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KEY CONCEPTS

KEY CONCEPTS

  • image Palliative care may be provided to any patient with a serious illness, at any point in the course of the illness, including while a patient receives curative or disease-focused therapy.

  • image Hospice is a form of palliative care, which has been defined by Medicare to encompass care solely focused on comfort and quality of life during the last 6 months of a patient’s life.

  • image Pain is a common symptom among patients receiving palliative care and may be managed safely and effectively using nonopioid, adjuvant, and/or opioid therapies.

  • image Opioids are the drug of choice for the management of dyspnea.

  • image Constipation, nausea, vomiting, anxiety, and delirium are common symptoms among patients receiving palliative care and may be managed effectively with drug and nondrug therapies.

  • image End-of-life care can be provided to patients in the last days of their lives through palliative or hospice care, and provides management of common terminal symptoms.

  • image Identifying a patient’s goals and structuring care to achieve those goals is a key component of palliative care. Identifying a patient’s goals of care involves communication with patients, their families and/or caregivers, as well as other healthcare professionals.

  • image Addressing nonphysical needs, such as spirituality and faith, are key components of providing quality palliative care.

PATIENT CARE PROCESS

Patient Care Process for Cancer Pain

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Collect

  • Patient-specific information (age, sex, goal of care, patient and family beliefs/preferences regarding pain management)

  • Past medical history, concurrent disease states

  • Social history (alcohol or other substance use)

  • Current medications

  • Subjective data

    • Pain score/severity (e.g. at best, at worst, at rest, with movement)

    • Time course (acute vs. chronic and intermittent vs. persistent) of pain

    • Patient description of pain quality (e.g. achy, sharp, localized, diffuse)

    • Associated symptoms

    • Precipitating or palliating factors

    • Impact on patient’s ability to function

  • Objective data

    • Respiratory rate

    • Labs: serum creatinine (SCr), estimated glomerular filtration rate (eGFR), liver function tests (ALT, AST)

    • Electrocardiogram (ECG), QTc interval

Assess

  • Etiology of pain

  • Why are symptoms presenting now?

  • Severity of symptoms

  • Is pain stable/unstable?

Plan*

  • Pain management regimen including drug and nondrug therapy, consider scheduled vs. "as needed" or PRN therapy

  • Monitoring parameters for efficacy (pain severity and patient functioning) and safety (adverse effects such as sedation, constipation, nausea, and other drug-specific adverse effects)

  • Frequency of monitoring and follow up

  • Patient and caregiver education (e.g. expectations improvement in pain severity and function, medication use, and expected adverse effects and management)

  • Appropriate use of "as needed" or PRN medications

  • Safe medication storage and disposal

  • Referrals to other providers, if appropriate (e.g. physical therapy, behavioral health, chaplain)

Implement*

  • Provide education to patient, caregivers, and family members regarding treatment plan using the teach-back method

  • Schedule follow-up labs and appointments as applicable

Follow-up: Monitor and Evaluate

  • Improvement in pain symptoms (severity, patient function)

  • Presence of adverse effects (e.g. sedation, constipation, nausea)

  • Changes in renal/hepatic function

  • Medication adherence 

*Collaborate with patient, caregivers, and other healthcare professionals.

PRECLASS ACTIVITY

Preclass Engaged Learning Activity

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