Upload
others
View
2
Download
0
Embed Size (px)
Citation preview
Rural Palliative Care Networking Group MeetingJanuary 28, 2014
Staples, Minnesota
Agenda
• Welcome and Introductions
• Educational Session
– Symptom Management at End-of-Life Part II
– Presented by Laura Scherer, RN, Director,
Unity Family Home Care and Hospice
• Round-robin discussion
• Wrap-up and next steps
Clinical Review for the
Hospice and Palliative Nurse
Symptom Management
3
Anxiety, Delirium/Agitation. and Depression
Objectives
1. Define anxiety, delirium/agitation, and depression that is
present at the end of life.
2. Identify possible etiologies of anxiety, delirium/agitation, 2. Identify possible etiologies of anxiety, delirium/agitation,
and depression at the end of life.
3. Assess for the physical and psychosocial aspects of
anxiety, delirium/agitation, and depression that are
common at the end of life.
4
Objectives
4. Describe pharmacological and nonpharmacological
interventions for anxiety, delirium/agitation, and
depression that can be included in the plan of care at the
end of life.end of life.
5. Describe the patient and family instructions needed for
patients and families at the end of life.
5
Domains of
Quality Palliative Care
Clinical Practice Guidelines of Quality Palliative Care
� Domain 2: Physical Aspects of Care
� Guideline 2.1 Pain, other symptoms, and side
effects are managed based upon the best available effects are managed based upon the best available
evidence, with attention to disease-specific pain
and symptom, which is skillfully and systematically
applied.
6
Anxiety
� Feeling of deep sense of unease without an
identifiable cause
� Prevalence - varies
7
Causes of Anxiety
� Poorly controlled pain
� Altered physiologic states
� Medications
� Withdrawal from alcohol/medications� Withdrawal from alcohol/medications
� Medical conditions
� Physiological/Emotional/Spiritual distress
8
Assessment of
Anxiety
Physical symptoms
� Cognitive symptoms
� Pain
� Bowel/bladder � Bowel/bladder
� Familiarity with environment
� Interview questions
� Explore psychological and emotional dimensions
9
Pharmacological
Treatment of Anxiety
Antidepressants
� Blocks serotonin reuptake
Benzodiazepines
� acts on limbic-thalmic-hypothalmic area of the CNS � acts on limbic-thalmic-hypothalmic area of the CNS
producing anxiolytic, sedative, hypnotic, skeletal muscle
relaxation
� Neuroleptics
� blocks dopamine reuptake
10
Non-pharmacological
Treatment of Anxiety
� Coping skills
� Reassurance and support
� Manage stress and decrease stimulation
� Symptom management� Symptom management
� Complementary therapies
� Counseling
11
Anxiety
Patient & Family Education
� Review causes
� Monitor for signs and symptoms
� Avoid stimulation
� Patient safety� Patient safety
� Discuss unresolved issues
12
Anxiety
References
1. Kazanowski M. Symptom management in palliative care. In: Matzo ML,
Sherman D W, eds. Palliative care nursing: Quality Care to the End of
Life. New York, NY: Springer, 2006: 319-344.
2. Pasacreta JV, Minarik PA, Nield-Anderson L. Anxiety and depression.
In: Ferrell B R, Coyle N, eds. Textbook of Palliative Nursing. 2nd ed.
New York, NY: Oxford, 2006: 375-399. New York, NY: Oxford, 2006: 375-399.
3. Bednash G, Ferrell BR. End-of-Life Nursing Education Consortium
(ELNEC – Geriatric ). Washington, DC: Association of Colleges of
Nursing, 2007.
4. Breitbart W, Chochinov H, Passik S. Psychiatric aspects of palliative
care. In: Doyle D, Hanks G, MacDonald N, eds. Oxford Textbook of
Palliative Medicine. New York, NY: Oxford, 2003.
5. Berry PH, ed. Core Curriculum for the Hospice and Palliative Nurse
2nd ed. Dubuque, IA:Kendal/Hunt; 2005.
