This case study describes the end-of-life care of Lorna, a 77-year old woman with metastatic renal cell carcinoma. Lorna originally presented with flank and abdominal pain and was diagnosed with advanced renal cell carcinoma in 2011. In 2014, the cancer recurred and metastasized to her spine, causing cauda equina syndrome with lower limb weakness and urinary/fecal incontinence. She was admitted to palliative care for pain and symptom management, where she received psychological support, medication via syringe pump, and focus on comfort. The document discusses renal cell carcinoma, cauda equina syndrome, medications, nursing interventions and compassionate end-of-life care.
Five priorities for care of the dying personMarie Curie
Dr Bill Noble, Medical Director of Marie Curie Cancer Care, speaks at the end of life sesion with Dr Adam Firth (RCGP Clinical Support Fellow for End of Life Care).
This session was chaired by Dr Peter Nightingale, Marie Curie and RCGP End of life lead at the RCGP Annual Conference, ACC Liverpool, 2-4 October, 2014.
For more information visit: mariecurie.org.uk/rcgp
45 minutes of suffering (or Anesthesia Grand Rounds on Palliative Care)Mike Aref
Presentation on what palliative care is, comparison with hospice, primary palliative care screening, goals-of-care, definitions of DNR, basics of acute pain management and WHO analgesic ladder.
Consolidating, Improving, and Novel Palliative Care: Order SetsMike Aref
A selection of slides, taken from a series of presentations, showing the evolution of consolidating and developing order sets for delivery of primary palliative care in our healthcare system.
The lecture I gave for the Indiana University Health Joint Transplant Education and Research Lecture Series on palliative care. That's right, palliative care in transplant patients NOT at the end-of-life.
Three hour slide deck for basics of palliative care including what is palliative care, symptom management (pain, dyspnea, nausea, constipation), goals-of-care, family meetings, comfort care, and issues around artificial nutrition.
Five priorities for care of the dying personMarie Curie
Dr Bill Noble, Medical Director of Marie Curie Cancer Care, speaks at the end of life sesion with Dr Adam Firth (RCGP Clinical Support Fellow for End of Life Care).
This session was chaired by Dr Peter Nightingale, Marie Curie and RCGP End of life lead at the RCGP Annual Conference, ACC Liverpool, 2-4 October, 2014.
For more information visit: mariecurie.org.uk/rcgp
45 minutes of suffering (or Anesthesia Grand Rounds on Palliative Care)Mike Aref
Presentation on what palliative care is, comparison with hospice, primary palliative care screening, goals-of-care, definitions of DNR, basics of acute pain management and WHO analgesic ladder.
Consolidating, Improving, and Novel Palliative Care: Order SetsMike Aref
A selection of slides, taken from a series of presentations, showing the evolution of consolidating and developing order sets for delivery of primary palliative care in our healthcare system.
The lecture I gave for the Indiana University Health Joint Transplant Education and Research Lecture Series on palliative care. That's right, palliative care in transplant patients NOT at the end-of-life.
Three hour slide deck for basics of palliative care including what is palliative care, symptom management (pain, dyspnea, nausea, constipation), goals-of-care, family meetings, comfort care, and issues around artificial nutrition.
Basics of palliative care including symptom management: pain, dyspnea, nausea and constipation; family meetings, goals-of-care, end-of-life care, and artificial nutrition.
Scoring Suffering to Address Patient Needs in Palliative Care: The "Maslow Sc...Mike Aref
Introduction
Palliative care patients have been scored by their symptom burden and performance but there is little standardization of their multidimensional suffering, needs, and wants. Maslow’s Hierarchy of Needs is a model for describing these needs as physiological, safety, love/ belonging, esteem, and self-actualization. The functional pain score is a validated method of scoring pain based on patient report and provider assessment. Using these two frameworks, the “Maslow Score” seeks to use Maslow’s Hierarchy to score the current patient situation based on symptom burden, plan, network, and meaning.
Methods
The scores are four-digit codes describing the patient situation at a given time base on team consensus. Each digit is a score from most secure, 0, to most vulnerable, 5. Both written examples and an algorithmic approach have been provided to obtain each score.
Results
Morning huddle has been expedited by utilizing scores recorded the previous day. Also if sudden changes have been reported they can be compared rapidly against a team standard. This triaging helps direct team resources as to whether patients should be reassessed by the entire team or specific members. The discussion has improved assessment of patients from an interdisciplinary perspective. In general, patients cannot improve their network and meaning scores until symptom and planning scores have been optimized.
