Sunday, April 15, 2018

Palliative Care Guideline



These guidelines were adapted from:

ACS TQIP Palliative Care Best Practices Guideline

Palliative Care Guidelines
·       Delivered in parallel with life-sustaining trauma care throughout the hospital course
·       Provided by the trauma team, even if palliative care consultation team is not available
·       Requires interdisciplinary team of physicians, nurses, psychosocial and rehabilitation providers, and palliative care team
o   Basic competencies in primary palliative care are required by all members

Interdisciplinary Palliative Care Team
·       Work as a team across all fields
·       Trauma leader will be responsible for building commitment in the program, ensuring precepts are carried out, and fully participating in the process
·       Provide ongoing education for all staff in palliative care communication skills
·       Shared decision-making between patients and providers
·       Palliative care team may provide consultation for
o   Advice and recommendations to a trauma service without direct patient contact
o   Brief, targeted interventions with a patient or family
o   Multiple visits for complex care of patients and their families

Essential Components of Palliative Care
·       Effectively communicate prognosis and treatment options to patient and family
·       Provide support and show understanding during the shared decision-making process
·       Routinely provide psychosocial, emotional, and spiritual care over the course of the hospitalization
o   Include pastoral care and social work
·       Provide early treatment of pain, discomfort and anxiety and continuously assess these symptoms
·       The patient and family should be at the center of care

Breaking Bad News
·       Show empathy
·       Consider “Ask-Tell-Ask” model – Ask the individual what he/she knows, tell the bad news with straightforward language, and ask if the information was understood
·       Huddle with team before the meeting and confirm all information. Get all updated clinical information before proceeding
·       Start with a warning (“I’m afraid I have some bad news…”), give a brief context sentence and deliver the news of death (use the word death or dying), allow for silence, and prepare family for what they will see

Palliative Care Assessment
·       Identify pre-existing advanced directives early (in the trauma bay or within 24 hours of admission)
·       Initiate the assessment on admission and complete within 24 hours
·       Hold a structural family meeting as soon as possible, but definitely within 72 hours of admission, and every 3-5 days thereafter
·       Provide patient and family prognosis which includes the risk of death and the expected functional and cognitive recovery

Goals of Care Conversation
·       Hold conversation as soon as possible and within 72 hours of admission
·       Ensure all therapy during hospitalization is concordant with the patient’s preferences and ultimate goals
·       Document discussion with great detail
·       Time-limited trials can be considered when seriously ill patients, their surrogates, or providers face difficult decisions about initiating major new interventions or continuing life-sustaining treatments in the face of poor or uncertain prognosis

End-of-Life Care
·       DNR or DNI orders do not preclude treatment or the delivery of care with curative intent
o   Document reconsideration of DNR/DNI orders around the time of surgery
·       Withdrawal of life support does not imply withdrawal of “care”
o   Focus shifts to eliminate patient pain, anxiety, and suffering
o   Remove all unnecessary equipment, monitors, and restraints
o   Silence all alarms
o   Create peaceful environment for patient and family
o   Inform family about the dying process
o   Allow time for rituals

Special Considerations for Geriatric Patients
·       Complete a frailty screen on admission for all patients 65 years or older
·       Presence of frailty should trigger palliative care processes, including identification of advance directive and GOC conversation

Special Considerations for Pediatric Patients
·       Decision-making for older children and adolescents needs to include patient assent
·       Age of consent in Kentucky is 18 years of age
·       Bereavement care for the family poses challenges and should involve the pediatric palliative care team

Special Considerations for Spinal Cord Injury
·       Provide patient and family data supporting prognosis and maximal functional outcomes after spinal cord injury, specific to the level or injury, to guide discussions related to advance care planning
·       Provide patients with high spinal cord injury, who wish to pursue WOLST, access to mental health specialists and rehabilitation specialists with expertise in spinal cord injury. Involve the specialists in the conversation to better inform decision making
·        
Special Considerations for Traumatic Brain Injury
·       GCS is an accurate predictor of death from TBI, but is less useful in predicting functional cognitive outcome in survivors
·       Focus conversation on potential cognitive and functional outcomes to determine their compatibility with the patient’s goals of care and/or advance directives

Supporting the Health Care Team
·       Palliative care team can provide support to health care providers
·       Stress management training and education is available
·       Debrief with staff

Clinical Documentation
·       Identification and contact information of family or surrogates
·       Status of advanced directives, POLST, and DNR/DNI status if known at time of admission
·       Any cultural or religious preferences
·       Identification of patient’s other health care providers who may be an invaluable source of health status
·       Prognostication/frailty assessment
·       What, if any, emotional and informational support was provided for the family and patient
·       Any goals of care or focused decision-making discussions

Published 4/15/18 (A Bernard/S Priest/Cecil Peppiat); Reviewed 9/26/24 (A Bernard)