13
Delirium/Agitation
� Delirium – a global, potentially reversible
change in cognition and consciousness that is
relatively acute in onset
� Common in patient near death (approx 88%)
� Agitation - excessive restlessness accompanied
by increased mental and physical activity
14
Delirium/Agitation
Prevalence
� Almost half of patients experience
delirium/agitation in last 48 hours
� Experienced by 77-85% of terminally ill cancer � Experienced by 77-85% of terminally ill cancer
patients
15
Causes of
Delirium/Agitation
� Infection
� Malignancies / Tumor burden and secretions
� Renal or hepatic failure
� Metabolic abnormalities (low/hi Na, low K, hi Ca,
low/hi glucose, hypothyroid, renal/liver failure) low/hi glucose, hypothyroid, renal/liver failure)
� Hypoxemia
� Sensory deprivation
� Medications
� Fecal impaction / Urinary retention
� Vitamin deficiencies
16
Assessment of
Delirium/Agitation
� Distinguish from other related symptoms
� Physical assessment
� History
� Spiritual distress
� Consider medical etiologies
17
Assessment of
Delirium/Agitation
Established tools
� Mini-Mental Status Examination (MMSE)
www.chcr.brown.edu/MMSE.pdf
� Memorial Delirium Assessment Scale (MDAS) � Memorial Delirium Assessment Scale (MDAS)
www.painconsortium.gov
� Delirium Rating Scale (DRS)
18
Assessment of
Delirium/Agitation
Established tools
� Confusion Assessment Method (CAM)
www.hartfordign.org/publications/trythis/issue13.pdf
� Neecham Confusion Scale (NCS)
www.unc.edu/courses/2005fall/nurs/213/001/neuropsychiatricwww.unc.edu/courses/2005fall/nurs/213/001/neuropsychiatric
/neecham.html
19
Treatment of
Delirium/Agitation
� Correct underlying cause
� Consider symptomatic and supportive therapies
� At end of life, causes may not be reversible and
medications are indicatedmedications are indicated
20
Treatment of
Delirium/Agitation
Pharmacological interventions
� Neuroleptics
� blocks dopamine uptake; metabolized by the liver
� Haloperidol (Haldol)� Haloperidol (Haldol )
� Severe agiation
21
Treatment of
Delirium/Agitation
� Benzodiapines
� Midazolam (Versed)
� Anxiolytics
� Lorazepam (Ativan) � Lorazepam (Ativan)
� Atypical Antidepressants – blocks dopamine
uptake selectively, but with less anticholingeric
effects
� Risperidone
22
Non-pharmacological
Treatment of Delirium/Agitation
� Encourage presence of family
� Avoid excessive stimulation
� Reorient if indicated
� Familiar people and items� Familiar people and items
� Acknowledge visions
� Complementary therapies
23
Delirium/Agitation
Patient & Family Education
� Reassure patient and family
� Review symbolic language
� Review medications
� Sensory stimulation if indicated� Sensory stimulation if indicated
� Instruct how to reorient
24
Delirium/Agitation
References
1. Emanuel L, von Gunten C, Ferris F. The Education for Physicians on End of Life Care (EPEC) Curriculum. Washington, DC: American Medical Association, 2003.
2. Breitbart W, Chochinov H, Passik S. Psychiatric aspects of palliative care. In: Doyle D, Hanks G, MacDonald N, eds. Oxford textbook of palliative medicine. New York, NY: Oxford, 2005.palliative medicine. New York, NY: Oxford, 2005.
3. Lichter I, Hunt E. The last 48 hours of life. Journal of Palliative Care 1990;6:7-15.
4. Pereira J, Bruera E. The frequency and clinical course of cognitive impairment in patients with terminal cancer. Cancer 1997;79:835-842.
5. Caraceni A. Delirium in palliative medicine. European Journal of Palliative Care 1995;2:62-67.
6. Kuebler KK, Heidrich D, Vena C, English N. Delirium, confusion, and agitation. In: Ferrell BR, Coyle N, eds. Textbook of Palliative Nursing. 2nd ed. New York, NY: Oxford, 2006:401-420.
25
Delirium/Agitation
Additional References
Bednash G, Ferrell BR. End-of-Life Nursing Education Consortium
(ELNEC). Washington, DC: Association of Colleges of Nursing, 2009.