Discussion
The “Maslow Score” appears to have improved the quality of care that our service delivers by improving efficiency. Further development and study is needed to standardize and validate our method.
Presentation on palliative care given at the Caregiver's Conference for the Cystic Fibrosis Affiliate and Satellite Sites at Riley Children's Hospital.
Building on the lecture I gave (and uploaded) "Palliative Care: what every primary care doctor should know" I built this talk. It is geared for 1st year medical students who are learning anatomy, physiology, and perhaps some pharmacology and pathophysiology.
In this talk, I do not explicitly address hospice care - as that was provided in an online chapter for students at UMass. I will later upload another slide set on that topic.
I hope you enjoy it.
FYI- the link to the youtube video: http://www.youtube.com/watch?v=XHtHXGhTIC4
Link to PDF of the slide show: https://files.me.com/s.mak/8fzat6
Geriatric Population. Geriatric Palliative and End-of-Life Care.Michelle Peck
During your journey through this slide deck Geriatric Population. Geriatric Palliative and End-of-Life Care you will experience what it means to die badly.
After practicing as a Geriatric Clinician for over a decade what I know for sure is: Life is a tremendous gift. 100% of us are going to die. If you don't communicate your end-of-life plan, then you should plan on dying badly.
In The Cost of Dying: End-of-Life Care on CBS 60 minutes Steve Kroft interviews Doctor Ira R. Byock. “Families cannot imagine that there could be anything worse than their loved one dying, but in fact there are things worse, generally it’s having someone you love die badly.” ~Doctor Ira Byock
“Dr. Byock what do you mean dying badly?” ~Mr. Kroft
“Dying suffering, dying connected to machines, denial of death at some point becomes a delusion and we start acting in ways that make no sense whatsoever.” ~Doctor Ira Byock
A majority of Americans say they want to die at home. Why is this not happening?
Place of death should be regarded as an essential goal in end-of-life care.
Let’s explore how the end-of-life decision occurs?
For Doctors
Bernacki & Block (2014) found in their review and synthesis of best practices that physician attitudes, training, and perceptions of feeling inadequate in managing the emotional and behavioral reactions of patients all play a role. A majority of trainees were not taught how to communicate and they express strong desires to learn more. Physician barriers also include not addressing psychosocial concerns, placing focus on diagnoses, treatments, and procedures during discussions about the medical care at the end-of-life.
For Patients
Bernacki & Block (2014) found that patients who do bring up dying concerns with their physicians often meet barriers and often are not aware that they are at the end-of-life. Patients that have not set goals based on meaningful conversations about their desires may overuse life-prolonging treatment and underuse services that support quality of life.
Conclusion
Bernacki & Block (2014) found that there is a large body of evidence demonstrating that early discussions of serious illness care goals are associated with:
♛ beneficial outcomes for patients,
♛ no harmful adverse effects, and
♛ potential cost savings.
Apply & Do
To prevent dying badly start early conversations, enhance your knowledge and establish goals. Dreams are only dreams until you write them down. When you write dreams down then they become goals.
Do ♛ The Conversation Project a collaboration with the Institute for Healthcare Improvement. http://theconversationproject.org/starter-kit/intro/
Do your conversation kit now and make your loved ones aware of your wishes.
Wishing you the very best, Michelle
Bernacki RE, Block SD, for the American College of Physicians High Value Care Task Force. Communication About Serious Illness Care Goals: A Review and Synthesis of Best Practices. JAMA Intern Med. 2014;174(12):1994-2003.
Acute hospitals end of life care best practiceNHSRobBenson
Delivering reliable best practice in an acute hospital setting for patients whose recovery is uncertain. Including details of the AMBER care bundle. Presentation from Anita Hayes and colleagues from England's National End of Life Care Programme as part of the Department of Health's QIPP end of life care workstream seminar series at Healthcare Innovation Expo 2011
Carle General Surgery Grand Rounds presentation on palliative care symptom management, specifically pain, nausea, constipation, and malignant bowel obstruction.
Basics of palliative care including symptom management: pain, dyspnea, nausea and constipation; family meetings, goals-of-care, end-of-life care, and artificial nutrition.
