PELATIHAN PERAWATAN PALIATIF PADA STROKE - 16 maret 2020
1. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
dr. Ika Syamsul Huda MZ, MPH, SpPD
Ketua Tim Perawatan Paliatif
RSUP dr. Kariadi Semarang
PERAWATAN PALIATIF DAN
MASA AKHIR KEHIDUPAN
PADA PASIEN STROKE
2. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
Butterflies
are known as a symbol of transformation, hope, life,
and spirit.
https://www.facebook.com/NHPCO/posts/butterflies-are-known-as-a-symbol-of-
transformation-hope-life-and-spirit-hospice/10155750819413907/
3. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
http://www.who.int/cancer/palliative/definition/en/
WHO Definition of Palliative Care
Palliative care is 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.
4. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
• Kualitas hidup (QoL) didefinisikan sebagai persepsi
individu tentang posisi mereka dalam kehidupan dalam
konteks budaya dan sistem nilai di mana mereka hidup
dan dalam kaitannya dengan tujuan, harapan, standar,
dan kekhawatiran mereka.
• Ini adalah konsep luas yang dipengaruhi secara kompleks
oleh kesehatan fisik seseorang, keadaan psikologis,
tingkat kemandirian, hubungan sosial, dan hubungan
mereka dengan ciri-ciri menonjol dari lingkungan mereka.
(QoL)
5. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
http://www.who.int/en/news-room/fact-sheets/detail/palliative-
care
PALLIATIVE CARE IS REQUIRED
FOR A WIDE RANGE OF DISEASES
35.50% 34%
10.30%
5.70%
4.60%
9.90%
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TOTAL PAIN
Total pain recognises
pain as being
physical,
psychological, social
and spiritual.
Dame Mary Cicely Saunders
INTERDISCIPLINARY
TEAMWORK IN PALLIATIVE CARE
Dame Mary Cicely Saunders
(22 Juni 1918 - 14 Juli 2005)
Hospice care movement
7. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
dr. Balfour Mount
Born 14 April 1939
Urological surgeon
Father of Canada's
palliative care
movement
PALLIATIVE
Palliare (Bahasa Latin)
= to cloak, cover
jubah, mantel
10. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
What ISN’T Palliative Care
• Palliative Care IS NOT only for actively/imminently dying
patients
• Palliative Care IS NOT doing nothing
• Palliative is never futile
• Palliative Care DOES NOT start when curative treatment
stops; it is simultaneous along the continuum of care
• Palliative Care DOES NOT convince patients to stop
treatment
• Palliative Care DOES NOT take the place of care by the
patient’s personal physician
• Palliative Care IS NOT Hospice Care
11. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
ILLNESS TRAJECTORY
Department of Health, Western Australia. Palliative Care Model of Care.
Perth: WA Cancer & Palliative Care Network, Department of Health, Western
Australian; 2008.
LINTASAN SAKIT
12. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
https://csupalliativecare.org/wp-content/uploads/Five-Trajectories-eBook-02.21.2018.pdf
14. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
People are ‘approaching the end of life’
if they are likely to die within the next 12 months.
People “at the end of life”
people who are imminently dying and might be in the last few
hours or days of life.
https://www.dyingmatters.org/sites/default/files/user/10Questions.pdf
15. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
Bear in mind that even
doctors with long
experience tend to
over-estimate
prognosis.
16. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
MODEL PERAWATAN PALIATIF
http://www.jpalliativecare.com/articles/2010/16/3
/images/IndianJPalliatCare_2010_16_3_107_7363
9_f1.jpg
17. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
INTEGRASI PERAWATAN PALIATIF
PASIEN
TIM
PALIATIF
KELUARGA
DAN
PERUMAT(CAR
E GIVER)
MASYARAKAT
DAN
KOMUNITAS
MANAJEMEN
DAN
FASILITAS
DPJP
(CURATIVE
CARE)
KERJASAMA TIM
PALLIATIVE CARE
18. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
TIM PERAWATAN PALIATIF RUMAH SAKIT
• Dokter
• Perawat
• Fisioterapis
• Rohaniawan
• Pekerja sosial
• Farmasis
• …
Multidisipliner
Kolaborasi
Koordinatif
19. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
Seven principles of the Palliative Care Program:
1. People with a life-threatening illness and their carers and
families have information about options for their future care and
are actively involved in those decisions in the way that they wish
2. Carers of people with a life-threatening illness are supported by
health and community care providers
3. People with a life-threatening illness and their carers and
families have care that is underpinned by the palliative approach
Source:
Stroke care strategy for Victoria
https://www2.health.vic.gov.au/Api/downloadmedia/%7B012C7C05-3760-49A2-A19D-391DA710D5A7%7D
20. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
Seven principles of the Palliative Care Program:
4. People with a life-threatening illness and their carers and
families have access to specialist palliative care services when
required
5. People with a life-threatening illness and their carers and
families have treatment and care that is coordinated and
integrated across all settings
6. People with a life-threatening illness and their carers and
families have access to quality services and skilled staff to meet
their needs
7. People with a life-threatening illness and their carers and
families are supported by their communities.
