Paliative Care and Pahrmacist


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  • The cause of cervical cancer is a sexually transmitted virus, called the human papillomavirus. There are many HPV types and only some cause cancer. HPV infections (even high-risk types) usually go away without treatment. Low-risk HPV types can cause genital warts. It is the high-risk types cause most abnormal pap tests, precancer and cancer of the cervix, vagina and vulva.
  • The longer you wait to have sex, the fewer partners you are likely to have, thus reducing your risk for cervical cancer. Your partner’s partners also can increase your risk. If you already smoke, talk to your health care provider about programs to help you stop. Good nutrition helps strengthen your immune system and allows the body to dilute the effects of cancer-causing agents. Some research suggests that adequate folic acid, found in foods such as uncooked spinach, romaine lettuce, rice, lentils and, believe or not, Cap’n Crunch, can reduce your risk of cervical cancer. Condoms do decrease the spread of HPV as well as other sexually transmitted diseases, so use them. Most importantly, if Pap tests are performed regularly, you will be identified as having a problem before it is life threatening, in most cases. Now, a new vaccine can additionally help protect you from developing cervical cancer. If your healthcare provider recommends it, get the cervical cancer vaccine. [Mark--why not say if you are between 9-26, get vaccinated. We have not applied the healthcare provider caveat elsewhere.}
  • Usually women with cervical cancer have no symptoms, particularly if the cancer is small. The common symptoms of cervical cancer are: Bleeding between periods Bleeding or spotting after sexual intercourse Bleeding or spotting in women who have already gone through menopause Unusual, continuous, foul-smelling vaginal discharge In women with more advanced cervical cancer additional symptoms may occur, such as: Progressive and ultimately constant pelvic pain One-sided leg pain caused by nerve involvement A pelvic mass Bleeding from the bladder or rectum. It is not unusual for a woman with cervical cancer to have no symptoms.
  • Most women are at risk since sex is a normal adult activity. The more partners a woman has the greater her chances of being infected with HPV. Studies show that even women who report one lifetime sexual partner have about a 10% chance of having HPV infection. We really don’t know everything about how this virus is transmitted. [Mark, we say that it is sexually transmitted, so this seems a contradiction.]
  • Paliative Care and Pahrmacist

    1. 1. Instalasi Farmasi RSU Dr Soetomo
    2. 2. <ul><li>Kasus penyakit yang belum dapat disem buhkan semakin meningkat jumlahnya baik pada pasien dewasa maupun anak; Penyakit2 tsb : </li></ul><ul><li>kanker, penyakit degeneratif, penyakit paru obstruktif kronis, cystic fibrosis, stroke, Parkinson, gagal jantung/heart failure, penyakit genetika dan </li></ul><ul><li>penyakit infeksi seperti HIV/AIDS </li></ul><ul><li>yang memerlukan perawatan paliatif, </li></ul>
    3. 3. <ul><li>Meningkatkan kualitas pelayanan kesehatan kuratif dan rehabilitatif juga diperlukan perawatan Paliatif bagi pasien dengan stadium terminal; </li></ul>
    4. 4. <ul><li>Masyarakat menganggap perawatan paliatif hanya untuk pasien dalam kondisi terminal yang akan segera meninggal. </li></ul><ul><li>Namun konsep baru perawatan paliatif menekankan pentingnya integrasi perawatan paliatif lebih dini agar masalah fisik, psikososial dan spiritual dapat diatasi dengan baik </li></ul>
    5. 5. <ul><li>Rumah sakit memberikan perawatan paliatif masih terbatas terdapat di 5 (lima) ibu kota propinsi yaitu Jakarta, Yogyakarta, Surabaya, Denpasar dan Makassar. </li></ul><ul><li>Ditinjau dari besarnya kebutuhan dari pasien, jumlah dokter yang mampu memberikan pelayanan perawatan paliatif juga masih terbatas. </li></ul>
    6. 6. <ul><li>Dengan pertimbangan tsb diatas perlu Kebijakan Perawatan Paliatif. </li></ul><ul><li>Adanya KepMenkes RI NOMOR : 812 / Menkes/ SK/ VII / 2007, tentang Perawatan Paliatif </li></ul>
    7. 7. <ul><li>Perawatan paliatif yang bermutu dapat dilaksanakan di RSDS </li></ul><ul><li>Dapat di susun pedoman-pedoman pelaksanaan /juklak perawatan paliatif. </li></ul><ul><li>Tersedianya tenaga medis , farmasi dan non medis yang terlatih. </li></ul><ul><li>Tersedianya sarana dan prasarana yang diperlukan. </li></ul>
    8. 8. <ul><li>Perawatan paliatif adalah pendekatan yang bertujuan memperbaiki kualitas hidup pasien dan Keluarga yang menghadapi masalah yang berhubungan dengan penyakit yang dapat mengancam jiwa, melalui pencegahan dan peniadaan melalui identifikasi dini dan penilaian yang tertib serta penanganan nyeri dan masalah-masalah lain, fisik, psikososial dan spiritual </li></ul><ul><li>(sumber referensi WHO, 2002). </li></ul>
    9. 9. <ul><li>Palliative care is care which aims to ameliorate the effects of progressive, advanced disease , or terminal illness and improve the quality of life of the patient, his or her partner, family and friends. </li></ul><ul><li>Palliative care is generally provided to people of all ages whose condition has progressed beyond the stage where curative treatment is effective and cure is attainable , or to those who choose not to pursue curative treatment. </li></ul>
    10. 10. <ul><li>Kualitas hidup pasien </li></ul><ul><li>adalah keadaan pasien yang dipersepsikan terhadap keadaan pasien sesuai konteks budaya dan sistem nilai yang dianutnya, termasuk tujuan hidup, harapan, dan niatnya. </li></ul>
    11. 11. <ul><li>Dimensi kualitas hidup (Jennifer J. Clinch, Deborah Dudgeeon dan Harvey Schipper)/(1999), : </li></ul><ul><li>a. Gejala fisik </li></ul><ul><li>b. Kemampuan fungsional (aktivitas) </li></ul><ul><li>c. Kesejahteraan keluarga </li></ul><ul><li>d. Spiritual </li></ul><ul><li>e. Fungsi sosial </li></ul>
    12. 12. <ul><li>f. Kepuasan terhadap pengobatan (termasuk masalah keuangan) </li></ul><ul><li>g. Orientasi masa depan </li></ul><ul><li>h. Kehidupan seksual, termasuk gambaran terhadap diri sendiri </li></ul><ul><li>i. Fungsi dalam bekerja </li></ul>
    13. 13. <ul><li>Palliative home care </li></ul><ul><li>adalah pelayanan perawatan paliatif yang dilakukan di rumah pasien, oleh tenaga paliatif dan atau keluarga atas bimbingan/ pengawasan tenaga paliatif. </li></ul>
    14. 14. <ul><li>Prevention and relief of symptoms </li></ul><ul><li>Attention to emotional and spiritual needs </li></ul><ul><li>Care for the patient and family as a unit </li></ul><ul><li>Sensitive communication, goal setting and advance planning </li></ul><ul><li>Interdisciplinary care </li></ul><ul><li>Services appropriate to the various settings in which people die </li></ul>
    15. 15. <ul><li>When you are facing a serious illness, you need relief. </li></ul><ul><li>Relief from pain. </li></ul><ul><li>Relief from other symptoms, such as fatigue, nausea, loss of appetite and shortness of breath. </li></ul><ul><li>Relief from stress. </li></ul>
    16. 16. <ul><li>Be Pharmacists better to understand the patient’s condition and choices for care. </li></ul><ul><li>Pharmacists need to improve the ability to tolerate medical treatments. </li></ul><ul><li>And, Pharmacists need to be able to carry on with everyday the patient’s life. </li></ul>
    17. 17. <ul><li>A program designed to provide palliative care when life expectancy is six months or less </li></ul><ul><li>Covered by Medicare and Medicaid </li></ul><ul><li>Covered by private insurance plans with enhanced home care benefits </li></ul><ul><li>The term hospice applies to care administered towards the end of life, hospice care is also palliative </li></ul>