Scoring Suffering to Address Patient Needs in Palliative Care: The "Maslow Sc...Mike Aref
Introduction
Palliative care patients have been scored by their symptom burden and performance but there is little standardization of their multidimensional suffering, needs, and wants. Maslow’s Hierarchy of Needs is a model for describing these needs as physiological, safety, love/ belonging, esteem, and self-actualization. The functional pain score is a validated method of scoring pain based on patient report and provider assessment. Using these two frameworks, the “Maslow Score” seeks to use Maslow’s Hierarchy to score the current patient situation based on symptom burden, plan, network, and meaning.
Methods
The scores are four-digit codes describing the patient situation at a given time base on team consensus. Each digit is a score from most secure, 0, to most vulnerable, 5. Both written examples and an algorithmic approach have been provided to obtain each score.
Results
Morning huddle has been expedited by utilizing scores recorded the previous day. Also if sudden changes have been reported they can be compared rapidly against a team standard. This triaging helps direct team resources as to whether patients should be reassessed by the entire team or specific members. The discussion has improved assessment of patients from an interdisciplinary perspective. In general, patients cannot improve their network and meaning scores until symptom and planning scores have been optimized.
Discussion
The “Maslow Score” appears to have improved the quality of care that our service delivers by improving efficiency. Further development and study is needed to standardize and validate our method.
Presentation on palliative care given at the Caregiver's Conference for the Cystic Fibrosis Affiliate and Satellite Sites at Riley Children's Hospital.
Building on the lecture I gave (and uploaded) "Palliative Care: what every primary care doctor should know" I built this talk. It is geared for 1st year medical students who are learning anatomy, physiology, and perhaps some pharmacology and pathophysiology.
In this talk, I do not explicitly address hospice care - as that was provided in an online chapter for students at UMass. I will later upload another slide set on that topic.
I hope you enjoy it.
FYI- the link to the youtube video: http://www.youtube.com/watch?v=XHtHXGhTIC4
Link to PDF of the slide show: https://files.me.com/s.mak/8fzat6
Geriatric Population. Geriatric Palliative and End-of-Life Care.Michelle Peck
During your journey through this slide deck Geriatric Population. Geriatric Palliative and End-of-Life Care you will experience what it means to die badly.
After practicing as a Geriatric Clinician for over a decade what I know for sure is: Life is a tremendous gift. 100% of us are going to die. If you don't communicate your end-of-life plan, then you should plan on dying badly.
In The Cost of Dying: End-of-Life Care on CBS 60 minutes Steve Kroft interviews Doctor Ira R. Byock. “Families cannot imagine that there could be anything worse than their loved one dying, but in fact there are things worse, generally it’s having someone you love die badly.” ~Doctor Ira Byock
“Dr. Byock what do you mean dying badly?” ~Mr. Kroft
“Dying suffering, dying connected to machines, denial of death at some point becomes a delusion and we start acting in ways that make no sense whatsoever.” ~Doctor Ira Byock
A majority of Americans say they want to die at home. Why is this not happening?
Place of death should be regarded as an essential goal in end-of-life care.
Let’s explore how the end-of-life decision occurs?
For Doctors
Bernacki & Block (2014) found in their review and synthesis of best practices that physician attitudes, training, and perceptions of feeling inadequate in managing the emotional and behavioral reactions of patients all play a role. A majority of trainees were not taught how to communicate and they express strong desires to learn more. Physician barriers also include not addressing psychosocial concerns, placing focus on diagnoses, treatments, and procedures during discussions about the medical care at the end-of-life.
For Patients
Bernacki & Block (2014) found that patients who do bring up dying concerns with their physicians often meet barriers and often are not aware that they are at the end-of-life. Patients that have not set goals based on meaningful conversations about their desires may overuse life-prolonging treatment and underuse services that support quality of life.
Conclusion
Bernacki & Block (2014) found that there is a large body of evidence demonstrating that early discussions of serious illness care goals are associated with:
♛ beneficial outcomes for patients,
♛ no harmful adverse effects, and
♛ potential cost savings.
Apply & Do
To prevent dying badly start early conversations, enhance your knowledge and establish goals. Dreams are only dreams until you write them down. When you write dreams down then they become goals.
Do ♛ The Conversation Project a collaboration with the Institute for Healthcare Improvement. http://theconversationproject.org/starter-kit/intro/
Do your conversation kit now and make your loved ones aware of your wishes.
