Download Timely Specialist Palliative Care Input

Palliative Care: Phase of Illness
Learning Package
LEARNING OUTCOMES
At the conclusion of this package, participants will be able to:
1. understand the definitions and indicators for each phase of the
illness
2. identify the phase of care for a particular patient situation
3. use the phase of care to identify likely factors influencing clinical
management
4. use the phase of care to identify likely factors influencing discussions
with carers and family
Phase of Illness: Learning Package
PALLIATIVE CARE PHASE OF ILLNESS
Taken from the Palliative Care Outcome Collaborative
(internet access required - PCOC website)
Phase 1: Stable
Phase 2: Unstable
Phase 3: Deteriorating
Phase 4: Terminal
Phase 5: Bereavement
Phase of Illness: Learning Package
Phase 1.
Stable
Consider one of the points opposite,
then click on the question mark beside
that point to see clinical examples of
this phase.
When you have completed all of the
points, click the “Next” button below.
• All patients not classified as
unstable, deteriorating, or
terminal.
• The patient symptoms are
adequately controlled by
established management.
Further interventions to
maintain symptom control
and quality of life have
been planned.
• The situation of the
family/carers is relatively
stable and no new issues
are apparent. Any needs are
met by the established plan
of care.
Phase of Illness: Learning Package
Not unstable, deteriorating or terminal
This may sound self explanatory, but it may be useful to identify
what phase this isn’t, to confirm that the patient is, in fact,
stable.
Example
Patient with COPD on continuous O2, and requiring assistance with
personal ADLs
*No recent exacerbation of shortness of breath;
*No change in functional status (able to mobilize with walking frame
and portable O2);
*Respiratory function tests completed 6 monthly and no significant
change over last 2 years.
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Phase of Illness: Learning Package
Symptoms controlled and further interventions planned
There have been symptoms develop but are now well controlled.
Discussions have occurred regarding treatment options, and the
patient is aware of how to manage their current situation.
Example
Patient with COPD on continuous O2, and requiring assistance with
personal ADLs
*Self Management Plan has been documented and patient has a
copy;
*Is managed on preventer inhaler and has reliever if needed;
*Has indications for adjusting dose of corticosteroid and script for
antibiotics to commence if indicated (triggers documented on plan).
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Phase of Illness: Learning Package
Family / Carer situation stable
• Support for the carer has been planned and now in place. There
may be one or more types assistance and support from services.
Example
Patient with COPD on continuous O2, and requiring assistance with
personal ADLs
*Son is the main carer, and visits every weekday evening after work
to monitor and run errands as required. Daughter visits weekends,
does shopping and prepares meals for the following week;
*There has been contact and initial discussion with Carer Support
Services, and the son has their 24 hour contact details;
*Personal care workers attend weekdays, assisting with dressing and
breakfast Mon-Fri, and with showering twice/week. Weekends
patient stays in night attire and gown.
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Phase of Illness: Learning Package
Phase 2.
Unstable
Consider one of the points opposite,
then click on the question mark beside
that point to see clinical examples of
this phase.
When you have completed all of the
points, click the “Next” button below.
• The patient experiences the
development of a new
unexpected problem or a
rapid increase in the
severity of existing
problems
• The family/carers
experience a sudden
change in their situation
requiring urgent
intervention by members of
the multidisciplinary team.
Phase of Illness: Learning Package
New unexpected problem or rapid increase in severity of
existing problem
Either requires an urgent change in management or emergency
treatment
Example
Patient with breast cancer and multiple bone metastases on ribs
now presents with severe chest wall pain after a recent chest
infection
*History of severe coughing episode just prior to onset of pain
*Pain worsened on deep breathing or palpation of rib
*Immediate adjustment of Analgesia and referral to radiotherapy
for review
.
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Phase of Illness: Learning Package
Sudden change in family/carer situation
Either requires an urgent change in management or emergency
treatment
Example
Patient with breast cancer and multiple bone metastases on ribs
now presents with severe chest wall pain after a recent chest
infection
*patient has been managing personal ADLs independently until
onset of pain – now need assistance showering and dressing
*Husband is Carer and is managing housework and cooking, can
organize clothing, but not able to assist with showering
*Nurses arranged to visit to assist showering three times / week,
personal carers other days to assist with dressing
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Phase of Illness: Learning Package
Phase 3.
Deteriorating
Consider one of the points opposite,
then click on the question mark beside
that point to see clinical examples of
this phase.
When you have completed all of the
points, click the “Next” button below.
• The patient experiences
gradual worsening of
existing symptoms or
development of new but
expected problems.
• The family/carers
experience gradually
worsening distress and
other difficulties, including
social and practical
difficulties, as a result of the
illness of the person.