    18. 18. <ul><li>1. Jenis kegiatan perawatan paliatif meliputi : </li></ul><ul><li>􀂃 Penatalaksanaan nyeri (Relief pain) </li></ul><ul><li>􀂃 Penatalaksanaan keluhan fisik lain. </li></ul><ul><li>􀂃 Asuhan keperawatan </li></ul><ul><li>􀂃 Dukungan psikologis </li></ul><ul><li>􀂃 Dukungan sosial. </li></ul>
    19. 19. <ul><li>Opioid Safety in Patients With Renal or Hepatic Dysfunction </li></ul>
    20. 20. <ul><li>..PALIATIVE CARE DES 2010Opioids-Renal-Hepatic-Dysfunction.pdf </li></ul><ul><li>..PALIATIVE CARE DES 2010who-living-with-hivaids.pdf </li></ul>
    21. 21. <ul><li>(..........Lanjutan): </li></ul><ul><li>􀂃 Dukungan kultural dan spiritual </li></ul><ul><li>􀂃 Dukungan persiapan dan selama masa dukacita ( bereavement). </li></ul><ul><li>2. Perawatan paliatif dilakukan melalui rawat inap, rawat jalan, dan kunjungan/rawat rumah. </li></ul>
    22. 22. <ul><li>Terapi Paliatif </li></ul><ul><li> Operative </li></ul><ul><li> Radiotherapy </li></ul><ul><li> Chemotherapy </li></ul><ul><li> Physiotherapy </li></ul><ul><li> Psychotherapy </li></ul><ul><li> Complimentary </li></ul><ul><li>Terapi Paliatif </li></ul><ul><li> Operative </li></ul><ul><li> Radiotherapy </li></ul><ul><li> Chemotherapy </li></ul><ul><li> Physiotherapy </li></ul><ul><li> Psychotherapy </li></ul><ul><li> Complimentary </li></ul>
    23. 24. <ul><li>Pelayanan Obat pasien Paliatif dengan Tindakan : </li></ul><ul><li> Operative (GBPT) </li></ul><ul><li> Radiotherapy (GDC) </li></ul><ul><li> Chemotherapy (POSA, OBGYN, BEDAH, ANAK, MEDIK) </li></ul><ul><li> Physiotherapy (Rehab Medik) </li></ul><ul><li> Psychotherapy (Syaraf) </li></ul><ul><li> Complimentary (POTI) </li></ul>
    24. 25. <ul><li>Protap Pengkajian Resep ISO2010.doc </li></ul>
    25. 26. <ul><li>Nama pasien Mrs. X (39 tahun) </li></ul><ul><li>Dx : Ca Cervix stad III B </li></ul><ul><li>Terapi symptom : Relief Nyeri </li></ul><ul><li>R/Codifam </li></ul><ul><li>Codein </li></ul><ul><li>Amitrip </li></ul>
    26. 27. <ul><li>Lower part of the uterus </li></ul><ul><li>Connects the body of the uterus to the vagina (birth canal) </li></ul><ul><li>Source: American Cancer Society </li></ul>
    27. 28. <ul><li>The central cause of cervical cancer is human papillomavirus or HPV: </li></ul><ul><ul><li>HPV is transmitted through sexual contact </li></ul></ul><ul><ul><li>The HPV detected today could have been acquired years ago </li></ul></ul><ul><ul><li>There are many different types of HPV that can infect the cervix, vagina and vulva </li></ul></ul><ul><ul><ul><li>‘ Low-risk’ types may cause genital warts </li></ul></ul></ul><ul><ul><ul><li>‘ High-risk’ types may cause precancer and cancer of the cervix </li></ul></ul></ul><ul><ul><li>Most women who are infected with HPV will never have any symptoms </li></ul></ul>
    28. 29. <ul><li>Delay onset of sexual activity or remain abstinent </li></ul><ul><li>Know your sexual partner </li></ul><ul><li>Do not smoke </li></ul><ul><li>Maintain a healthy diet and lifestyle </li></ul><ul><li>Practice safe sex. Condoms decrease the chance of HPV exposure. </li></ul><ul><li>If eligible, consider getting the vaccine that prevents most cervical cancers. </li></ul><ul><li>Get your Pap test and HPV testing as recommended by your health care provider. </li></ul>
    29. 30. <ul><li>Abnormal bleeding </li></ul><ul><ul><li>Between periods </li></ul></ul><ul><ul><li>With intercourse </li></ul></ul><ul><ul><li>After menopause </li></ul></ul><ul><li>Unusual vaginal discharge </li></ul><ul><li>Other symptoms </li></ul><ul><ul><li>Leg pain </li></ul></ul><ul><ul><li>Pelvic pain </li></ul></ul><ul><ul><li>Bleeding from the rectum or bladder </li></ul></ul><ul><li>Some women have no symptoms </li></ul>
