Fusing Palliative Consideration Into Your Dialysis Unit.

Consolidating Palliative Care Into Your Dialysis Unit Alvin H. Greenery, MD West Virginia University

RWJF ESRD Workgroup Recommendation: Dialysis Units Dialysis units ought to establishment palliative consideration programs that incorporate agony and side effect administration, advance consideration arranging, and psychosocial and profound backing for patients and families.

Objectives Describe the segments of a dialysis unit palliative consideration program Explain how every segment can be actualized Apply the components of palliative consideration to an appalling ESRD tolerant case

"Not prepared to go yet" A 73 year old lady created end-stage renal disappointment from different myeloma. She has had the different myeloma for a long time and got various courses of chemotherapy. Her oncologist said that her marrow was presently "wore out" and that further chemotherapy would not be of advantage. The patient had been incessantly sick and had been conceded month to month for contaminations, iron deficiency, and dying. She was iron deficient with a Hb of 7 and thrombocytopenic with a platelet check of 90,000.

"Not prepared to go yet" Because she had a terminal condition, her going to doctor did not surmise that dialysis ought to be offered to the patient. The patient, nonetheless, expressed that she was "not prepared to go yet" and that she needed dialysis.

"Not prepared to go yet" The patient was begun on CAPD and lived for nine months. Amid this time, she had 13 clinic affirmations for paleness, upper and lower GI dying, and CHF, and she was transfused with 46 units of stuffed RBCs and 190 units of platelets.

"Not prepared to go yet" On the day she kicked the bucket, she encountered a heart failure at her girl\'s home. The salvage squad was called, and the patient experienced unsuccessful CPR for 60 minutes. She was announced dead in the healing center crisis room.

"Not prepared to go yet" Sadly, she was not any more prepared to follow nine months of dialysis then she had been preceding the begin of dialysis. What is absent from the consideration of this patient?

Components of a Renal Palliative Care Program A Palliative Care Focus - Educational exercises (in-administrations) - QI exercises (M & M gatherings) - "Would you be astonished… ?" Pain & Sx Assessment & Management Protocols Systematized Advance Care Planning Psychosocial and Spiritual Support (peer advisors) Terminal Care Protocol (incorporates hospice) Bereavement Program (incorporates commemoration administration)

Pain and Symptom Assessment and Management Protocols

ESRD Patient Assessments of QOL N=165 Sites: DC, NY, WV Mean age: 60.9 yrs Gender: 52% men Dialysis span: 44 months Race: 33% African-American Biochemical markers: Hb 11.8; Kt/V 1.6; Alb 3.7 Diabetics: 34% Karnofsky Performance Score: 60%

ESRD Patient Assessment of QOL Single thing scale: Considering all parts of my life—physical, passionate, social, profound, and budgetary—in the course of recent days the nature of my life has been : Very terrible 0 - - 10 Excellent

Single Item Assessment of QOL

ESRD Patient Assessment of QOL Please list the PHYSICAL SYMPTOMS or PROBLEMS which have been the most concerning issue for you in the course of recent days. In the course of recent days, one troublesome manifestation has been:_________________

The Importance of Pain As a Symptom

Types of Pain Reported

Association Between Reports of Troublesome Symptoms and Quality of Life Measures Total Score Note: All outcomes factually critical, p values <.01

Pain Assessment Ask the patient and BELIEVE his/her protestation Use a precise way to deal with evaluation utilizing an approved torment scale Pain History Physical examination Diagnostic Procedures Reassess as often as possible

WHO 3-Step Ladder 3 extreme Morphine Hydromorphone Methadone Levorphanol Fentanyl Oxycodone ± Adjuvants 2 direct A/Codeine A/Hydrocodone An/Oxycodone A/Dihydrocodeine Tramadol ± Adjuvants 1 gentle ASA Acetaminophen NSAIDs ± Adjuvants

Nociceptive agony . . . Direct incitement of in place nociceptors Transmission along ordinary nerves sharp, dull, hurting, throbbing  substantial simple to depict, confine  instinctive hard to portray & restrict Tissue damage obvious Management opioids adjuvant/co-analgesics

Neuropathic torment . . . Cluttered fringe or focal nerves Compression, transection, invasion, ischemia, metabolic harm Described as blazing, shivering, shooting, wounding, electrical Management opioids adjuvant/co-analgesics frequently required

Opioids to Avoid in Kidney Failure meperidine morphine propoxyphene

Constipation . . . Normal to all opioids Opioid consequences for CNS, spinal string, myenteric plexus of gut Easier to avert than treat Start stimulant diuretic in the meantime as opioid Senna Casanthranol EPEC Module 4, 1999

Advance Care Planning

RWJF ESRD Workgroup Recommendation: Advance Care Planning Nephrologists ought to routinely welcome patients to express their end-of-life consideration inclinations in the required semi-yearly fleeting and yearly long haul care arranging gatherings.

