The information in this "Want to know more" section is organized according to the following major components of the NURSING PROCESS:
Palliative care: The World Health Organization’s (WHO) definition is 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 physical, psychosocial and spiritual problems (WHO, 2005).
Geriatric palliative care: the approach to care for the chronically ill and frail elderly. The focus is on quality of life, support for functional independence, and centrality of the patient's values and experiences in determining the goals of medical care (Morrison & Meier, 2003).
Geriatric palliative care is integrative using interdisciplinary delivery of care. The goal to relieve pain and suffering and improve quality of life for elderly patients and their families. The core principles are comprehensive patient/family unit centered that enhance functional independence and quality of life transitioning between levels of care (Morrison & Meier, 2003).
Symptom management: recognition and treatment of physical and nonphysical symptoms to prevent suffering and improve quality of life (Kazanowski, 2003).
Goal of Palliative Care
The goal of palliative care is "to prevent and relieve suffering and to support the best possible quality of life for patients and their families regardless of the stage of disease"(National Consensus Project for Quality Palliative Care, 2004).
Background of Geriatric Palliative Care
Markers for Initiation of Palliative Care in Geriatrics
(Adapted from Morrison & Meier except as noted)
Core End-stage Indicators indicating terminal phase of chronic illness are physical decline, weight loss, multiple comorbidities, and a serum albumin of <2.5 g/dL. Dependence on assistance with most activities of daily living and a Karnofsky Performance score of less than 50% (Matzo, 2004).
Non-Disease Specific Indicators
Disease Specific Markers
Needs of the Geriatric Palliative Care Patient
Edmonton Symptom Assessment Scale. (Victoria Hospice Society, 2001). http://www.palliative.org/PC/ClinicalInfo/
Palliative Performance Scale. Relevant to palliative care function. (Victoria Hospice Society, 2001). http://www.palliative.org/PC/ClinicalInfo/
Karnofsky Performance Scale. Allows patients to determine their own functional capacity. http://www.hospicepatients.org/karnofsky.html
Criteria for Hospice Eligibility for in Persons with Dementia
It is important for medical providers to be familiar with the criteria for Hospice eligibility. Hospice is often under-utilized in end stage dementia and often times not utilized until the last days or weeks of life. In fact, less than 3% of the nation's hospice census comprises patients with Alzheimer’s dementia (the most prevalent form of dementia), according to the Virginia-based National Hospice and Palliative Care Organization (NHPCO). (Miller, 2003; Schonwetter et al, 2003). View eligibility criteria at: http://www.aafp.org/afp/20031015/tips/2.html
Symptom Management in Palliative Care
Research indicates that persons near the end of life, those that are frail and those that have multiple chronic symptoms suffer symptoms of distress (Morrison & Meier, 2003; Kazanowski, 2003; National Consensus Project for Quality Palliative Care, 2004). Research also indicates that aging persons are often under-treated if treated at all for distressing symptoms. (Evers, Meier, & Morrison, 2002). Assessment and management of distressing symptoms is paramount for quality of life in aging persons.
The following are common symptoms in geriatric palliative care. There is an abundance of information available on the web. Assessment tools and intervention strategies for each are provided, many via web links.
Definition: "Dyspnea is a subjective experience described as an uncomfortable awareness of breathing, breathlessness, or severe shortness of breath"(HPNA, 1996).
Potential Causes of Dyspnea
(Adapted from Morrison & Meier, 2003 except as noted)
Assessment of dyspnea
Management of Dyspnea
Goal of managing dyspnea in the palliative care patient is to ensure the best quality of life (Morrison & Meier, 2003).
Treatment and Interventions for Dyspnea
Specific Causes and Treatment for Dyspnea
BREATH AIR mnemonic (Dickerson et al, 2001)
See also: EPERC Fast Fact #027: Dyspnea at End-of-Life: Weissman, DE(2005). 2nd Edition. End-of-Life Palliative Education Resource Center. Access at: http://www.eperc.mcw.edu/fastFact/ff_027.htm
Patient and Family Education
The overlap of physical illness symptoms with signs and symptoms of depression complicates reliable diagnosis during illness. Incidence increases with higher levels of disability, advanced illness and pain (Morrison & Meier, 2003). Persistent feelings of helplessness, hopelessness, inadequacy, depression and suicidal ideation are not normal at the end of life or in aging and should be aggressively evaluated and treated (Morrison & Meier, 2003).
Prevalence of Depression (Morrison & Meier, 2003)
Assessment/Screening Tools for Depression
EPERC Fast Fact: Is it Grief or Depression?
