Palliative Care Assessment PDF

Palliative care assessment ARIF IMAM HIDAYAT., M.N.S Palliative care Palliative care bertujuan untuk meningkatkan kesejahteraan pasien dari segi fisik, psikologis, social, dan spiritual. Palliative care diberikan untuk meningkatkan QOL pasien dan keluarganya ketika menghadapi permasalahan yang berk...

Palliative care assessment ARIF IMAM HIDAYAT., M.N.S Palliative care Palliative care bertujuan untuk meningkatkan kesejahteraan pasien dari segi fisik, psikologis, social, dan spiritual. Palliative care diberikan untuk meningkatkan QOL pasien dan keluarganya ketika menghadapi permasalahan yang berkaitan dengan penyakit yang mengancam jiwa. Penyakit yang mengancam jiwa: 1. Berjalan dengan progresif dan berefek fatal 2. Progress nya tidak dapat diatasi dengan pengobatan Kapan pasien dirujuk ke palliative care? 1. Mengalami kondisi yang menancam jiwa 2. Sedang atau akan mengalami kesulitan terkait pengendalian gejala penyakit, perencanaan menjelang ajal, kebutuhan pelayanan psikososial maupun spiritual yang tidak dapat dipenuhi oleh pemberi asuhan sebelumnya. Siapa saja yang perlu dikaji ? All people with life-limiting conditions irrespective of age or setting. This guidance focuses on identifying the needs of adult patients. Children and adolescents requiring palliative care have their own unique needs which are outside the remit of this session. Local specialist palliative care teams are always available to discuss individual cases. It is recognized that carers’ needs may well have an impact on the level of care required and may prompt referral to specialist palliative care.  Kapan Pengkajian Palliative care dimulai Good clinical practice dictates that assessment should be an ongoing process throughout the course of a patient’s illness. We suggest that assessments be carried out at key transition points in the patient pathway, for example: 1. At diagnosis of a life-limiting condition 2. At episodes of significant progression/exacerbation of disease 3. a significant change in the patient’s family/social support 4. a significant change in functional status 5. at patient or family request, 6. at end of life. Dimana pengkajian dilakukan? Assessing the palliative care needs for a patient can be carried out in any physical setting that ensures comfort and privacy and could include the patient’s home or hospital setting  Siapa yang boleh melakukan pengkajian? The patient’s current health and social care team is responsible for ensuring that the assessment takes place. For continuity of care, it is often helpful to have a single team member responsible for assessing an individual’s needs. In line with good clinical governance, the patient’s physician should be involved in the decision to carry out an assessment. The assessor should be a clinical professional with an appropriate level of knowledge of the disease, its symptoms, treatment and likely prognosis. The assessor should have reached an agreed level of competence in key aspects of the assessment process. Domain 1 : Physical Wellbeing Patients with life limiting conditions frequently have multiple symptoms. Patient self report of symptoms varies from person to person. Some physical symptoms are readily reported by patients while others often require prompting. Domain 1 : Physical Wellbeing (cont’d) Physical problems un the last year of life Pain Somatic, visceral, neuropathic Take a detailed pain history outlining Location, quality, intensity, duration, frequency Associated / aggravating / relieving factors Treatment interventions to date Fatigue Fatigue disproportionate to level of activity or not relieved by rest Respiratory Dyspnea, cough, oropharyngeal secretions Gastrointestinal Anorexia, nausea, vomiting, constipation Neurological Insomnia, confusion, delirium, anxiety, depression Other Functional status, balance problem, edema, wound problems Domain 1 : Physical Wellbeing (cont’d) Approach: An introductory question to prompt the person to identify the physical needs of most concern to them. Thereafter a thorough and careful systems review will determine the presence and severity of physical symptoms. Domain 1 : Physical Wellbeing (cont’d) After identification of symptoms: Elicit a history of symptoms including previous treatments received. Ascertain the effect of the problem on the patient’s normal activities/function. Consider treatment options. Domain 1 : Physical Wellbeing (cont’d) Action: Agree and implement a care plan with the patient and multidisciplinary team. Establish whether these symptoms can be managed by the current treating team. If severe or intractable physical problems are identified or anticipated, consider referral to the specialist palliative care service. Domain 2: Social and occupational wellbeing The family is the unit of care. When assessing patients with life-limiting illness it is important to explore their concerns in relation to their home, family and community, and to identify risk in relation to their autonomy and social functioning. Approach: A social assessment seeks to gain some understanding of an individual’s life experience with regard to their: Background, Family support, Emotional and social support, Practical concerns.  Domain 2: Social and occupational wellbeing (cont’d) Suggested Prompts Family support Invite discussion about family and relationships: Who lives with you? Any children / adults dependents? Any concerns / worries regarding family or personal relationship Emotional and social Do you have any other support for example PHN. Home help, private carers, friends, neighbours? support How often do you see them? Do you need more support? What would help? Practical concerns and Discussion about practical issues advance care planning How are you managing? Any difficulties in: mobilising, managing the stairs, household chores e.g. washing, cooking, etc? Any concerns about future care needs, income, finances, sorting out your affairs? What are the person’s wishes regarding: Goals of care? Acceptable levels of intervention? Preferred place of care (person and family)? Domain 2: Social and occupational wellbeing (cont’d) After identification of concerns : Elicit history of concerns including previous supports/interventions received. Ascertain the effect of the problem on the patient’s normal activities/functioning. Consider treatment options/interventions. Domain 2: Social and occupational wellbeing (cont’d) Action: Agree and implement a care plan with the patient and multidisciplinary team. Establish whether