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What Is Palliative Care?
Palliative Care is an approach to care which focuses on
comfort and quality of life for those affected by life-
limiting/life-threatening illness. Its goal is much more
than comfort in dying; palliative care is about living,
through meticulous attention to control of pain and
other symptoms, supporting emotional, spiritual, and
cultural needs, and maximizing functional status.
What Is Palliative Care?
Not defined by:– Body system (compare with dermatology,
cardiology)– What is done (compare with anesthesiology,
surgery) – Age (compare with pediatrics, geriatrics)– Sex of patient (such as with gynecology)– Location of Care (compare with ER, critical care)
Any illness, any age, any location…
What Is Palliative Care?
The spectrum of investigations and interventions
consistent with a palliative approach is guided by goals
and expectations of patient and family and by accepted
standards of health care, rather than being bound by
preconceptions of what is or is not "palliative".
Potential Palliative Care Interventions
Palliative
EmotionalSpiritualPsychosocial
Support
Control of
• Pain• Dyspnea• Nausea• Vomiting
Variable
Infections
Transfusions
Hypercalcemia
Dialysis
Tube Feeding
CPR
Ventilation
Highly burdensomeInterventions
Generally Not Palliative
No Community Outreach
Seven Oaks
Hospital
Seven Oaks
Hospital
HSCHSCConcordia Hospital
Concordia Hospital
VictoriaHospitalVictoriaHospital
GraceHospitalGrace
HospitalSBGH
•20 beds•served SBGH and local area
SBGH•20 beds•served SBGH and local area
39 PCH
s
39 PCH
s
RHC•30 beds•patients primarily from HSC & community
RHC•30 beds•patients primarily from HSC & community
JocelynHouse
•5 beds
JocelynHouse
•5 beds
Winnipeg Palliative Care Services: Pre-RegionalizationWinnipeg Palliative Care Services: Pre-Regionalization
Inpatient attending & consulting
Home consultative support
No formal services
CC
Seven Oaks
Hospital
Seven Oaks
HospitalHSCHSC Concordia
HospitalConcordia Hospital
VictoriaHospitalVictoriaHospital
GraceHospitalGrace
Hospital
SBGH•15 beds
SBGH•15 beds
39 PCHs
39 PCHs
GraceHospice
•12 beds
GraceHospice
•12 beds
RHC•30 beds
RHC•30 beds
JocelynHouse
•4 beds
JocelynHouse
•4 beds
Winnipeg Palliative Care Services: Post-Regionalization
Inpatient attending & consulting
Home & facility consultative support
Children’sHospital
Children’sHospital
Completely newcomponent
Palliative Care Program
Two streams of service delivery:1. Registration on Program2. Consultative Services
Registration on Program
Patients can be “registered” on the Palliative Care Program if they meet program criteria:
– Prognosis of less than 6 months–No longer receiving aggressive treatment which
requires on-going monitoring for and treatment of serious complications
–Have chosen a comfort-focused approach including a decision to decline attempted resuscitation
Registration on Program
Once registered with the program, patients are eligible for:
– Case management through Palliative Care Coordinator– Access to Community Palliative Care Nursing 24/7
• Palliative Care Nurses have access to Palliative Care Physician
– Admission to Palliative Care Units (PCU) and Hospice – if bed available
– Enrollment on Provincial Palliative Care Drug Access Program
When to Register a Patient on Palliative Care Program
• Patients are considering going home from acute care– Need to plan for services to be in place
• Patients being transferred to Long Term Care Setting
How to Register a Patient on PC Program
• Complete the “Application for Registration” form – 2 page form– “completed” forms can be processed more quickly
• Completed forms are reviewed by PC coordinator– Accepts on to Program– Rejects application – all reviewed by Manager, Program
Director or Medical Director
Acute Palliative Care Units
St. Boniface Hospital• 15 bed unit• Access to tertiary care services
Riverview Health Centre• 30 bed unit (2 beds currently closed)• Long term care facility
Acute Palliative Care Units (PCU)
• Admission to PCU for symptom issues– Physical symptoms– Psycho-social distress– Caregiver distress
• Admissions managed centrally by PC program staff– Bed management guidelines
Acute Palliative Care UnitsOnce symptoms are controlled, actively
discharge to appropriate site– Approximately 75% of patients die on PC unit– Approximately 20% of patients are discharged
home from Palliative Care Units– Lack of care options if home not possible
• PCH• Chronic Care• Hospice
Hospice settings in WRHA
• Grace Hospice• 12 beds in stand alone facility near Grace hospital• RN staffing 24/7• Limitations in care that can be provided
Hospice settings in WRHA
• Jocelyn House• 4 beds in split-level home in St. Vital• RN staffing 4 hours a day – 5 days a week
• HCA provide care 24/7
Hospice
Hospice is appropriate when:– Symptoms well controlled– Care needs are not complex– Prognosis of 1 – 3 months– Patients cannot or do not wish to be cared for in
the community
Care in the Community
• Majority of patients on Palliative Care program are in the community
• Recently expanded community model of care to incorporate an Inter-professional approach
PCHs
PCHs
PCHs
NortheastNorthwest
South
Central
Patients at home
Home
PCHs
Patients at home
Patients at home
7 Oaks
HSC
VGH
ConcordiaGrace
CommunityClinics
CommunityClinics
CommunityClinics
Community Teams:•Community
Nurses•CNS•MD•Coordinator•Psychosocial
Inter-professional Community Model• Each community team considers patients in their
area as their “ward”– Inclusive of all care settings – home, acute care and long
term care– Team meetings to discuss patient care needs especially
when transitioning between care settings– Focus on meeting needs in a proactive way– Opportunity to strengthen networks with other care teams
to support patients and families including the opportunity to model “palliative care”
Care at Home
• Palliative patients in community have same service limitations as all Home Care clients– HCA and PSW services provided by Home Care
Program
• Families/caregivers must be very involved in providing care
Consultative Services
• Available to anyone with a life limiting illness in any care setting for symptom management, psycho-social support or assistance with discharge planning
• Consultation services are provided by inter-professional team members including:– Palliative Care Physician– Palliative Care Clinical Nurse Specialist– Psycho-social Support Specialist
When should Palliative Care be consulted?
• Assistance with symptom issues– Managing Physical symptoms
• MD to MD consults for advice 24/7
– Psycho-social
• Assistance with care planning– What might care team expect as patient nears end
of life?• Will oral route be available?• Could symptoms escalate?
When should Palliative Care be consulted?
• Goals of care are not clear– Discrepancy between patient, family and/or
members of care team with plan of care
• Discharge to community or LTC is anticipated– Does patient need to be or are they currently
“registered” on Palliative Care program?– Would it be appropriate for Palliative Care nurse
to see the patient in the community?
What information is needed on consult?
• Main reason for consult– What is the main symptom issue?
• Urgency of consult• Is the physician aware of the consult?
Diagnosis ofLife-Limiting
Illness
Transitioning to Palliative
Palliative
Consult Service
Community Palliative Nursing
• Case Coordinator• Admission Eligibility• Medication Coverage
• comfort-focusedcomfort-focused• prognosis prognosis ““6 mo. or less6 mo. or less””• some treatment limitationssome treatment limitations
(DNAR, no TPN, no (DNAR, no TPN, no chemoTx with high chemoTx with high adverse effectsadverse effects
• aggressive, often toxic treatment focused on cure or life-prolonging disease modification