    30. 31. <ul><li>Women who have ever had sex </li></ul><ul><li>Women who have had more than one partner </li></ul><ul><li>Women whose partner (s) has had more than one sexual partner </li></ul><ul><li>Women who have had a sexually-transmitted disease </li></ul>
    31. 32. <ul><li>Vaginal bleeding </li></ul><ul><li>Menstrual bleeding is longer and heavier than usual </li></ul><ul><li>Bleeding after menopause or increased vaginal discharge </li></ul><ul><li>Bleeding following intercourse or pelvic exam </li></ul><ul><li>Pain during intercourse </li></ul><ul><li>Source: American Cancer Society </li></ul>
    32. 33. <ul><li>Human papillomavirus infection (HPV) – Primary factor </li></ul><ul><ul><li>HPV 16, HPV 18, HPV 31, HPV 33, HPV 45 </li></ul></ul><ul><ul><li>50% are caused by HPV 16 AND 18 </li></ul></ul><ul><li>Sexual behavior </li></ul><ul><li>Smoking </li></ul><ul><li>HIV infection </li></ul><ul><li>Chlamydia infection </li></ul><ul><li>Diet </li></ul><ul><li>Oral contraceptives </li></ul><ul><li>Multiple pregnancies </li></ul><ul><li>Low socioeconomic status </li></ul><ul><li>Diethylstilbestrol (DES) </li></ul><ul><li>Family history </li></ul><ul><li>Source: American Cancer Society </li></ul>
    33. 34. <ul><li>Surgery </li></ul><ul><ul><li>Preinvasive cervical cancer </li></ul></ul><ul><ul><ul><li>Cryosurgery </li></ul></ul></ul><ul><ul><ul><li>Laser surgery </li></ul></ul></ul><ul><ul><ul><li>Conization </li></ul></ul></ul><ul><ul><li>Invasive cervical cancer </li></ul></ul><ul><ul><ul><li>Simple hysterectomy </li></ul></ul></ul><ul><ul><ul><ul><li>Removal of the body of the uterus and cervix. </li></ul></ul></ul></ul><ul><ul><ul><li>Radical hysterectomy and pelvic lymph node dissection </li></ul></ul></ul><ul><ul><ul><ul><li>Removal of entire uterus, surrounding tissue, upper part of the vagina, and lymph nodes from the cervix. </li></ul></ul></ul></ul><ul><li>Radiation </li></ul><ul><li>Chemotherapy </li></ul><ul><li>Paliative Care </li></ul><ul><li>Source: American Cancer Society </li></ul>
    34. 35. Skin Liver Bone Pleura Lung Lymph nodes Brain
    35. 36. <ul><li>Hormone receptor status </li></ul><ul><ul><li>Any Estrogen Receptor (ER) or Progesterone Receptor (PR) expression indicates possible response to hormonal therapy </li></ul></ul><ul><ul><li>1% or more cells positive or ER or PR by immunohistochemistry </li></ul></ul><ul><li>Her2/neu (ErbB-2) overexpression </li></ul><ul><ul><li>High overexpression of Her2/neu indicates possible responder to trastuzumab therapy </li></ul></ul><ul><li>ER/PR/Her2 negative patients: chemotherapy </li></ul><ul><li>Paliative Care </li></ul>
    36. 37. <ul><li>Generally considered incurable </li></ul><ul><li>For most patients, primary goal should be palliation </li></ul><ul><li>First recurrences are always biopsied to confirm diagnosis </li></ul><ul><ul><li>Confirm ER/PR status and Her2/neu status </li></ul></ul>
    37. 38. <ul><li>Hormonal therapy for indolent disease </li></ul><ul><li>Single agent chemotherapy for aggressive/symptomatic disease or disease not responsive to hormonal therapy </li></ul><ul><li>Polyagent chemotherapy for visceral crisis or disease requiring rapid response </li></ul>
    38. 39. Metastatic Breast Cancer <ul><li>Limited metastases (bone & soft tissue) </li></ul><ul><li>Positive hormone receptors </li></ul><ul><li>Hormone responsive </li></ul><ul><li>Disease-free interval  2 years </li></ul><ul><li>Extensive metastases or visceral crisis </li></ul><ul><li>Negative hormone receptors </li></ul><ul><li>No response to hormones </li></ul>Hormonal Therapy Chemotherapy Response No response No progression Progression of disease If disease progresses, second-line hormonal therapy Second-line chemotherapy
    39. 40. Fundus Tube Ovary Fimbria Round ligament Fibroid
    40. 41. 6,810 grams, 20 cm X 40 cm Benign serous cystadenoma
    41. 42. <ul><li>Palliative+Care+Inform.pdf </li></ul>
    42. 43. <ul><li>TERIMA KASIH </li></ul>