Wishing you the very best, Michelle
Bernacki RE, Block SD, for the American College of Physicians High Value Care Task Force. Communication About Serious Illness Care Goals: A Review and Synthesis of Best Practices. JAMA Intern Med. 2014;174(12):1994-2003.
Acute hospitals end of life care best practiceNHSRobBenson
Delivering reliable best practice in an acute hospital setting for patients whose recovery is uncertain. Including details of the AMBER care bundle. Presentation from Anita Hayes and colleagues from England's National End of Life Care Programme as part of the Department of Health's QIPP end of life care workstream seminar series at Healthcare Innovation Expo 2011
Carle General Surgery Grand Rounds presentation on palliative care symptom management, specifically pain, nausea, constipation, and malignant bowel obstruction.
Renal Tubular Pigmentation Associated with Senna-Related MetabolitesEPL, Inc.
“Renal Tubular Pigmentation Associated with Senna-Related Metabolites.” Willson GA (presenter) Malarkey DE, Allison N, Harris N, Miller RA. The 54th Annual Society of Toxicology Meeting. San Diego, CA. March 25, 2015.
For full-resolution viewing, please open or save as a PDF.
Mark Haas Kidney Summary Banff 2013 in Brazil Kim Solez ,
Kidney summary from 12th Banff Conference on Transplant Pathology from the meeting in Comandatuba-Bahia, Brazil on August 23rd, 2013 http://cybernephrology.ualberta.ca/banff/2013
Immunohistochemistry Antibody Validation Report for Anti-Phospho-JNK1/2/3 (T1...St John's Laboratory Ltd
Serine/threonine-protein kinase involved in various processes such as cell proliferation, differentiation, migration, transformation and programmed cell death. Extracellular stimuli such as proinflammatory cytokines or physical stress stimulate the stress-activated protein kinase/c-Jun N-terminal kinase (SAP/JNK) signaling pathway. In this cascade, two dual specificity kinases MAP2K4/MKK4 and MAP2K7/MKK7 phosphorylate and activate MAPK8/JNK1. In turn, MAPK8/JNK1 phosphorylates a number of transcription factors, primarily components of AP-1 such as JUN, JDP2 and ATF2 and thus regulates AP-1 transcriptional activity. Phosphorylates the replication licensing factor CDT1, inhibiting the interaction between CDT1 and the histone H4 acetylase HBO1 to replication origins. Loss of this interaction abrogates the acetylation required for replication initiation.
Anti-Phospho-JNK1/2/3 (T183)-http://www.stjohnslabs.com/phospho-jnk123-t183-antibody
Join our Antibody Validation Project - http://www.stjohnslabs.com/services/antibody-validation
Out-patient Primary and Specialty Palliative CareMike Aref
Presentation on primary and specialty palliative care, covering what is palliative care, basics of primary palliative care including pain and symptom management, and referral criteria for out-patient specialty palliative care.
SOAP NOTE
Name: C.M.
Date: 04/08/2016
Time: 10:55
Pt. Encounter #
Age: 52
Sex: Female
SUBJECTIVE
CC:
“My hands are swollen and painful”
HPI:
This is a 51-year-old female who comes to the office with complains of fatigue, general malaise, and pain and swelling in her hands that has gradually worsened over the last few weeks. She reports that pain, stiffness, and swelling of her hands are most severe in the morning. Also, she report weight loss, anorexia, aching, and stiffness. Morning stiffness lasts for as long as 1 to 2 hours.
Medications:
1. Diovan 80mg po daily
2. Singular 10mg po at bed time
3. Tylenol 500mg 1 tab po every 6 hours x pain
4. Albuterol 2 puff every 6 hours as needed
PMH
Allergies: NKA
Medication Intolerances: None
Chronic Illnesses/Major traumas: Hypertension, Asthma.
Hospitalizations/Surgeries: Hysterectomy 5 years ago.
Family History
Mother diagnosed with: Asthma, Hypothyroidism, Rheumatoid Arthritis
Father diagnosed with: HTN, Dementia
Sister diagnosed with: HTN
Social History
Patient has a high school education. She works as a mail carrier for the post office for 15 years. She has been widowed for the last two years. Currently, she lives alone in a rented apartment. She has two living children, who all live close by and have families of their own. She reports her family is supportive and denies any needs at this time. She has adequate shelter and food. She denies any leisure activities. She refuses to practice exercises. She just goes to the local church on Sunday. She eats a diet low sodium. She denies substance use, ETOH, tobacco, marijuana or illicit drugs.
