
- the patient will need to modify his/her goals - suffer loneliness and fears, need someone to talk to - help the patient through this difficult process
Procedures
Dont rush. Stay there
Pitfalls to avoid
Abandoning the patient when your
Make sure that the patient knows that you will stay with him/her.
End-of-Life Discussions
End-of-Life Discussions
Must take place in both longstanding and
new doctor-patient relationships Need to know our patients preference To reach plans that feel right to them and seem possible to us.
PRINCIPLES:
Begin the discussion when the patient is feeling
healthy
PRINCIPLES:
2 sorts of advance directives :
- living wills
- appointment of another person as a legal representative for health care decisions *Both take effect only when the patient loses decision-making capacity
Policies and laws dictate who can represent a
PROCEDURES
1. The sequence is a) Bring up the topic b) Ask what ideas and experiences the patient has about
advance directives c) Ask who else might be available to speak for the patient if he/she is not able to communicate d) Make the discussion formal. e) Ask the patient to complete documents. f) Rediscuss it all in the future
*be sure that your patient is cognitively and emotionally capable of making these decisions before beginning this discussion
resuscitation plans for all our admitted patients a good starting point Ask all your patients about their desires for resuscitation even if theyre young. Even though the patients come to you already filled out some forms about their desires in case of inability to communicate, you still have to have a conversation about end-of-life issues Be sure that the key family members understand your patients wishes.
PITFALLS TO AVOID
Shying away from discussions about dying
and death. Hoping that you arent on call when the patient dies. Failing to document end-of-life discussions with the patient. Leaving key players out of the discussion, chancing explosive conflicts among relatives at big decision points.
Discuss end-of-life issues regardless of the patients age, and document your conversation.
patient
PROCEDURES:
Be available. If possible, be on the scene to orchestrate
events at the deathbed. Just be there Practice empathy - ask how the family members are feeling. Ask to hear about the patients life. The more the grieving relatives talk about the dying person, the calmer and more soothed they will be. If you knew this patient enough to add to the narrative, you can add your comments, especially the positive ones.
- confirm with his/her family members - call the appropriate staff to talk with the family about the process of donation. If you were present at the death, you might want to consider some sort of follow-up action, such as sending a card or even attending the funeral.
PITFALLS TO AVOID:
Leaving arrangements and communication
with the family to the nurse. Avoiding anything personal. Talking with the family about biomedical and technical issues. Missing the chance to hear the familys feelings and memories.
Reference
Field guide to the difficult patient interview, 1999 Communication skill for final MB, 2006