26
Depression
� Intense and often prolonged feelings of sadness,
hopelessness and despair
27
Depression
Prevalence
� 25–77% terminally ill population
� 22% of nursing home residents
� Often not recognized at end-of-life� Often not recognized at end-of-life
28
Causes of Depression
� Medical conditions
� Pain
� Treatment-related factors
� Medications� Medications
� Psychological factors
� Financial issues
29
Assessment of Depression
� Symptoms associated with medically ill
� Enduring sad mood
� Hopelessness
Fatigue� Fatigue
� Diminished ability to make decisions
30
Assessment of Depression
� Risk factors
� Medical co morbidity
� Male > age 45
� Stressful life events
� Uncontrolled pain
31
Assessment of Depression
� Screening tools
� Mini-Mental Status Examination (MMSE)
� Beck Depression Inventory
� Geriatric Depression Scale
� Cultural influences
� Cultures may judge severity of depressive symptoms
differently
� Symptoms should not be dismissed because it is seen as a
characteristic of a particular culture
� Chinese may use the term ‘imbalance’
� Latino/Mediterrean may say ‘nerves’, ‘headaches’
32
Assessment of Depression
� Ask questions regarding
� Mood
� Behavior
� Cognition� Cognition
� Suicide assessment risk factors
� Psychiatric disorder
� Depression
� Alcohol abuse
33
Treatment of Depression
� Optimal
� Pharmacological
� Non-pharmacological
� Interpersonal interventions� Interpersonal interventions
� Complementary
34
PharmacologicalTreatment of Depression
� Antidepressants
� Blocks serotonin, (5HT) reuptake
� SSRIs
� Considered as first line treatment� Considered as first line treatment
� For debilitated patients start at 1/3 dose
35
PharmacologicalTreatment of Depression
� Tricyclics
� Blocks reuptake of various neurotransmitters at the
neuronal membrane
� Improves sleep
� Effective on 70% of patients treated
36
PharmacologicalTreatment of Depression
� Stimulants
� Stimulates CNS and respiratory centers
� Increases appetite and energy levels
� Improves mood� Improves mood
� Reduces sedation
37
PharmacologicalTreatment of Depression
� Other
� Steroids
� Improves appetite
� Elevates moodElevates mood
� Non-benzodiazepines
� Useful in patients wit mixed anxiety/depressive
symptoms
38
Non-pharmacological
Treatment of Depression
� Counseling
� reinforce goals and interventions of care plan established by
interdisciplinary team
� Behavioral interventions
� Provide directed / structured activities
� Focus on goal attainment / prepare for future adaptive coping
39
Non-pharmacological
Treatment of Depression
� Cognitive interventions
� Assist patient to reframe negative thoughts into positive
thoughts
� Interpersonal interventions
Build rapport with frequent, short visits� Build rapport with frequent, short visits
� Mobilize family and social support systems
� Complementary therapies
� Guided imagery
� Art and music therapy
40
Non-pharmacological
Treatment of Depression
Specific Behavioral Strategies
� Negotiate structured schedule
� Realistic goals
� Positively reinforce� Positively reinforce
41
Depression
Patient & Family Education
� Review signs and symptoms
� Instruct on prevalence
� Review medications
� Review non-pharmacological interventions� Review non-pharmacological interventions
� Provide private opportunity to talk
42
Depression
References
1. Bednash G, Ferrell BR. End-of-Life Nursing Education
Consortium (ELNEC ). Washington, DC: Association of Colleges
of Nursing, 2009.
2. Pasacreta JV, Minarik PA, Nield-Anderson L. Anxiety and
depression. In: Ferrell BR, Coyle N, eds. Textbook of Palliative
Nursing. 2nd ed. New York, NY: Oxford, 2006:375-399.Nursing. 2nd ed. New York, NY: Oxford, 2006:375-399.
3. Breitbart W, Chochinov H, Passik S. Psychiatric aspects of
palliative care. In: Doyle D, Hanks G, MacDonald N, eds.
Oxford Textbook of Palliative Medicine. New York, NY: Oxford,
2005.
4. Wrede-Seaman L. Symptom management algorithms: A
handbook for palliative care. Yakima, WA: Intellicard, 1999.
43
Questions?
Please join us on May 6 for Part 3 or 3
Symptom Management – Respiratory ,
Fatigue, & pressure ulcers
Laura Scherer RN, CHPN
Director at Unity Family Home Care and Hospice
320-631-5595 44
Round-Robin Discussion
Wrap-Up and Next Steps
• Next meeting
– Tuesday, May 6, 2014, 10 am – noon
– Knute Nelson Grand Arbor hosting
• 4403 Pioneer Road SE
Alexandria, MN 56308
– Educational Session: Symptom
Management Part III– Respiratory,
Fatigue, & pressure ulcers
• Presented by Laura Scherer
Questions?
Janelle Shearer, MA, RN, BSN
� 952-853-8553 or 877-787-2847
www.stratishealth.org
Stratis Health is a nonprofit organization based in Minnesota that leads collaboration
and innovation in health care quality and safety, and serves as a trusted expert in
facilitating improvement for people and communities.
This effort is sponsored by UCare and supported by Stratis Health.