ROS
General
Weight loss and fatigue
Decreased energy level
Cardiovascular
Denies chest pain, palpitations, PND, orthopnea, edema
Skin
Denies delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles
Respiratory
Denies cough, wheezing, dyspnea at this time
Eyes
Corrective lenses
Gastrointestinal
Denies abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools
Ears
Denies ear pain, hearing loss, ringing in ears, discharge
Genitourinary/Gynecological
Denies urgency, frequency burning, change in color of urine, vaginal discharge or STDS. Hysterectomy 5 years ago. Last mammography 1 years ago.
G2, P2, A0
Nose/Mouth/Throat
Denies sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, and throat pain
Musculoskeletal
Localized symptoms in hand joints: pain, tender, swollen, and decrease range of motion.
Breast
SBE every month, denies lumps, bumps or changes
Neurological
Denies syncope, seizures, transient paralysis, weakness, paresthesias, black out spells
Heme/Lymph/Endo
Denies HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance
Psychiatric
Denies depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx
OBJECTIVE
.
End-of-life care refers to health care provided in the time leading up to a person's death. End-of-life care can be provided in the hours, days, or months before a person dies and encompasses care and support for a person's mental and emotional needs, physical comfort, spiritual needs, and practical tasks.
Effective pain management in terminally ill requires
Understanding of pain control strategies
Ongoing assessment
Diagnosis of pain
Breakthrough pain relief
Fine adjustment of medications
Opioid rotation
Unresolved psychosocial or spiritual issue can be great impact to pain management
Explore our infographic on 'Essential Metrics for Palliative Care Management' which highlights key performance indicators crucial for enhancing the quality and efficiency of palliative care services.
This visual guide breaks down important metrics across four categories: Patient-Centered Metrics, Care Efficiency Metrics, Quality of Life Metrics, and Staff Metrics. Each section is designed to help healthcare professionals monitor and improve care delivery for patients facing serious illnesses. Understand how to implement these metrics in your palliative care practices for better outcomes and higher satisfaction levels.
Health Education on prevention of hypertensionRadhika kulvi
Hypertension is a chronic condition of concern due to its role in the causation of coronary heart diseases. Hypertension is a worldwide epidemic and important risk factor for coronary artery disease, stroke and renal diseases. Blood pressure is the force exerted by the blood against the walls of the blood vessels and is sufficient to maintain tissue perfusion during activity and rest. Hypertension is sustained elevation of BP. In adults, HTN exists when systolic blood pressure is equal to or greater than 140mmHg or diastolic BP is equal to or greater than 90mmHg. The
Empowering ACOs: Leveraging Quality Management Tools for MIPS and BeyondHealth Catalyst
Join us as we delve into the crucial realm of quality reporting for MSSP (Medicare Shared Savings Program) Accountable Care Organizations (ACOs).
In this session, we will explore how a robust quality management solution can empower your organization to meet regulatory requirements and improve processes for MIPS reporting and internal quality programs. Learn how our MeasureAble application enables compliance and fosters continuous improvement.
India Clinical Trials Market: Industry Size and Growth Trends [2030] Analyzed...Kumar Satyam
According to TechSci Research report, "India Clinical Trials Market- By Region, Competition, Forecast & Opportunities, 2030F," the India Clinical Trials Market was valued at USD 2.05 billion in 2024 and is projected to grow at a compound annual growth rate (CAGR) of 8.64% through 2030. The market is driven by a variety of factors, making India an attractive destination for pharmaceutical companies and researchers. India's vast and diverse patient population, cost-effective operational environment, and a large pool of skilled medical professionals contribute significantly to the market's growth. Additionally, increasing government support in streamlining regulations and the growing prevalence of lifestyle diseases further propel the clinical trials market.
