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