Goals of Care Discussions and formulating treatment plans
Navigating our healthcare system can be a burdensome endeavor for many of our patients with multiple complex conditions. Often randomly treating the conditions without a plan of care aligned with the patient and family's goals leads to inappropriate expensive, sometimes harmful care, causing collateral problems as a result of the interventions themselves. Having a coordinated plan of care that can be executed through the care continuum is not only imperative for these persons, but also helps to align their goals to the options offered to formulate a customized plan of care for their ailments. This prevents them from getting lost in a healthcare maze of repetitive burdensome interventions, hospital visits and specialist follow-ups.
Comprehensive Symptom Management
Palliative care is a specialized wholesome treatment of the person and the family. It is not disease focused, but rather attuned to the general symptoms and suffering be it physical or psychological. As the treatments for the advanced illnesses grows more and more complex, the incidence of stress and suffering like depression, anxiety and caregiver stress is anticipated to rise. During visits with the palliative care team, we diligently screen and treat for these symptoms, apart from general symptoms like pain, breathing problems and constipation, in a coordinated approach with help of a social worker, chaplain and nurses.
Advanced Care Planning
It is not uncommon to get caught unawares with the progress of advanced illnesses. This often happens with conditions like dementia, congestive heart disease or COPD. Though the trajectory of progression varies with each individual, the projection tends to be relentless given the fact the ailments tend to be progressive. Palliative care professionals have structured discussions with persons and their families to prepare them for what can happen next and down the line.
Comprehensive Medication Review
With progression of multiple advanced ailments, it is not uncommon for these patients to have multiple active prescriptions. This leads to medication errors, duplications, inter-actions and adverse drug reactions. . Careful and comprehensive medication review can help to prevent medication related problems like polypharmacy.
Management of geriatric syndromes
Progressive decline that is often associated with ageing can lead to certain conditions called geriatric syndromes. The common examples are frailty, dementia, depression or delirium. Screening and management of these conditions helps to better manage problems related to ageing that is often associated in patients with complex illnesses.
Want to share this with you all about what happened earlier today. A Palliative Care patient needed to come to the CDMC to be re-evaluated by our PC team. She is in horrific pain with open sores all over her body, very painful to touch – even clothing hurts her. Her mom knew she wouldn’t be able to walk into the center to be seen so our team headed outside to bring their care to her. The patient remained laying down in the car in the parking lot while Dr. Williams and his team, met with her mother to discuss the plan of care and provide supportive services to her. Our team removed the barrier that the patient couldn’t come to them so they went to the patient. This demonstrates what our PC team does for their patients. I know this patient really touched our PC team due to the nature of her illness and her young age. This team deals with these types of patients and circumstances every day yet continue providing special care to every patient, every time, every day.
This brought tears to my eyes when I saw this. I’m honored to work with this group of amazing individuals – they are heroes in my book.
Tracy S, Nurse Manager
Thank you palliative care team for the compassion you show our patients. I know several examples of tenderness and thoughtfulness that Palliative Care team engages in on a routine basis. We are proud of each of you and applaud you for providing loving comfort and support to our sickest patients.
Ed L, Director of Patient Experience