Growing Prevalence of Lifestyle Diseases
The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
One of the most developed cities of India, the city of Chennai is the capital of Tamilnadu and many people from different parts of India come here to earn their bread and butter. Being a metropolitan, the city is filled with towering building and beaches but the sad part as with almost every Indian city
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
2. Lorna’s story
77 y. o. retired female
Lived with her husband and sister in a shared
rental unit
2 supportive daughters and 2 granddaughters
Goes to small local chapel nearby
History of Hypertension, Obesity, Anxiety,
Cholecystectomy (surgical removal of the
gallbladder)
3. Lorna’s story cont.
Allergic to Hydrochlorothiazide (diuretic drug)
Presented to GP with intermittent left flank pain,
abdominal pain and increased fatigue and
weakness
Diagnosed with advanced renal cell carcinoma in
early 2011
L nephrectomy the same year
4. Lorna’s story con.
Reoccurrence of renal disease in April 2014
First admission to CHCB for symptom management of
increasing right hip pain and functional decline - not
able to cope at home
X-ray showed bilateral joint degenerative changes
with subchondral sclerosis and degenerative changes
to lumbar spine
Ongoing complex, severe pain difficult to manage
Increasingly depressed, anxious and tearful
Anaemia requiring transfusion
MRI in August 2014 – cauda equina compression (T1-
L2)
Drowsy, urine retention (IDC inserted), faecal
incontinence, severe lower limbs weakness
(secondary to the tumour infiltration)
Palliative radiotherapy to spine
5. Story cont.
Readmitted to CHCB for ongoing symptom
management
Decreased appetite/Minimal oral intake
Lost at least 20 kg since diagnosis
Focus on pain & symptom management
Non-essential medications ceased
CSCI via syringe driver
Psychological and spiritual support to patient and
family
Terminal care
LCP
6. Metastatic renal cell carcinoma
RCC or adenocarcinoma – the most common type
of kidney cancer – starts in the lining of small
proximal tubules in the kidney
Stage 4 – tumour has invaded other organs
The 10th most frequently seen cancer in Australia
typically discovered when the person is 50-70
Average survival = 5 years
Risk factors: cigarette smoking, hypertension,
obesity and genetics
Most common metastases – lungs, liver and long
bones
Early warning signs – abdominal discomfort,
fatigue, weight loss.
Later – haematuria, flank pain, anaemia, palpable
abdominal mass
7. Proximal
Convoluted
Tubule
circulates
water and
reabsorbs
glucose,
amino acids,
metabolites
and
electrolytes
from the
filtrate into
nearby
capillaries.
This is where
the RCC in
most cases
starts from.
8. Cauda Equina syndrome (CES)
CES affects a bundle of nerve roots called the
cauda equina (Latin for horse's tail) where
something is compressing on the spinal nerve roots
such as a tumour.
These nerve roots send and receive messages to
and from your legs, feet, and pelvic organs.
Damage to these may result in severe low back
pain, faecal incontinence, urinary retention and
severe lower limb weakness.
11. Medication
Variable dose medication delivered subcut via
Syringe Driver every 24 hrs - Oxycodone
Injection (40mg) for pain
Regular prescriptions – Dexamethasone 2mg
PO/SC in the Morning – Indication: Cauda equina
compression Olanzapine 2.5mg PO/Sublingual/SC
Twice Daily – Indication: agitation
As Required prescriptions – Metoclopramide
10 to 20mg q4 hours PRN, PO/SC up to 80 mg per
24 hours for nausea/vomiting
Midazolam Injection 2.5 to 5mg q1hour PRN, up
to 2 doses per 4 hours, SC – indication: agitation
12. Medication as required con.
Glycopyrrolate 0.2mg/1mL Injection SC 0.2 to
0.4mg q 4 hours PRN for respiratory secretions
Pregabalin 75mg capsule, 75 mg q 12 hours PRN,
2nd line for severe pain not responding to
oxycodone
Haloperidol 0.5 to 1mg q 1 hour PRN, PO/SC up
to 2 doses per 6 hours. For agitation/delirium:
minimum dosage interval = 1 hr. For nausea or
vomiting: minimum dosage interval = 6 hrs
Oxycodone Injection 5 to 7.5mg q 1 hour, PRN,
SC
13. End Of Life Nursing Care
Symptoms and Interventions
Skin integrity is maintained – assessment (itch,
sweating, pressure areas) - cleansing,
repositioning, use of special aids (Braden score 10)
Urinary problems – IDC/use of pads
Bowel problems – constipation/diarrhoea
Administration of medications – CSCI/ SC butterfly
Personal hygiene – skin care, eye care, wash
Psychological well being – verbal and non-verbal
communication, listening, information and
explanation, use of touch, spiritual/cultural needs
14. Symptoms and Interventions
Nausea/Vomiting – treatment depends on the area
of stimulation (chemoreceptor trigger zone/CTZ
and the vomiting centre) – often difficult to control
Agitation/distress/anxiety – consider spiritual
issues, listening, support, open discussion with
patient and family, psychotropic drugs –
benzodiazepines, antidepressants
Respiratory secretions – ‘death rattle’ – positioning
to allow postural drainage, drugs – anticholinergics
(hyoscine hydrobromide, glycopyrrolate)
15. Pain
“Pain is whatever the person experiencing it says it
is, existing whenever he says it does.”