Phase of Illness: Learning Package
Gradual worsening of symptoms or new symptoms
These require the application of specific plans of care and regular
review but not urgent or emergency treatment
Example
Patient with lung cancer, on low dose sustained release analgesia
and prn breakthrough dose. Previously only short of breath on
heavy exertion.
*Still mobilizing with walking stick around house, but increasingly
unsteady – Arrangement for walking frame to have on hand;
*Increase in shortness of breath when lying down – electric bed to
be delivered (semi-recumbent for sleeping);
*Dietary intake has decreased and weight loss of 5kg over last
month – dietary supplements to be trialed.
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Phase of Illness: Learning Package
Gradually worsening family/carer distress, including
social and practical difficulties
This requires a planned support program and counselling as
necessary.
Example
Patient with lung cancer, on low dose sustained release analgesia
and prn breakthrough dose. Previously only short of breath on
heavy exertion.
*No family local, neighbour drops in regularly and notices that
patient is not getting dressed and going shopping;
*Neighbour is concerned about weight loss and calls the patient’s
daughter, who contacts the GP;
*Discussed with patient to consider prepared meals or shopping
assistance.
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Phase of Illness: Learning Package
Phase 4.
Terminal
Consider one of the points opposite,
then click on the question mark beside
that point to see clinical examples of
this phase.
• Death is likely in a matter of
days and no acute
intervention is planned or
required.
• The family/carers recognise
that death is imminent
When you have completed all of the
points, click the “Next” button below.
Phase of Illness: Learning Package
Death likely within days – no acute interventions
These require the use of frequent, usually daily interventions aimed
at physical, emotional and spiritual issues. Typically the person may
be: profoundly weak; bed bound; drowsy for extended periods; disoriented;
limited attention span; disinterested in food and drink; increasing difficult
to swallow medication
Example
Patient with lung cancer, on sustained release analgesia and prn
breakthrough dose. Previously only short of breath on heavy exertion.
Not taking diet, minimal fluids, complete bed rest.
*Extreme dyspnoea, and only occasionally responding to verbal stimuli
*Request from the patient for ‘comfort’ measures - no intubation
*S/C Opioid for analgesia and dyspnoea, benzodiazepine for distress
*Oral medications ceased
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Phase of Illness: Learning Package
Family / carers recognise death is imminent
Care is focussed on emotional and spiritual issues as a prelude to
bereavement
Example
Patient with lung cancer, on sustained release analgesia and prn
breakthrough dose. Previously only short of breath on heavy
exertion. Not taking diet, minimal fluids, complete bed rest.
*Discussion with family / carer to determine need for priest / pastor
*Discussion with family / carer to notify other family of impending
death, visits as necessary
*Confirmation of planning for funeral arrangements
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Phase of Illness: Learning Package
Phase 5.
Bereavement
Consider one of the points opposite,
then click on the question mark beside
that point to see clinical examples of
this phase.
• Death of the patient has
occurred and the carers are
grieving.
• Bereavement support
program is available
When you have completed all of the
points, click the “Next” button below.
Phase of Illness: Learning Package
Immediate After Death Care
This care may include care of the deceased patient, and carer and
immediate family. There may be different needs if the patient has
died at home, or in hospital / care.
Example
Patient has died at home and the family are asking you what to do next.
* Does the doctor need to visit before the Undertaker arrives?
* Who else do I need to notify?
Patient has died in the hospital/RACF and family have come to collect
the patient’s belongings
* Talking about the funeral service / arrangements
* Their plans of what they have to do now
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Phase of Illness: Learning Package
Bereavement Support
There may be different needs for different family members and
carers.
Partner has been reliant on the decease person for shopping and bill
paying. Discussion may include:
*how the person will manage these tasks now
*possible referral to community services to assist with these tasks
Sibling is displaying reactions of guilt about having lost touch for many
years prior to the death. Discussion may include:
*how they assisted the dying person in their last weeks of life
*what they need to be able to reconcile their feelings of guilt
* possible referral to a bereavement counselor
Click here to return to previous slide
Phase of Illness: Learning Package
Congratulations!
You have now completed the “Phase of Illness” training package.
You should now be better equipped to:
1.
understand the definitions and indicators for each phase of the illness
2.
identify the phase of care for a particular patient situation
3.
use the phase of care to identify likely factors influencing clinical management
4.
use the phase of care to identify likely factors influencing discussions with carers
and family
For more information, contact your local Specialist Palliative Care Service,
or the Loddon Mallee Regional Palliative Care Consortium.
Remember to add this to your Continuing Professional Development record.
Recommended time is 1 hour of learning.