end of life care: spiritual aspects in home based palliative care
TRANSCRIPT
“Healing The Whole”(Home Health Rotation Feedback)
Dr.M. Mataro HingorjoResident Year 04
Family Medicine AKU Karachi Sindh
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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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What is Palliative Care?
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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 eachhuman 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. 7
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?
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
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. 10
Spiritual Care
Cues Spiritual Diagnosis“My life is meaningless”“I feel useless”
Existential
Why would God take mylife… its not fair”
Anger at God or others
“I want to have a deeperrelationship with God”
Concerns about relationship withHigher being
“I am not sure if God is with meanymore”
Conflicted or challenged beliefsystems
Spiritual, Religious And Existential Aspects Of Palliative Care, Journal Of Palliative Medicine 2005 11
Spiritual Cues in the History
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 nottrue”
Religious/SpiritualStruggle
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Spiritual Cues In History
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
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-2007Puchalski 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
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. 15
1. Good relationship with God/Some one significant2. Clear conscience3. Hope4. Meaning5. Purpose6. Life concluded with no loose ends7. 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
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
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
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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 kidsAll 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
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