Periyakoil, VJ. Fast Facts and Concepts #43: Is it grief or depression? August 2005, 2nd edition. End-of-Life Physician Education Resource Center www.eperc.mcw.edu
Geriatric Depression Scale
Assess for Depression Risk Factors (Dickerson, Benedetti, Davis et al., 2001)
For further Assessment and Interventions for Depression in Aging persons see ConsultGeriRn Depression Topic.
Depression in Advanced Cancer
Warm, E, and Weissman, DE. (July, 2005). Depression in Advanced Cancer. Fast Facts and Concepts #7; 2nd Edition End-of-Life Physician Education Resource Center www.eperc.mcw.edu. http://www.eperc.mcw.edu/fastFact/ff_007.htm
Fatigue: "an overwhelming, sustained sense of exhaustion and decreased capacity for physical or emotional work"(Tiesinag,Dassen & Halfens, 1996). Described by patients as worn out, exhausted sleepiness, tired, low energy and care providers as lethargy or malaise (Morrison & Meier, 2003).
There has been no consensus on the definition of fatigue in palliative care; however the following criteria was delineated by Dean & Anderson: (Dean & Anderson, 2001).
Background (Morrison & Meier, 2003)
Background (Morrison & Meier, 2003)
Causes of Constipation
(Dickerson, Benedetti, Davis, et al., 2001)
Directly related to tumor site: bowel cancers, secondary bowel cancers, pelvic cancers, hypercalcemia, and surgical interruption of bowel integrity, inactivity, weakness and/or inability to reach toilet, poor nutrition, and dehydration related to nausea and vomiting, polyuria, or fever.
Hypercalcemia: low calcium causes decreased absorption leading to constipation.
Concurrent disease related (Morrison & Meier, 2003)
Diabetes, hypothyroidism, hypokalemia, diverticular disease, hemorrhoids, colitis, or chronic neurological diseases.
Opioids, anticholinergic effects, tricyclic antidepressants, antiparkinson medications, antihypertensives, antihistamines, antacids, diuretics, vinca alkaloids, NSAIDs, or anticholinergics.
Screening Tool: Constipation Scale
|Box 1. Constipation Scale|
Perform: Plain, Supine x-ray of abdomen, divided into 4 quadrants. Evaluate for constipation:
|Adapted from McMillian and Williams, 1989|
Suggestions for Treatment for Constipation (Sykes, 1997)
The loss of appetite is common in end stages of illness. However, it needs to be sorted out from potential reversible causes such as medication induced constipation. Reversible causes should be evaluated in aging persons prior to adding further medications. Anorexia accompanies physical deterioration and frequently causes significant concern in patients and families (Morrison & Meier, 2003). It also contributes to the cachexia syndrome (which is not due to inadequate food intake – see resources below). Weight loss often ensues before anorexia and the only treatment is to reverse the underlying cause(Morrison & Meier, 2003).
Potential Reversible Causes of Anorexia (Morrison & Meier, 2003)
Interventions/Treatment for Anorexia
Consider treatment for anorexia only after reversible causes are ruled out.
See Oral Healthcare topic.
Cancer Anorexia/Cachexia: Palliative Care Tips
Program, Edmonton Alberta. (April, 2005). Access at: http://www.palliative.org/PC/ClinicalInfo/PCareTips/
ABCs of Palliative Care: Anorexia, Cachexia, and Nutrition. Access free journal article at: http://bmj.bmjjournals.com
Courtesy of Blackwell Publishing. www.blackwellpublishing.com
Dysphagia affects 12% of one study of 800 palliative care patients (Sykes, Baines, Carter, 1988). 30% of these were not confirmed by assessment and attributed to possible anxiety and poor appetite (Sykes, Baines, Carter, 1988). Dry mouth or inadequate chewing in edentulous patients can also cause dysphagia when no obstruction or neuro deficit exits(Morrison & Meier, 2003).
Mouth problems left untreated can lead to further problems: difficulties with nutritional intake, infections, pain, and difficulty communicating. These problems may include dry mouth, infections or mucositis (due to chemotherapy). See Oral Healthcare Topic for management of general aging mouth problems.
Assessment, Interventions and Treatment of Mouth Problems
ConsultGeriRn Oral HealthCare and Nutrition topics
Fast Facts: Oral Mucositis Prevention and Treatment
Henson DF and Arnold R.( September 2004). Fast Facts and Concepts #121: Oral Mucositis: Diagnosis and Assessment. End-of-Life Physician Education Resource Center www.eperc.mcw.edu.
