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Introduction to Palliative Care


Introduction to Palliative Care Robyn Anderson, APRN Lauren King, MSW JJ Peters VA Medical Center October 1, 2008 Goals of presentation Overview of history, growth ... – PowerPoint PPT presentation

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Title: Introduction to Palliative Care

Introduction to Palliative Care
  • Robyn Anderson, APRN
  • Lauren King, MSW
  • JJ Peters VA Medical Center
  • October 1, 2008

Goals of presentation
  • Overview of history, growth and principles of
    palliative care programs
  • Key principles palliative care
  • Understand key features of the Medicare hospice
  • Cases for discussion

End of Life in America Today
  • The world death rate is holding steady at 100
  • lt10 suddenly (myocardial infarction, accident,
  • gt90 protracted, life-threatening illness
  • 90 of respondents to NHO Gallup survey want to
    die at home
  • Locations
  • Hospitals 50
  • Nursing homes 20-25
  • Home 25
  • Other 4

Traditional Health Care Model
  • Curative
  • The primary goal is cure
  • The object of analysis is the disease process
  • Symptoms are treated primarily as clues to
  • Primary value is placed on measurable data
  • Tends to devalue information that is subjective,
    immeasurable, or unverifiable
  • Therapy is medically indicated if it eradicates
    or slows the progression of disease

Symptoms at the End of Life
Cancer Other
  • Pain 84 67
  • Trouble breathing 47 49
  • Nausea and vomiting 51 27
  • Sleeplessness 51 36
  • Confusion 33 38
  • Depression 38 36
  • Loss of appetite 71 38
  • Constipation 47 32
  • Bedsores 28 14
  • Incontinence 37 33
  • Seale and Cartwright, 1994

Palliative Care
  • Comprehensive care for patients whose diseases
    are not responsive to curative treatment
  • Care is provided by an interdisciplinary team of
    physicians, nurses, social workers, chaplains and
    other health care professionals
  • Palliative Care Teams practice in hospitals,
    nursing homes and in the outpatient setting.

Google Images
History of Palliative Care
  • Dame Cecily Saunders was the founder of St
    Christophers Hospice which opened in London in
  • Connecticut Hospice- first Modern Hospice in USA
    in 1974
  • Medicare Hospice Benefit introduced in 1983

General Principles
  • Patient and family as unit of care
  • Attention to whole person
  • Interdisciplinary team approach
  • Education and support of patient and family
  • Extends across illnesses and settings
  • Bereavement Support
  • National Consensus Project for Quality Palliative
    Care, 2004

  • Provides coordinated, comprehensive care for
    terminally ill patients and their families.
  • Provides care at home and in medical facilities
    through an interdisciplinary team of healthcare
  • Entitlement under Medicare and other health
    insurance programs.

Palliative Care vs Hospice
  • Hospice is a Medicare benefit- other insurance
    plans also have Hospice benefits it is a way of
    paying for a certain type of care
  • Hospice care can be provided in the home setting
    or in a facility
  • Palliative care encompasses all of hospice care,
    but also supports curative or life prolonging
    therapies prognosis gt 6mo

Domains of Palliative Care
  • Structure and Processes of Care
  • Physical Aspects of Care
  • Psychological and Psychiatric Aspects of Care
  • Social Aspects of Care
  • Spiritual, Religious and Existential Aspects of
  • Cultural Aspects of Care
  • Care of the Imminently Dying Patient
  • Ethical and Legal Aspects of Care
  • Clinical Practice Guidelines for Quality
    Palliative Care, 2004

Structure and Processes of Care
  • Comprehensive, interdisciplinary plan of care
    based on expressed values and goals of patient
    and family
  • Teams have relationships with one or more
    community hospice programs
  • The physical environment in which care is
    provided meets the needs of the patient and
    family to the extent possible
  • Patients and families have access to palliative
    care staff 24 hours a day, seven days a week

Physical Aspects of Care
  • Pain, other symptoms, and side-effects are
    managed based upon the best available evidence
  • Breathlessness Anorexia
  • Insomnia Fatigue/weakness
  • Anxiety Nausea
  • Depression Confusion
  • Constipation
  • The outcome of symptom management is the safe and
    timely reduction of the symptom to a level that
    is acceptable to the patient

Psychological and Psychiatric Aspects of Care
  • The interdisciplinary team includes professionals
    with training and skills in the psychological
    consequences and psychiatric co-morbidities of
    serious illness
  • Appropriate pharmacologic and non-pharmacologic
    therapies are initiated for depression, anxiety,
    insomnia or other symptoms
  • Bereavement support is available for up to 13

Social Aspects of Care
  • Comprehensive interdisciplinary assessment
    identifies the social needs for patients and
    their families
  • Referrals to appropriate services are made that
    meet identified social needs
  • Access to care Transportation
  • Rehabilitation Medications
  • Counseling Community resources
  • Equipment Advocacy
  • Help in the home, school or work

Spiritual, Religious and Existential Aspects of
  • Professionals with expertise in assessing and
    responding to spiritual and existential issues
    are included on the interdisciplinary team
  • Regular ongoing exploration of spiritual and
    existential concerns occurs as appropriate
  • Contacts with spiritual/religious communities,
    groups, or individuals as desired by the patient
    and/or family are facilitated
  • Religious or spiritual rituals as desired by the
    patient and/or family are supported

Cultural Aspects of Care
  • The Palliative Care team assesses and attempts to
    meet the culture-specific concerns of patients
    and their families
  • Communications are respectful of cultural
    preferences regarding disclosure, truth-telling
    and decision-making
  • The program attempts to respect and accommodate
    the range of language, dietary, and ritual
    practices of patients and their families

Care of the patient who is imminently dying
  • Signs and symptoms of impending death are
    recognized and communicated and appropriate care
    is provided to the patient and family based on
    their preferences
  • End-of-life concerns, hopes, fears and
    expectations are addressed openly and honestly in
    the context of social and cultural customs

Ethical and Legal Aspects of Care
  • Care is consistent with the professional code of
    ethics for all involved disciplines
  • The team aims to prevent, identify and resolve
    ethical dilemmas related to specific
  • withholding or withdrawing treatments
  • instituting DNR orders
  • use of sedation
  • Team members are knowledgeable about legal and
    regulatory aspects of palliative care

Medicare Hospice vs. Home Care
Medicare Hospice vs. Home Care
Cases for Review
  • Ms. M is a 77 year old who is diagnosed with
    stage IV colon cancer. While consistently in
    pain, she refuses any medications to address the
    issue. Ms. M is also unable to eat any solid
    food but is adamant about being able to return
    home, where she lives alone.

  • Mr. D is an 84 year old with metastatic prostate
    cancer and dementia. He had been living at home
    with his son and receiving home hospice services,
    but due to increasing need for 24/hr care the
    hospice agency felt being at home was no longer a
    safe environment. Attempts to assist family with
    Medicaid applications (for additional home
    services) were unsuccessful.

  • The major goals of hospice and palliative care
    are to relieve suffering and to help patients
    live the remainder of their lives fully and
  • Palliative care is provided by an
    interdisciplinary team of health professionals
  • Hospice is both philosophy of care and an
    entitlement program that can greatly enhance the
    quality of care at the end of life.