1. A Palliative Approach to Care
The introductory end of life care training program

2. Introduction Learning Objectives
We are all born, we experience, we die
All between is living
Death is last challenge of life – part of life
Learning Objectives
Understand Palliative Care and when to implement.
Understand how to communicate empathy and respond to challenging conversations.
Understand Goals of care
How to care for yourself

3. A Palliative approach to care?
Not just for cancer
Extends to all chronic diseases
Frailty
Death affects carers and professionals, and not only patients and their families.
Not what we do but how we do it

4. World Health organisation (WHO)
Palliative care is: “...an approach which improves the quality of life of patients and their families facing life-threatening illness, through the prevention, assessment and treatment of pain and other physical, psychosocial and spiritual problems”.

5. ACTIVE (“CURATIVE”) TREATMENT
Historical Understanding of Palliative Care
Early Palliative Care
PALLIATIVE
CARE
ACTIVE (“CURATIVE”) TREATMENT
False: Palliative Care is an alternative to dialysis or other treatments
False: Palliative care is considered only at end-of-life care and excludes patients who want aggressive care
False: Palliative care discussions are related to fears of depleting patient/family hope
False: Nursing role is limited and indirect (only making suggestions to sympathetic physicians)
Mahon, M & McAuley, W (2010)
Courtesy Dr Pippa Hawley 5

6. Palliative approach an other words. The POCT nurses constructed this
Palliative approach an other words. The POCT nurses constructed this.. I think the PA is an oval around this. My best understanding of the palliative approach is that we putting into px knowledge about chronic illness together with palliative care. Ideally it occurs upstream in the illness even right at dx.

7. Time to plan
One of the biggest complaints in healthcare is that family/carers recognise someone is dying but staff don’t communicate this.
This highlights the importance of recognising the unpredictability but alongside this starting these conversations early so that people have time to plan.

8. False Hope Hope is not a plan, but hope is our plan.
We imagine that we can wait until Drs say there is nothing more they can do – rarely is there nothing more Drs can do.
Hope for the best- plan for the worst

9. 3 Step approach
Identify
Discuss
Plan

10. Identify - Palliative Care Approach - indicators
There are disease specific flags that indicate an increased possibility that the resident may die within the next 6 months. (Disease Specific Markers).
Frailty and dementia staging
Significant change – eg
Surprise question

11. Some older people live extremely well to a great age.
Age matters – It does not identify
Consider that biological age, and chronological age can be very different. 
Young people with chronic conditions will be affected by limitation of life span and quality of life.
Some older people live extremely well to a great age.

12. Cleveland clinic video
Empathy: The Human Connection to Patient Care

13. Discuss - Compassionate honesty
Providing information for the patient, family and loved ones can help prepare them for death.
Allows patients and families the opportunity to discuss any worries they may have about any aspect of the illness or dying process.
Allows them to understand the need to review the appropriateness of current medical and nursing interventions – Goals of Care
Address concerns about the process of dying; for example, what to expect as they approach their final hours.
Address concerns about death itself, such as not being here any more, unfinished business, leaving family behind.

14. Communication - Needs and issues at end of life
Communication = Intent + Perception
Sending mixed messages
Answer with a question
Emotion and anxiety
ESL
Taboos and assumptions
Agonizing decisions must be made

15. Communication with challenging Families
There is always a reason for challenging behaviour.
Your role is to find out why
Reactions to threat/loss
Multiple losses
Guilt
Anticipatory grief
Fear
Communicate empathy and support
Convey respect and understanding

16. Curiosity
What does the resident care about? What is important to them?
What has the resident been forced to forfeit? – freedom? (Home is where your own priorities are important, how you spend your time, share your space, manage your possessions.)
What are their fears/worries?
What are unacceptable outcomes?

17. Plan - Modern life and healthcare
Connections between events of previous couple of months – join the dots
Closing phase of modern day life = a mounting series of crises from which medicine can offer only brief and temporary rescue
ODTAA –not totally predictable path but direction becomes clear

18. Plan - challenges and goals
Resident focused goal
↑ falls ↓ mobility
To minimise injury
Keep independent as long as possible.
↓ appetite/swallowing and weight loss
To encourage intake
Promote enjoyment and quality of life.
↑ pain & discomfort
To keep comfortable and prevent pain
Decrease medication burden and promote comfort.
↑ weakness, fatigue and ↓ activity
To prevent skin breakdown.
To participate in activity meaningful to resident and promote comfort.
↑ infections (UTI/Pneumonia/wounds)
To treat distressing symptoms
Maintain comfort minimise anxiety.
↑ concerns from family
To ensure resident focused care
To ensure client wishes are met and not family needs

19. Predictable Challenges
Functional decline-mobility, transfers, toileting, communication
Can’t swallow meds, food, fluids.
Dyspnoea (sob)
Delirium-agitation
Concern of family/friends/patient
Be prepared
Report Changes in the patient such as
Restlessness or anxiety
Changes in breathing
Pain or discomfort
Need for spiritual support or guidance for the resident or family/SW, Chaplain
Religious, cultural or ethnic traditions important to the family
Voiced fears or worries