Knowing when to start palliative treatment is a significant factor to ensure an appropriate plan of care that provides the most benefits to both patient and cost. The Palliative Performance Scale (PPS) provides a guide to meaningful survival estimates thus allowing the palliative care team to create a course that will meet the needs of the patient from time of admission to death. Palliative care works best when begun at a diagnosis of the patient having approximately two years life expectancy. Allowing the palliative care team to evaluate and plan enables the best use of resources for patient and healthcare. The PPS is “a modification of the Karnofsky Performance Scale which measured five functional dimensions: ambulation, activity level and evidence of disease, self-care, oral intake and level of consciousness. The PPS is divided into 11 levels, from PPS 0% to PPS 100%, in 10% increments - a patient at PPS 0% is dead and at 100% is ambulatory and healthy.” (Lau 2009) It is designed to give an estimate of survival time and is subject to change constantly due to variables that occur in reality. As a tool, it is useful for healthcare professionals to have a better idea of when to initiate palliative care. “In the meta-analysis by Downing et al. on the survival patterns of 1808 patients from four independent studies, the PPS was confirmed as a strong predictor of survival for palliative care patients; higher PPS levels were associated with increased lengths of survival.” (Lau 2009) “…the study also identified the value of providing survival probabilities and lengths of survival in a way to assist clinicians in meaningful communication with patients and families.” (Lau 2009) Using the PPS and related tools to help healthcare professionals realize when palliative care is the best option for their patient would assist with beginning a palliative plan of care early. This would use the available resources more suitably for the needs of the patient and family. Early intervention also gives the family more time to adjust to a terminal diagnosis and complete tasks related to the eventual death of the patient. The palliative care team uses spiritual, psychological counseling and social workers to decrease the stress level for patient and family.

  Once a patient begins to be cared for by palliative care does all other treatment stop, is pain medication the only treatment? This is a misconception that keeps patients and healthcare professionals from using palliative care. Palliative care is defined by the World Health Organization as “an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.” (Kuziemsky 2007) Improving the quality of life means controlling the symptoms and pain associated with the patient’s condition. For example, the later stages of COPD causes a form of dyspnea referred to as air hunger, the terrible sensation of not getting enough air with each breath. Using low doses of morphine can relieve this symptom; however, most physicians and nurses are not educated as to opioid use for this purpose. In fact, one will often hear that the opioid will depress the respiratory drive and stop breathing. The truth is that “…Opioids are very effective in relieving dyspnea, although the exact mechanism is not understood. Contrary to common belief, this effect does not result through inhibition of respiratory drive. Relief from the “work of breathing” is a function of steady-state opioid levels, much like steady-state opioid levels relieve pain. Inhibition of respiratory drive results primarily from rising opioid serum levels. Studies have demonstrated significant relief of dyspnea from opioids without significant effects on ventilation or pCO2 levels in common therapeutic doses. Having said this, patients with dyspnea are fragile. Respiratory drive suppression can occur if serum opioid levels rise rapidly. Thus, when initiating therapy with opioids for dyspnea, one should start with a low dose and raise the dose slowly as needed” (Hallanbeck 2003).

  The pharmacology of palliative care is a creative and inventive science; often it benefits from necessity and discovers new uses for old drugs. The B.A.D. drip, for example, is an unlikely remedy for unresponsive nausea. It is Benadryl™, an antihistamine; Ativan™, a sedative and Decadron™, a cortisteroid. Individually each drug has no indications to use for nausea, but mixed together in a solution that is given intravenously over 24 hours at rate of 1 to 3 ml/hour and it eases nausea. Patients with end stage congestive heart failure (CHF) find that even small fluid weight gain can produce exhaustive dyspnea; using combinations of diuretics and doses based on daily weight gain can lessen the energy demand needed to breathe. End stage and dying patients have different physical tolerances to medication than the rest of the population. The disease process killing them can increase the amount of analgesic to control pain to exceptionally high levels; due to a combination of increased pain receptors and failing systems. The needs of these patients must be evaluated and treated in the sphere of palliative standards, with the goal being that the symptoms are controlled and/or relieved. Understanding that for palliative patients, an improved quality of the lifespan left to that person is the goal. Even a dying person can experience the healing impact of palliative care.

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