Palliative Care

Sry Suryani Widjaja

Murni Teguh Memorial
Hospital

Questions the palliative doctor and other team

members may ask include
How can we help you live well?
What makes you happy?
What activities or experiences would you like to do or continue doing
so that you feel you are living well?
Are there any special events or activities that you are looking forward
to?
What are your fears or worries about your illness or medical care?
What needs or services would you like to discuss?
What do you hope for your family and loved ones?
What keeps you going when lifes challenges seem overwhelming?
Do you have religious or spiritual needs that are important to you?
In what way do you feel you could make this time especially
meaningful to you?
If you have to choose between living longer and living more
comfortably or energetically, how would you approach this balance?

Care giver

Health care team

Common treatments for pain relief
Relationship
Plan to live well
What additional needs
Communicate with family

Determine where and how much it hurts.

Provide the right pain relief.
Help children understand and cope with the illness.
Tips for Caring for a Child with Serious Illness
Be sensitive to signs that your child wants to talk about the
illness and don't change the subject or distract him or her. If your
child isnt ready to talk, however, don't force the conversation.
Make your child feel safe by using comforting language.
Say "I love you" frequently.
Let your child be a kid; let him or her play and enjoy life as much
as possible.
Continue to be a parent, setting limits as you would if your child
were well. Letting your child misbehave can actually make him or
her feel out of control and less protected

Treatment
Medical Treatments for Pain Relief
Opioids
Such as morphine, oxycodone, hydromorphone, methadone,
fentanyl, meperidine, codeine, hydrocodone, and
propoxyphene
Other pain medicines
Such as nonsteroidal anti-inflammatories (including naproxen,
celecoxib, and ibuprofen), tricyclic antidepressants,
anticonvulsants, N-methyl D-aspartate receptor antagonists,
anesthetics, alpha-2 agonists, and anticholinergics
Other pain relievers
Such as nerve blocks, spinal infusions, surgery, and radiation
therapy.

 Treatments for Other Symptoms

Shortness of breath
Change to a more upright position; open windows; use a fan,
humidifier, or air conditioning; avoid strong odors; and
identify triggers that cause the problem and eliminate them.
Nausea and vomiting
Avoid disagreeable foods and odors; avoid fatty and fried
foods; take most medications after eating; suck on a mint or
hard candy; eat small, frequent meals; and use relaxation
techniques.
Constipation
Certain foods and beverages, such as prune juice, can help,
but medical treatment is likely the best option.

 Disorientation or delirium
Loss of appetite
Depression and anxiety

Legal Document
The Five Wishes cover
which person you want to make
healthcare decisions for you when
you can't make them
the kind of medical treatment you
want or don't want
how comfortable you want to be
how you want people to treat you
What you want your loved ones want
to know

For clinicians
The following criteria have been developed to help
you assess whether a palliative care consultation
would be beneficial to you and your patient.
General Referral Criteria (one or more of the following):
Presence of a Serious, Chronic Illness
Declining ability to complete activities of daily living
Weight loss
Multiple hospitalizations
Difficult to control physical or emotional symptoms related to serious medical illness
Patient, family or physician uncertainty regarding prognosis
Patient, family or physician uncertainty regarding goals of care
Patient or family requests for futile care
DNR order conflicts
Use of tube feeding or TPN in cognitively impaired or seriously ill patients
Limited social support and a serious illness (e.g., homeless, chronic mental illness)
Patient, family or physician request for information regarding hospice appropriateness
Patient or family psychological or spiritual distress

 Intensive Care Unit Criteria

Admission from a nursing home in the setting of one or
more chronic life-limiting conditions (e.g., dementia)
Two or more ICU admissions within the same hospitalization
Prolonged or difficult ventilator withdrawal
Multi-organ failure
Consideration of ventilator withdrawal with expected death
Metastatic cancer
Anoxic encephalopathy
Consideration of patient transfer to a long-term ventilator
facility
Family distress impairing surrogate decision making

 Oncology Criteria
Metastatic or locally advanced cancer progressing despite
systemic treatments with or without weight loss and
functional decline;
Karnofsky < 50 or ECOG > 3
Progressive brain metastases following radiation
New spinal cord compression or neoplastic meningitis
Malignant hypercalcemia
Progressive pleural/peritoneal or pericardial effusions
Failure of first or second-line chemotherapy
Multiple painful bone metastases
Consideration of interventional pain management procedures
Severe prolonged pancytopenia in the setting of an untreatable
hematological problem (e.g., relapsed leukemia)

 Emergency Department Criteria

Multiple recent prior hospitalizations with same
symptoms/problems
Long-term-care patient with Do Not Resuscitate (DNR) and/or
Comfort Care (CC) orders
Patient previously enrolled in a home or residential hospice
program
Patient/caregiver/physician desires hospice but has not been
referred
Consideration of ICU admission and or mechanical ventilation in a
patient
with metastatic cancer and declining function
with moderate to severe dementia
with one or more chronic diseases and poor functional status at baseline

Five Things Physicians and

Patients Should Question
1. Dont recommend percutaneous feeding
tubes in patients with advanced dementia;
instead, offer oral assisted feeding.
2. Dont delay palliative care for a patient
with serious illness who has physical,
psychological, social or spiritual distress
because they are pursuing diseasedirected treatment.

 3. Dont leave an implantable

cardioverter-defibrillator (ICD)
activated when it is inconsistent with
the patient/family goals of care.
4. Dont recommend more than a
single fraction of palliative radiation
for an uncomplicated painful bone
metastasis.

 5. Dont use topical lorazepam

(Ativan), diphenhydramine
(Benadryl), haloperidol (Haldol)
(ABH) gel for nausea.

Palliative care team

Prescribe treatments to control pain and other
uncomfortable symptoms
Assist with difficult medical decisions , helping you
weigh the pros and cons of various treatments
Coordinate care with your other doctors and help
you navigate the often confusing healthcare
system
Guide you in making a plan for living well, based
on your needs, concerns, and goals for care
Provide you and your loved ones
emotional and spiritual support and guidance .

End of life
Providing Comfort at the End of
Life.
Comfort needs near the end of
life:
Physical Comfort
Mental and Emotional Needs
Spiritual Issues
Practical tasks