Henson CF and Arnold R. (January 2005). Fast Facts and Concepts #130: Oral mucositis: Prevention and treatment. End-of-Life Physician Education Resource Center www.eperc.mcw.edu. http://www.eperc.mcw.edu/fastFact/ff_130.htm
Pain is the most distressing and feared symptom near the end of life (Morrison & Meier, 2003). Older persons tend to under-report pain and are often under-treated for pain(Evers, Meier, & Morrison, 2002). In addition, ageing persons often have complications from treatment however can pain be relieved in aging persons if managed appropriately (Morrison & Meier, 2003). Medical personnel have a moral obligation to provide effective pain relief and prevent unnecessary suffering, particularly in those at the end of life (AGS Ethics Committee, 2003).
Assessment, Interventions, Treatment and Family Education for Pain
Relieving Pain, Pain Algorithms, Pain in Nursing Homes and other information. Innovations in End of Life Care on–line (2002) at http://www2.edc.org/lastacts/pain.asp
See also ConsultGeriRn Pain Topic
Symptom Management: Treatment Approaches
Reproduced with permission of Promoting Excellence in End-of-Life Care, a national program of The Robert Wood Johnson Foundation. Access at: http://www.promotingexcellence.org/index.html
Treatment Tables for Specific Symptoms at: American Academy of Hospice and Palliative Medicine. Access at: http://www.aahpm.org
Guidelines for Health Workers Supporting Families in the Community
Includes symptom specific algorithms, interventions and education of families providing care at home. (European approach). World Health Organization. (2004). Palliative Care, Symptom Management and End of Life Care: Interim Guidelines for first-Level Facility Health Workers. http://ftp.who.int/htm/IMAI/Modules/IMAI_palliative.pdf
Geriatric Palliative Care. Morrison, RS and Meier, DE (eds.). (2003) order at http://www.oup.com/us/catalog/general/subject/
AGS Ethics Committee. (2003). The care of dying patients: a position statement. Journal of American Geriatrics Society, 43, 577-578.
Alzheimer’s Association. (2005). Original Medicare: An outline of benefits. Accessed Jan 31, 2006 at http://www.alz.org/Resources/FactSheets/FSMedicareOutline.pdf
Bednash G. & Ferrell B. (2001). End-of-Life Nursing Education Consortium (ELNEC). Washington, DC: Association of Colleges of Nursing.
Dean, G.E. & Anderson, P.R. (2001). Fatigue. In Ferrel, BR & Coyle, N (Eds). The Textbook of Palliative Nursing. New York: Oxford University Press, 91-100.
Dickerson, D., Benedetti C., Davis, M., Graur, P., Santa-Emma, P., et al. (2001). Palliative Care Pocket Consultant. Kendall-Hunt Publishing Company.
Evers, M.M., Meier, D.E. Morrison, R.S. (2002). Assessing differences in care needs and service utilization in geriatric palliative care patients. Journal of Pain and Symptom Management, 23 (5), 424-32.
Hospice and Palliative Nurses Association (HPNA). (1996). Clinical practice protocol: Dyspnea. Pittsburgh, PA: HPNA.
Kazanowski, M.K. Symptoms management in palliative care. (2003). In Mazo, ML & Sherman, DW. Palliative Care Nursing: Quality Care to the End of Life, 327-361. Springer Publishing Company: New York.
Matzo, ML. (2004). Palliative care: Prognostication and the chronically ill. American Journal of Nursing, 104 (9), 40-49.
Miller, K.E. (2003). News & Publications: Predicting life expectancy in patients with dementia. American Family Physician, 68 (8), 1613.
Morrison, R.S. & Meier, D.E. (eds). (2003). Geriatric Palliative Care. Oxford University Press: NY.
National Consensus Project for Quality Palliative Carea. (2004). American Academy of Hospice and Palliative Medicine & Hospice and Palliative Nursing Association Task Force. Clinical Practice Guideline for Quality palliative Care. Accessed 10/29/2005 at: http://www.nationalconsensusproject.org/
Schonwetter, R.S., Han, B., Small, B.J., Martin B., Tope, K., Haley, W.E. (2003). Predictors of six-month survival among patients with dementia: an evaluation of hospice Medicare guidelines. Am J Hosp Palliative Care; 20:105-13.:
Sykes, N.P. (1997). A volunteer model for the comparison of laxatives in opioid-induces constipation. Journal of Pain and Symptom Management, 11, 363-69.
Sykes, N.P., Baines, M., Carter, R.L. (1988). Clinical and pathological study of dysphagia conservatively managed in patients with advanced malignant disease. Lancet, ii, 726-28.
Tiesinag, L.J., Dassen T.W., Halfens, R.J. (1996). Fatigue: A summary of the definitions, dimensions and indicators. Nursing Diagnosis 7, 51-56.
World Health Organization (WHO). (2005). Definition of Palliative Care. Accessed 10/27/05 at http://www.who.int/cancer/palliative/definition/en/
Last updated - March 2006
These protocols were revised and tested in NICHE hospitals.