these needs can be managed by the current treating team. If significant complex family and social concerns are identified or anticipated, consider referral to the Specialist Palliative Care Service. Domain 3: Psychological Well-being Patients with life limiting conditions frequently have psychological concerns. In order to identify these concerns, it is important that the assessor is proactive in asking about emotional and psychological issues. Domain 3: Psycological Well-being (cont’d) Approach: Begin with an open exploratory question that invites the person to identify any concerns. “Is there anything worrying you?” Followed by consideration of the following: Mood and interest Adjustment to illness Resources and strengths Uncontrolled multidimensional pain (total pain) Pre-existing mental illness  Domain 3: Psychological Well-being (cont’d) Suggested Prompts Mood and interest How is your mood During the last month have you: o Been feeling down and/or hopeless? o Lost enjoyment in interests? Are you depressed? Do you feel tense and anxious? Have you ever had a panic attack? Are there things you are looking forward to? Adjustment to illness What is your understanding of your illness? Resources and strengths What is source of support for you? Look for range of possible supports : people, hobbies, faith, beliefs Total pain Uncontrolled multidimensional pain e.g. psychosocial, spiritual pain; consider if distress contributing to physical symptoms Are there psychological, social, emotional, spiritual issues that may be contributing to symptoms? Pre existing mental Persons with a history of current or past mental health problems may be particularly at risk of illness psychological distress.  Domain 3: Psychological Well-being (cont’d) After identification of concerns Ascertain the effect of the problem on the patient’s normal activities/function. Consider treatment options/interventions. Action: Agree and implement a care plan with the patient and multidisciplinary team. Establish whether these needs can be managed by the current treating team. If significant complex family and social concerns are identified or anticipated, consider referral to the Specialist Palliative Care Service. Domain 4: Spiritual well-being People have many different understandings to the word spiritual and how it impacts on their lives. When completing spiritual assessment, assessors need to be aware of alternative terms i.e. faith, belief, philosophy, religion, inner strength. Domain 4: Spiritual well-being (cont’d) Approach: An introductory question/s to alert individuals to a change in focus from clinical is required e.g. How has this illness impacted on your life? The following is a suggested approach to assessment. Domain 4: Spiritual well-being (cont’d) Suggested Prompts Sourced of Hope What gives you hope (strength, comfort peace) in the time of illness Organized religion Are you part or member of religious or spiritual community? Does it help you Personal spirituality & practices What aspect of your spiritual beliefs do you find most helpful and meaningful personally? Effect on medical care and end of life How do you beliefs affect the kind of care you would like me to issues provide over the next few days/weeks/months ? Domain 4: Spiritual well-being (cont’d) After identification of concerns: Elicit history of concerns including previous supports/interventions received. Ascertain the effect of the problem on the patient’s normal activities/function. Consider treatment strategies/interventions.  Domain 4: Spiritual well-being (cont’d) Action Agree and implement a care plan with the patient and multidisciplinary team. This may include referral to pastoral care service. Establish whether these needs can be managed by the current treating team. If significant complex spiritual concerns are identified or anticipated, consider referral to specialist palliative care service. Establish whether these needs can be managed by the current treating team. If significant complex spiritual concerns are identified or anticipated, consider referral to specialist palliative care service. On completion of assessment Where specific needs or concerns are identified, establish whether these can be met by the current health and social care team or whether referral to additional services is required. Decide on the appropriate actions. If the outcome is to refer to the specialist palliative care service, this should be discussed with the patient and consent sought for referral and sharing of information.  The results obtained indicate that most subjects undergo mood aggravation. 76.2% of patients were diagnosed with depressive states. Only 19.6% of the population under investigation showed no signs of anxiety states. The study demonstrates irritation to be yet another unfavourable emotional state coupled with the advanced stage of cancerous disease with as few as 4.4% (4.2%) respondents claiming not to suffer any such symptoms. The patients highly prize the support they receive and it notably improved their well-being. Social support is essential in the advanced stage of the disease. Less severe mental disorders were noted in people who have received all kinds of support. Patients and caregivers reported maintaining a normal routine and turning to family and friends for support with symptom management, which often varied in its effectiveness. Whereas support from health-care professionals and complementary and alternative medicine were viewed favorably  We obtained complete data from 807 patients. Factors related to ‘self- management’ concerns were the most common (61.2%), followed by concerns about ‘psychological symptoms’ (48.5%), ‘medical information’ (46.2%), ‘daily living’ (29.9%), ‘pain’ (17.6%), ‘constipation’ (15.6%) and other ‘physical symptoms’ (15.2%). Multiple regression analysis revealed that all concerns except those about ‘medical information’ significantly contributed to quality of life. What are the problems? Barriers to good cancer pain control  Key barriers Patients and carers reluctant to complain about symptoms fear pain and don’t know how to get help lack knowledge about strong opioid analgesia fear adverse effects leading to poor adherence. Healthcare professionals fail to assess pain adequately reluctant to prescribe and monitor effective analgesia provide insufficient education to promote self-management Healthcare systems fail to recognise patients with cancer pain communicate data on pain ineffectively prevent patients receiving timely analgesia