This was my Home Health/Home based Palliative Care Rotation Feedback; It is major part is concerned about how to take spiritual history and how to address spiritual concerns/Cues of our patients
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Rotation in final year residency
Three days in a week for one month
Once per week : Saturday Cover
My Rotation period: February 2015
Supervisor: Dr. Faizan Qaiser, SMO, Family Medicine Department
Introduction: Rotation
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Any diagnostic, therapeutic, or social support service provided in the
home
OR
Home health care offers the opportunity to provide care that takes into
consideration patients’ home lives, living situations, chronic illnesses,
and functional limitations and aims to deliver patient-centered care.
Introduction: Home Health
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Hospital Inpatient Referrals
Palliative Care Referrals from oncology/palliative care clinics
Geriatric Clinic Referrals
Consulting clinic Referrals
Self Referrals
Patient to patient Referrals
Hospice/Nursing homes
Follow up Visits
Types of Referrals
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88 year old lady, diagnosed patient of CA Endometrium, known to
palliative care services for past 06 months
HBPC physician called by family to Visit
As she has become more irritable and screams at times…….!!
Patient says, She feels that some body is calling her ,She is afraid of that
She further says she is angry with God
How will you approach to that patient?
How will you counsel the family?
Patient Problem
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Whole Person Approach/Respect humanity of each individual
Multifactorial Pain = Suffering
Physical/Emotional/Psychological/Social/Spiritual
All dimensions should be treated equally
Team Approach= Multiple expertise
Respect for dignity and inherent value of each
human being
Bio Psycho-socio-spiritual Model
Puchalski CM, Ferrell B, Virani R, Otis-Green S, Baird P, Bull J, et. al.: Improving the quality of spiritual care as a dimension of palliative
care: The Report of the Consensus Conference. J Palliate Med 2009; 12(10):885-904.
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Spirituality is the aspect of humanity that refers to
the way individuals seek and express meaning and purpose of their
existence
the way they experience their connectedness to the moment, to self, to
others, to nature, and to the significant or sacred
Puchalski CM, Ferrell B, Virani R, Otis-Green S, Baird P, Bull J, et. al.: Improving the quality of spiritual care as a dimension of palliative care: The Report of the
Consensus Conference. J Palliate Med 2009; 12(10):885-904. 8
Spirituality: Meaning?
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meaning: activities, values that are meaningful but don’t define ultimate
purpose/value in life
Ultimate Meaning: values, beliefs, practices, relationships, experiences,
that lead you to the awareness of the sacred or significant, to sense of
ultimate purpose
halski CM, Ferrell B, Virani R, Otis-Green S, Baird P, Bull J, et. al.: Improving the quality of spiritual care as a dimension of palliative care: The Report of
the Consensus Conference. J Palliate Med 2009; 12(10):885-904. 9
Meaning v/s meaning
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Interventions, individual or communal, that facilitate the ability to
express the
integration of the body, mind, and spirit
to achieve wholeness, health, and a sense of connection to self, others,
and[/or] a higher power.
American Nurses Association, & Health Ministries Association. (2005). Faith and community nursing:
Scope and standards of practice. Silver Spring, MD: American Nurses Association.
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Spiritual Care
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Cues Spiritual Diagnosis
“My life is meaningless”
“I feel useless”
Existential
Why would God take my
life… its not fair”
Anger at God or others
“I want to have a deeper
relationship with God”
Concerns about relationship with
Higher being
“I am not sure if God is with me
anymore”
Conflicted or challenged belief
systems
Spiritual, Religious And Existential Aspects Of Palliative Care, Journal Of Palliative Medicine 2005 11
Spiritual Cues in the History
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Cues Spiritual Diagnosis
“Mere liye kuchh naheen bacha dunya meen” Despair/ Hopelessness
“Mere apne kaise chhor sakta hoon” Grief/loss
“I do not deserve to die painfree” Guilt/shame
“Meen sab ko maaf karta hoon, mujhe bhi maaf
kiya jae”
Reconciliation
“Meen is halat men ibadat naheen kar sakta dr
sahib”
Religious specific
“What if all that I believe is not
true”
Religious/Spiritual
Struggle
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Spiritual Cues In History
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Physical: Progressive Disease, Worsening Symptoms
Psychological: Stress, Depression, Psychosis
Social: Good Family support, Wants to see her grand children living in
USA before death, Worried about her husband
Spiritual: Distress, Angry with God, feels relief with Tasbih, thinking
about Khana Kaaba, Worried about death, wanted to discuss death with
family/Alwaiz
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Back To Our Patient: Issues
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Impaired ability to experience and integrate meaning and purpose in
life through connectedness with self/others, art, music, literature,
nature, and or a power greater then oneself/some one significant
Clinical Spiritual Distress
Nanda-2007
Puchalski CM, Ferrell B, Virani R, Otis-Green S, Baird P, Bull J, et. al.: Improving the quality of spiritual care as a dimension of palliative
care: The Report of the Consensus Conference. J Palliate Med 2009; 12(10):885-904. 14
15. 1. What is the reason of fear?