Verbal if Pt conscious
Non-verbal cues
Positional change
PRN / BT analgesia for incident pain/prior
movement
16. Pain
Psychological and spiritual elements of pain –
anxiety, sadness, anger, frustration
Pain of loss
Loss of role
Loss of independence
Loss of future
Nurse being at the bedside, fully present giving a
‘dose’ of herself – respectful verbal and non-verbal
communication, caring touch
17. LCP issues
One –way road to death?
Backdoor form of euthanasia?
OR
Improves care at the end of life?
Results in more “good deaths”?
OR
Travel to Liverpool for treatment (as one husband
misunderstood)
Review the use of LCP in palliative settings – poor
implementation and possible falsification
18. Compassionate care
Patient satisfaction is closely related to the quality
of kindness, caring, compassion and trust
Magical moments of healing occur when a profound
connection is made
The patients emotional and psychological wellbeing
impacts more powerfully on physical health
outcomes than most of the medicines we use
Work intensity, demands, lack of recourses –
disorganised, pressured reactive pattern of patient
care that focuses on clinical tasks rather than
caring for the whole person
Very often the human touch is missing
Hug – form off communication because it can say
things you don’t have words for.
19.
20. Four major shifts to re-humanise
healthcare (Youngson, 2012)
Reductionist focus on
Pathology
Detached care
Focus on sickness,
defects and problems
Health professional
directing care
Focus on whole person
Empathetic, compassionate
care
Focus on wellbeing, strengths
and resilience
Health professional serving
the patient’s goals
21. Think about....recommendations
“We don’t have time to care”- the first step in finding
time to care is simply to stop/slow down. Give your
patient complete attention – in moments of close
connection, the time stands still – patients feel you
spent much more time with them.
Tell patients you have time – “Is there anything else I
can do for you before I leave? I have time.”
Small acts of kindness
Stop treating patient impersonally, detached – “MND in
room 6” or ‘darling, honey, sweetie’
Bad moods are contagious
A ‘good’ nurse doesn’t mind being moved from one job
to another???
Effective healthcare system needs to inspire and support
compassionate caring and healing relationships –
difficult to achieve in the stressed healthcare institutions
we mostly work in.
22. Tell us a story about a time when
you had an extraordinary
connection with a patient/client
23.
24. References:
Institute of Medicine (IOM). (2008). Cancer care for the whole patient:
Meeting psychosocial health needs, Washington, DC: The National
Academies Press
MacLoad, R., Vella-Brincat, J. & Macleod, A. D. (2012). The palliative care
handbook: Guidelines for clinical management and symptom control (6th
ed.). Wellington, New Zealand:Crucial Colour
NHS Improving Quality. (2013). Liverpool care pathway for the dying
patient. Retrieved from http://www.endoflifecare.nhs.uk/care-pathway/
step-care-in-the-last-days-of-life/liverpool-care-pathway.aspx
Sachdeva, K., Makhoul, I., Javeed, M., & Curti. Renal cell carcinoma.
Retrieved from www.emedicine,medscape.com/article/38054
Watson, J., & Woodward, T. K. (2010). Jean Watson’s theory of human
caring. In M. I. Parker, & M. C. Smith (Eds.), Nursing theories & nursing
practice (3rd ed., pp. 351-369). Philadelphia, PA: F. A. Davis Company
Youngson, R. (2012). Time to care: How to love your patients and your
job. Raglan, New Zealand: Rebelheart Publishers
Gardner, A., Gardner, E. & Morley, T. (2011). Cauda equina syndrome: a
review of the current clinical and medico-legal position. Eur Spine J
20:690-697