Source:
Stroke care strategy for Victoria
https://www2.health.vic.gov.au/Api/downloadmedia/%7B012C7C05-3760-49A2-A19D-391DA710D5A7%7D
22. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
PROVIDING A PALLIATIVE APPROACH TO CARE
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Identify if the patient would benefit from
palliative care earlier in their illness trajectory
Three triggers that suggest that patients could benefit from a palliative care
approach:
1. The Surprise Question: ‘Would you be surprised if the
patient were to die in the next year?’
2. General indicators of decline: deterioration, advanced
disease, decreased response to treatment, choice for no further disease
modifying treatment.
3. Specific clinical indicators related to certain conditions.
24. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
Tool
https://www.spict.org.uk/
25. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
NATIONAL INSTITUTES OF HEALTH STROKE
SCALE (NIHSS)
26. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
ICD-10 Version:2019
https://icd.who.int/browse10/2019/en#/Z51.5
27. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
Contoh:
• Nontraumatic intracerebral
hemorrhage, unspecified
• Hemiplegia, unspecified
• Hypertension grade 2
• Sepsis due to Staphylococcus aureus
• Paliative Care
I61.9
Z51.5
I10
G81.9
A41.0
28. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
Assess the person’s current and future
needs and preferences across all domains of
care.
Screening Tools
• Palliative Performance Scale (PPSv2)
• Edmonton Symptom Assessment System (ESAS-r)
https://www.ontariopalliativecarenetwork.ca/en/node/31896
29. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
www.victoriahospice.org/sites/default/files/pps_english.pdf
30. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
PAIN
TIREDNESS
DROWSINESS
NAUSEA
LACK OF APPETITE
SHORTNESS OF BREATH
DEPRESSION
ANXIETY
WELLBEING
OTHER PROBLEM
31. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
1. Pain
2. Anorexia
3. Nausea and vomiting
4. Constipation
5. Diarrhoea
6. Dyspnea
7. Fatigue
8. Delirium
9. Depression
10. Anxiety
11. Respiratory tract secretions
11 SYMPTOMS
33. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
Goals of palliative care of stroke
• Manage stroke symptoms through medicines
and other treatments
• Counsel patient and his family on what to expect
from disease and treatment
• Support the patient for the best quality of life
• Improve of quality of life for both patient and his
family
34. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
INFORMATION
BREAKING BAD NEWS
FAMILY SUPPORT
ADVANCED CARE PLANNING
35. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
BREAKING BAD NEWS
• Persiapkan dan Rencanakan
• Cari Tahu Apa yang Pasien dan Keluarga Tahu dan
Ingin tahu
• Dukungan Emosi (Support Mental Pasien dan
Keluarga)
• Membuat Rekomendasi
• Resolusi konflik
36. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
Providing good psychosocial care
comes down to good
communication skills, both
verbal and non-verbal.
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DNR
DNI
Do-not-resuscitate
Do-not-intubate
38. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
All people admitted to hospital with Acute stroke should receive:
• Swallow screen
modification of diet or institution of NG feeding as
appropriate within 48 hours
• Hydration Status: Maintain euvolemia.
• Assessment of continence
• Evaluation of pressure risk
• Early mobilisation where appropriate
• Occupational therapy and seating assessment
• Multidisciplinary assessment and discussion
• Assessment of mood
• Information meeting with relatives and patient
Source:
https://www.hse.ie/eng/services/publications/clinical-strategy-and-programmes/stroke-unit-management-care-
bundle.pdf
39. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
https://www.nwcscnsenate.nhs.uk/files/4914/0742/3855/Spirituality_Guidel
ines_-June_2014_FINAL.pdf
Every patient record should
demonstrate a record of the patient’s
faith tradition (religious affiliation or
belief system) or its absence.
SPIRITUAL CARE
40. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
MENAHAN DAN MENGHENTIKAN TERAPI MEDIK
(TO WITHHOLD AND WITHDRAW = CURING VERSUS
CARING)
Sesuai prinsip perawatan paliatif, tujuan terapi
pada pasien stadium terminal adalah untuk
mencapai kondisi nyaman dan meninggal secara
bermartabat.
Sehingga terapi yang diberikan bertujuan untuk
memperpanjang proses kematian harus
dihentikan dan terapi yang tidak sesuai dengan
tujuan di atas tidak mungkin diberikan.
41. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
Anticipatory Medicines
‘Just in Case’ medicines
• Pain
• Shortness of breath
• Sickness/Nausea
• Secretions in the throat
• Restlessness/agitation
44. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
WITHHOLD & WITHDRAW
Tidak memberikan dan Menghentikan
Obat-obatan, Tindakan dan Pemeriksaan
mungkin perlu dipertimbangan untuk tidak
diberikan, dan yang sudah diberikan tidak
diberikan lagi.
46. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
When Death Nears:
• Sleeping
• Loss of Interest in Food and Fluids
• Coolness
• Changes in Skin Color
• Rattling Sounds in the Lungs and Throat
• Bladder and Bowel Changes
• Disorientation and Restlessness
• Surge of Energy
• Breathing Pattern Changes
47. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
MOTTLED SKIN
Mottled skin occurs before
death and is a strong indicator
that death is imminent.
49. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
Palliative sedation
In medicine, specifically in end-of-life care, palliative sedation (also
known as terminal sedation, continuous deep sedation, or
sedation for intractable distress in the dying/of a dying
patient) is the palliative practice of relieving distress in a
terminally ill person in the last hours or days of a dying patient's
life,
From Wikipedia
51. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
Here are indications
that death has occurred:
• No breathing for a prolonged period of time
• No heartbeat
• Eyes are fixed and slightly open, with
enlarged pupils
• Jaw relaxed, with the mouth slightly open
52. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
KHUSNUL KHATIMAH
Principles of a good death
1. · To know when death is coming, and to understand what can be expected
2. · To be able to retain control of what happens
3. · To be afforded dignity and privacy
4. · To have control over pain relief and other symptom control
5. · To have choice and control over where death occurs (at home or
elsewhere)
6. · To have access to information and expertise of whatever kind is necessary
7. · To have access to any spiritual or emotional support required
8. · To have access to hospice care in any location, not only in hospital
9. · To have control over who is present and who shares the end
10. · To be able to issue advance directives which ensure wishes are respected
11. · To have time to say goodbye, and control over other aspects of timing
12. · To be able to leave when it is time to go, and not to have life prolonged
pointlessly
53. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
Rumah sakit menetapkan proses untuk mengelola
ASUHAN PASIEN DALAM TAHAP TERMINAL.
Proses ini meliputi
a) intervensi pelayanan pasien untuk mengatasi nyeri;
b) memberikan pengobatan sesuai dengan gejala dan
mempertimbangkan keinginan pasien dan keluarga;
c) menyampaikan secara hati-hati soal sensitif seperti autopsi
atau donasi organ;
d) menghormati nilai, agama, serta budaya pasien dan keluarga;
e) mengajak pasien dan keluarga dalam semua aspek asuhan;
f) memperhatikan keprihatinan psikologis, emosional, spiritual,
serta budaya pasien dan keluarga.
http://www.pdpersi.co.id/kanalpersi/manajemen_mutu/data/snars_edisi1.pdf
STANDAR NASIONAL AKREDITASI RUMAH SAKIT
(Edisi 1)
54. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
TAMAN PALIATIF
RSUP DR KARIADI SEMARANG, 2019
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Nama:
Prof. Raden Sunaryadi Tejawinata,
dr. SpTHT(K-Onk), FICS, FAAO, PGD,
Pall.Med.(ECU)
Lahir:
Cirebon, 23 Agustus 1934
Prof. Sunaryadi
BAPAK PALIATIF INDONESIA
56. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
DEKLARASI PERDOPIN
(Perhimpunan Dokter Paliatif Indonesia)
Surabaya, 22 Februari 2014
57. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
APHC 2019 - 13th Asia Pacific Hospice
Conference
Aug 01 - 04, 2019, Surabaya
58. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
BIMTEK PELAYANAN PERAWATAN PALIATIF DAN AKHIR KEHIDUPAN
RSUD TUGUREJO, SEMARANG. (13 FEBRUARI 2020)
59. Pelatihan Perawatan Paliatif dan Masa Akhir Kehidupan pada Pasien Stroke , 16 Maret 2020
RESOURCES TO SUPPORT YOUR CONTINUED LEARNING
ABOUT PALLIATIVE CARE AND END OF LIFE CARE
https://acclaimhealth.ca/programs/palliative-care-consultation/palliative-care-
resources
https://www.palliativecareguidelines.scot.nhs.uk/guidelines.aspx
https://www.ontariopalliativecarenetwork.ca/en/node/31896
http://www.mhpcn.net/palliative-care-toolbox
https://library.nshealth.ca/PalliativeCare
https://palliativecareindonesia.blogspot.com
SUGGESTED READING
Perawatan paliatif adalah sebuah pendekatan yang meningkatkan kualitas hidup pasien dan keluarga mereka menghadapi masalah yang terkait dengan penyakit yang mengancam jiwa, melalui pencegahan dan penghentian penderitaan dengan identifikasi dini dan penilaian dan perawatan yang sempurna dari rasa sakit dan masalah lainnya, fisik. , psikososial dan spiritual.