2. What do u think, who would be calling you?
3. Do you think of Death at times?
4. Which feelings surface when you think about your death?
5. Know for sure where you are going when you die?
6. Satisfied with ultimate destination?
7. If you could choose, how would you like to die?
8. Which way of dying is the most unacceptable to you?
9. Which person most difficult to leave behind when you die?
10.Which things most difficult to leave behind?
11.Adequate preparations regarding your own death and burial?
Discussing Death
Puchalski CM, Ferrell B, Virani R, Otis-Green S, Baird P, Bull J, et. al.: Improving the quality of spiritual care as a dimension of
palliative care: The Report of the Consensus Conference. J Palliate Med 2009; 12(10):885-904.
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1. Good relationship with God/Some one significant
2. Clear conscience
3. Hope
4. Meaning
5. Purpose
6. Life concluded with no loose ends
7. Prepared for the transition
The Dying Person: 7 Basic Spiritual Needs
Puchalski CM, Ferrell B, Virani R, Otis-Green S, Baird P, Bull J, et. al.: Improving the quality of spiritual care
as a dimension of palliative care: The Report of the Consensus Conference. J Palliate Med 2009; 12(10):885-904. 16
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Define Goals of Treatment to patient and family
Family support
Compassionate presence and follow up
Reflective listening/query about important life events—spirituality as connection
Support patient sources of spiritual strength and note in chart
Explore sources of hope/meaning
Connect patient to community spiritual resources
Referral to chaplain/Alwaiz/Pandat or other spiritual care professional/Spiritual
Leader
Self practiced spiritual rituals
Puchalski CM, Ferrell B, Virani R, Otis-Green S, Baird P, Bull J, et. al.: Improving the quality of spiritual care as a
dimension of palliative care: The Report of the Consensus Conference. J Palliate Med 2009; 12(10):885-904. 17
Management: Interventions by Physicians
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Every patient should be screened for spiritual distress
Clinicians should include a spiritual history as part of the routine
history
Spiritual issues, distress, resources of strength should be identified and
documented in patient chart and followed up appropriately
Spiritual Care Provider should be the integral part of healthcare team
and should be the trained in clinical spiritual care
Recommendations
Puchalski CM, Ferrell B, Virani R, Otis-Green S, Baird P, Bull J, et. al.: Improving the quality of spiritual care as a dimension of
palliative care: The Report of the Consensus Conference. J Palliate Med 2009; 12(10):885-904. 18
20.
82 year old lady, known Hypertensive, Diabetic, diagnosed patient of
Renal Cell CA, S/P nephrectomy, mates in urinary Bladder/bones (S/P
radiotherapy, Chemotherapy, S/P cystoscopy)
Referred to Home Based Palliative Care Team in late February 2015 for
pain management at home
Patient Problem
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Patient is more sleepy
Not eating/drinking
Altered mentation
Changes in breathing patterns/ slow and fast breathing
Unstable Oxygen saturation
Talking with someone who is already dead
Blood Pressure changes (some times high/some times low)
Calling kids
All for past one day………….!!!
Complains
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Family is in panic state
They want their patient back in baseline status
Not properly counseled by primary physician
We were having first encounter with patient and family
Issues
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Increased pain
Changes in blood pressure, respiratory rate, oxygen saturations and heart rate
Continued loss of appetite and thirst and difficulty taking medications by
mouth
Decline in bowel and bladder output
Changes in sleep-wake patterns
Temperature fluctuations that may leave the skin cool, warm, moist, or pale
Constant fatigue
Congested breathing
Disorientation or seeing and talking to people who aren't there
The Period of Transition
American Cancer society 23
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Breaking Bad News:
The SPIKES Protocol
SETTING UP the interview
Assessing patient’s/Family’s PERCEPTION
Obtaining the patient’s/Family’s INVITATION
Giving KNOWLEDGE and information
Addressing the patient’s/Family’s EMOTIONS
STRATEGY and SUMMARY
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25% Psychiatric morbidity is found in Palliative Care physicians
ABC of Palliative Care 25
House Keeping
Editor's Notes
Palliative care is an approach to looking after someone with a life threatening illness
It means not just looking after their physical needs but also taking into account what their illness means to their social, psychological and spiritual well being
The goal of Palliative Care is to achieve the best quality of life for patients and for their families for however long they have
It can be applicable at any stage in a patient’s disease journey - some patients may be diagnosed and die very quickly others may live with their chronic illness for years gradually losing their independence
Palliative care:
provides relief from pain and other distressing symptoms;
affirms life and regards dying as a normal process;
intends neither to hasten or postpone death;
integrates the psychological and spiritual aspects of patient care;
offers a support system to help patients live as actively as possible until death;
offers a support system to help the family cope during the patients illness and in their own bereavement;
uses a team approach to address the needs of patients and their families, including bereavement counseling, if indicated;
will enhance quality of life, and may also positively influence the course of illness;
is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications.