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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
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
30% senior oncologists had high scores on the Maslach burnout inventory
High emotional exhaustion High depersonalisation Low personal accomplishment
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:
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?