Advance Care Planning Identification of Medical Power of Attorney Goals of treatment Cardiopulmonary revival (CPR) Feeding tubes Mechanical ventilation Dialysis Organ and tissue gift

Focus on Health States, not Treatments " Under what conditions would you not have any desire to live?" "Is it more critical to you to live as far as might be feasible in spite of some torment or to live for a shorter time yet without affliction?"

Dialysis Patients\' Preferences for End-of-Life Care (%) Singer.JASN 1995

Increasing the Completion of AD by Chronic Dialysis Patients concentrate on wellbeing states, not mediations (Singer, Holley) include surrogates in discourses (Moss, Singer, Holley, Swartz) increment dialysis unit staff\'s thoughtfulness regarding and comfort with talking about development orders (Perry, Holley)

DNR in the Dialysis Unit: A Form of Advance Directive Poor results with CPR of dialysis Patients\' rights to self-determination Patients\' conviction that other patients\' desires for DNR status ought to be respected

Psychosocial and Spiritual Support

RWJF ESRD Workgroup Recommendation CMS ought to require dialysis units to give sensible time to social specialists to insight patients on psychosocial issues encompassing end-of-life consideration. At present, social specialists are not utilizing their expert abilities for psychosocial backing of patients since they are given different parts, for example, orchestrating persistent transportation. Others may play out these capacities.

Role demonstrating Information apportioning Empathic listening Teaching how to function with the human services framework Clarifying qualities Helping issue fathom Relieving tension Legitimizing sentiments Consumer personality Advocacy Bridging staff and patients Peer Resource Consulting

PRC Training

Questions to Explore Spiritual Issues Is confidence (religion, deep sense of being) essential to you in this disease? Has confidence (religion, deep sense of being) been imperative to you at different times throughout your life? Do you have somebody to converse with about religious matters? Might you want to investigate religious matters with somebody? Lo B, Quill T, Tulsky J. Talking about palliative consideration with patients. Ann Intern Med 1999 May;130(9):744-9.

Questions Useful to Discuss Spiritual and Existential Issues What would despite everything you like to achieve amid your life? What may be left fixed if you somehow happened to bite the dust today? What is your comprehension about what happens after you pass on? Given that your time is constrained, what legacy would you like to leave your family? What do you need your kids and grandchildren to recollect about you?

Terminal Care Protocol

Would you be amazed if the patient kicked the bucket in the following year?

Referral to Hospice or Use of a Palliative Care Approach Recommendation No. 9, RPA/ASN CPG "… With the patient\'s assent, people with skill in such care, for example, hospice social insurance experts, ought to be required in dealing with the therapeutic, psychosocial, and otherworldly parts of end-of-life tend to these patients. Patients ought to be offered the choice of biting the dust where they lean toward incorporating at home with hospice care. Loss backing ought to be offered to patients\' families."

RWJF ESRD Workgroup Recommendation: CMS and ESRD Networks CMS ought to work in conjunction with hospice and the ESRD Networks to create manuals and preparing for clinicians in regards to coordination and linkage of dialysis and hospice administer to ESRD patients.

RWJF ESRD Workgroup Recommendation: CMS ought to permit utilization of the Medicare hospice advantage to ESRD patients who are confirmed by their doctors as at death\'s door yet proceed with dialysis until they kick the bucket.

"Not prepared to go yet" A 73 year old lady created end-stage renal disappointment from numerous myeloma. She has had the various myeloma for a long time and got various courses of chemotherapy. Her oncologist said that her marrow was presently "wore out" and that further chemotherapy would not be of advantage. What ought to have been finished?

Bereavement Program

Baystate Medical Center Dialysis Unit Memorial Service Videotape (5 min)

Conclusions Pain and manifestation administration are straightforwardly identified with dialysis tolerant QOL. Torment is the most troublesome manifestation for dialysis patients. Advance consideration arranging is important to regard dialysis patients\' desires, including for CPR. Psychosocial and profound backing are key segments of ESRD patient consideration.

Take-Home Message The ne