Temsak Phungrassami, MD Division of Therapeutic Radiology, Faculty of. Prince of Songkla University

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1 Palliative Care Goals & Assessment Temsak Phungrassami, MD Division of Therapeutic Radiology, Faculty of Medicine Prince of Songkla University

2 Palliative Care Components 1. Pain and other symptoms relief 2. Psycho-socio-spiritual support 3. Involving the patient and family WHO: National Cancer Control Programmes: Policies and Managerial Guidelines 2nd ed. 2002

3 Structure Evaluation Pain/symptoms relief - availability: specialist, consultation, drugs, equipments, guidelines Process - number/type of service, intervention - drugs consumption Outcome - decrease in symptom severity - change in prescription

4 Severity e Assessment e VAS: Visual analog scale 0 10 VNS: Verbal numerical scale CS: Catagorical scale no mild moderate severe no yes

5 Evaluation Psycho-socio-spiritual support Structure - availability: specialist, consultation, drugs, equipments, guidelines, room/space Process - number/type of service, intervention Outcome - decrease in symptom severity - change in prescription - solved problem

6 Structure Evaluation Patient/family involvement - availability: specialist, consultation, equipments, guidelines, room/space Process - number of DNR, advance care plan discussion Outcome - DNR, DNR order - action according to advance care plan - death at preferred place

7 Overall Evaluation Structure - availability: committee, action plan, staff training, drugs, equipments, guidelines, room/space Process - number of patient, home visit, phone call, round/conference - patient t that t followed guidelines - patient accessibility to programme

8 Overall Evaluation Outcome - number of DNR, advance care plan, referral/death - patient quality of life - patient diagnosis/prognosis known - patient/family, referring physician/nurse satisfaction - unwanted readmission/cpr - ICU length of stay, out of ICU transfer - length of stay, before/after consultation - invasive/routine test, before/after consultation - total/pharmacy cost, before/after consultation

9 WHO Definition: Palliative Care 2002 An approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. WHO: www who int/cancer/palliative/definition/en/ WHO: [cited 2011]

10 EQ5D Quality of Life X X

11 Karnofsky Performance Scale scale KPS: Karnofsky performance scale 100 normal, no complaint, no evidence of disease 90 normal activity, minor symptom 80 normal activity with effort, some symptom 70 self care, unable to do active work 60 occas assist, able to care most of own need 50 considerable assist, frequent med care 40 disabled, special care and assist 30 severe disabled, hospital indicated 20 very sick, hospital necessary, active treatment 10 moribund, fatal progression rapidly

12 Palliative Performance Scale scale PPS: Palliative performance scale ambulation activity disease self care intake consciousness 100 full normal no full normal full 90 full normal some full normal full 80 full normal c effort some full normal/reduced full 70 reduced unable to do normal work/job some full normal/reduced full 60 reduced unable to do housework/hobby significant occasional assist normal/reduced full/confuse 50 mainly sit/lie unable to do any work extensive considerable assist normal/reduced full/confuse 40 mainly in bed unable to do any work extensive mainly assist normal/reduced full/confuse/drowsy 30 bed bound unable to do any work extensive total care reduced full/confuse/drowsy 20 bed bound unable to do any work extensive total care minimal sip full/confuse/drowsy 10 bed bound unable to do any work extensive total care mouth care drowsy/coma

13 KPS PPS EQ5D Pain /other symptom * * Anxiety/Depression * Ambulation * * Activity * * * Self care * * * Intake * Consciousness * Disease * *

14 Palliative at Care Phases Phases 1: Stable 2: Unstable 3: Deteriorating 4: Terminal 5: Bereaveded Patient - Symptoms are adequately controlled by established management. - Further interventions to maintain symptom control and QOL have been planned. Family - Relatively stable and no new issues are apparent. - Any needs are met by the established plan of care. The Australian National Sub-Acute and Non-Acute Patient Classification System: Version 1 The Australian National Sub-Acute and Non-Acute Patient Classification System

15 Palliative Care Phases Phases 1: Stable 2: Unstable 3: Deteriorating 4: Terminal 5: Bereaveded Patient - New unexpected problem or rapid increase in the severity of existing problems. - Urgent change in management or emergency treatment. Family - Sudden change in their situation. - Urgent intervention by members of the multidisciplinary team. The Australian National Sub-Acute and Non-Acute Patient Classification System: Version 1 The Australian National Sub-Acute and Non-Acute Patient Classification System

16 Palliative Care Phases Phases 1: Stable 2: Unstable 3: Deteriorating 4: Terminal 5: Bereaveded Patient - Gradual worsening of existing symptoms or the development of new but expected problems. - Specific plans of care and regular review but not urgent or emergency treatment. t t Family - Gradually worsening distress and other difficulties: social,,practical difficulties - Planned support program and counselling as necessary The Australian National Sub-Acute and Non-Acute Patient Classification System: Version 1 The Australian National Sub-Acute and Non-Acute Patient Classification System

17 Palliative Care Phases Phases 1: Stable 2: Unstable 3: Deteriorating 4: Terminal Patient 5: Bereaveded Family - Death is likely l in a matter of days profoundly weak, bed bound, drowsy, disoriented disinterested in food and drink, difficult to swallow medication. - No acute intervention. Frequent, usually daily, interventions aimed at social, emotional and spiritual issues. - Recognise that death is imminent. - Focus on emotional and spiritual issues as a prelude to bereavement. The Australian National Sub-Acute and Non-Acute Patient Classification System: Version 1 The Australian National Sub-Acute and Non-Acute Patient Classification System

18 Palliative Care Phases Phases 1: Stable 2: Unstable 3: Deteriorating 4: Terminal 5: Bereaveded Patient - Death. Family - Grieving. - Planned bereavement support program is available including referral for counselling as necessary. The Australian National Sub-Acute and Non-Acute Patient Classification System: Version 1 The Australian National Sub-Acute and Non-Acute Patient Classification System

19 Palliative Care Patients PSU2005 BED UNSTABLE % DETERIORATE % TERMINAL % TOTAL % WARD O S T O S T O S T O S T O S T O S T O S T O S T O S T ORTHO-M ORTHO-F GYNE-O GYNE-S OB-O OB-S PED PED PED-S % % % PICU NICU ICU ICU SX-M SX-M SX-F SX-NEURO MED-M1M MED-M MED-F RCU ENT EYE GEN-S GEN-S GEN-S ACCIDENT MED-S SXMED-S SX-S TOTAL

20 Palliative Palliative Care Phases Guidelines Palliative Care Phases 1: Stable A B C 2: Unstable 3: Deteriorating 4: Terminal 5: Bereaved A B C A B C A B C B C Palliative Care Components A. Pain and other symptoms relief The Australian National Sub-Acute and Non-Acute Patient Classification System: Version 1 B. Involving the patient and family C. Psycho-socio-spiritual support

Phone number: When and how did your pain begin? (a date is required for Medicare and some insurance policies) Date of onset:

Phone number: When and how did your pain begin? (a date is required for Medicare and some insurance policies) Date of onset: C H I R O P R A C T I C O R T H O P E D I C S A N D R E H A B I L I T A T I O N ILJXAi Pain Relief Clinics Please complete all sections. Full Name: Nickname: Gender: M F Age: Race: Date of Birth: I I Family