Palliative Care Consultation - PowerPoint Presentation

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Palliative Care Consultation

Elizabeth Whiteman, MD

James Davis MD

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Goals and Objectives

Provide effective consultation

Improve Communication skills with primary team

Be able to assess patient palliative symptoms

Write a concise exam and recommendations

Follow up and provide support to patient and family as well as assist primary team in patient care

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How does the role of a consultant differ from that of a treating physician?

Consultant

The consultant is asked to answer specific questions relating to an area of expertise.

The consultant provides advice and recommendations to another physician or colleague.

Treating Physician

The treating physician chooses whether or not to carry out

recommendations

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Who is your client

1. The requesting physician/ team

2. The Patient

3.The patients family

All of the above, but the requesting physician is the one who has the question and requested the consult

Often may be in a difficult situation, work together with team to address teams questions AND patient goals

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Key Components to effective consultation

Initial Contact

Patient Assessment

Written Note

Follow-Up

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Initial Contact, You Should...

Identify

the consulting physician – resident, attending

Establish the reason for the consultation and the urgency

Discuss/negotiate with the resident – in person or by phone

Additional suggestions

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Reasons for Inpatient

Palliative Care Consultation

Pain management

Other symptom management

End of Life Care

Goals of Care discussion

Family Support/ Physician Support

Hospice referral/ Discharge planning

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Palliative Medicine

The active” total care” of patients

With chronic disease

With reversible /curable disease

With palliative treatment plan

With disease not responsive to treatmentWith ongoing symptomsNear end of life

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Objectives for a Palliative Care physician

Control

of physical and psychological symptoms

Competency in bioethical principles

Understanding options for care in end of life patients; home care, hospice, nursing home

Communication skills

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Patient

Assessment

Assess

for any acute symptoms that need urgent management.

Review other palliative symptoms that may need treatment or intervention.

Contact family members, nurses report and address teams questions.

Facilitate discussion or family meeting, other interdisciplinary needs (

eg

: chaplain, social worker)

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Patient Assessment - cont’d.

Perform pertinent exam

Look for common secondary issues: malnutrition, weakness, anorexia, delirium, spiritual suffering

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The Palliative Examination

– Symptoms

Pain

Shortness of Breath

Nausea, Vomiting

Dry mouth, secretionsConstipation, diarrheaAnorexiaFatigue

Depression/Anxiety

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Rate

Pain 0-10

Factors that improve or make worse

Dyspnea

Rest, ambulation

Mental status: depression, Assess for delirium if appropriate

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Additional problems may need further assistance

Spiritual

Social

Ethical

Discharge plan

Facilitate communicationResourcesGoals of carePrognosisLegal : advance directives/POLST, wills

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The Written Note

Consulting Physician

Reason for consultation

Problem List

Recommendations

Discussion

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Consulting Physician

Write the name of the physician who called and name

the Attending Physician

I need advice could you help?

Sure

I need advice could you help?

SURE

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Reason for consultation

A concise phrase or sentence giving the reason or reasons you are seeing the patient. This should be agreed upon and understood by the treating physician.

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History/ Current Problems

List problems that relate to the reason for consultation first.

Summary syndromes related to diagnosis or symptoms.

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Past Medical history

List pertinent current diagnosis

Recent interventions, treatments

Coexisting medical conditions

Any surgical history especially related to disease

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Medications

List all current medications

Note any past medications on hold

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Allergies

True allergies

Side effects from medications

Eg: nausea from certain medicine

Eg: lethargy or insomnia

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Social history

Pertinent social history including:

Recent functional status prior to hospital AND current functional status (ADL and IADL)

Social support: caregivers, family

Living situation

Smoking , ETOH, drugsAdvance directive or primary contact in event of emergency

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Review of Symptoms- Palliative focus

Pertinent 14 point review of systems

Palliative care assessment

Anxious/nervous

Sad/Depressed

DyspneaN/VFatigueConsciousness

Stool Pattern

Spiritual/Emotional Distress

Other

Functional Status ECOG

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Physical exam

Vitals

General

HEENT: oral exam, NG tubes

Lungs

CV, vascularAbdomenExtremitiesSkin-decubitus ulcers, skin rashes, discolorationMuscle tone, motor function, contracturesPsych: depression, anxiety, delirium

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Labs, tests

Pertinent labs

Radiologic studies

X-rays

CT/ MRI/ PET

Other: swallow studies, EMGs etc.

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Assessment and plan

Short summary -1 LINE

List active symptoms

Make sure to address teams question

List other palliative care symptoms active AND those potential symptoms future

Code StatusGoals of care, include patient’s primary contact in event of emergencySocial-caregivers, family supportPlan for follow up

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Recommendations

List these in a column and number them.

They should look like orders that could be transcribed on to the order sheet.

Make specific recommendations and limit the number

FOCUS on Palliative recommendations

Carry out any recommendations you can with the agreement of the treating physician.

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Example:

68 year old male with metastatic colon cancer, new pain and nausea

Pain

Morphine sulfate 30 mg PO q 12 hour

Morphine sulfate 10mg q4 hr PRN

Nausea

Start prochlorperazine 10mg q6hr prn

Social- pt request info on hospice care, order hospice consult

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Follow-Up

Be flexible – be prepared to alter recommendations as events unfold. Add recommendations as new problems arise.

Maintain verbal communication – directly contact the consulting physician with any important new recommendations. Get feedback on prior recommendations.

Anticipate – every patient needs a discharge plan, advanced directives

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References

Weissman, D, Consultation in Palliative Medicine, Arch Internal med, Vol 157, Apr 14, 1997.