Transcript Pediatric critical care division

CHILD NEUROLOGY, CRITICAL CARE AND
INFECTIOUS DISEASES: THE INTERSECTION
A multidisciplinary Approach to CNS Infection
July 28, 2014

To present a case of CNS infection and
discuss the multidisciplinary approach in the
management of CNS infection and its
complications.
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1. To recognize, diagnose and manage status
epilepticus which is a usual co-morbidity of CNS
infection.
2. To discuss CNS infections and its differential
diagnoses.
3. To emphasize the different diagnostic
modalities necessary in the approach of CNS
infections.
4. To provide the current management of CNS
infections and its complications.
5. To present a framework for the long term care
of post-infectious cases with CNS complications
by a multidisciplinary team.
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ID: 4/M from Bulacan admitted for the first
time
CC: depressed sensorium
HPI:
◦ 2-week history of fever (T max: 39.6 C) relieved
with Paracetamol
◦ No other associated S/S
◦ Fever persisted until 3 days PTA, there was
decreased appetite and increased sleeping time
◦ Admitted in a local hospital. Imp: Kawasaki disease
◦ Patient then developed GTC seizures. Diazepam
was given at 0.3mg/kg/dose.
◦ Transfer to PCMC
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Past Medical History: unremarkable
Family History: (-) PTB
Social History: youngest of 5 siblings (only boy);
enrolled in Nursery class prior to illness
Birth/Maternal History: non-contributory
Developmental History: at par for age
Feeding: eats regular table food
Immunization: completed EPI
During transfer, patient continued to have brief
generalized tonic-clonic seizures without regaining
consciousness. Travel time was approximately 30
minutes. At the ER, patient was still in active seizures.

What is your impression of the case?
◦ A. Status epilepticus
◦ B
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ILAE (International League Against Epilepsy)
◦ A seizure which shows no clinical signs of
arresting after a duration encompassing the great
majority of seizures of that type in most patients
or recurrent seizures without resumption of
baseline central nervous system function
interictally.
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PNA (Philippine Neurological Association)
• Although the popular definition of status epilepticus is
recurrent or continuous seizures lasting at least 30
minutes, the group recommends initiating treatment with
the status epilepticus protocol when seizures persist for
more than 5 minutes. This operational definition is based
on studies of seizure durations by Gastaut and Broughton,
(Level IIC) and Theodore et al, (Level III), Lowenstein, Bleck
and Macdonald, 1999 (Level III).
SE may be classified as follows (Riviello AAN 2003):
1. Generalized SE
a. Convulsive (tonic-clonic, myoclonic)
b. Nonconvulsive (Absence)
2. Partial SE
a. Simple (no alteration of consciousness)
i. Somatomotor (epilepsia partialis continua)
b. Complex (alteration of awareness)
0 -5 mins
5 – 30 mins
ABG
Brief Hx
PE/NE
Labs Glucose , ABG
When appropriate electrolytes, AED
level,
toxic screen
(Save blood for other tests)
if seizures persist
Give a second dose of
IV DZP or MDZ6
DiazepamIV
IV0.3
0.3mg/kg/dose
mg/kg/dose
Diazepam
rate1mg/min
1mg/min(max
(maxdose:
dose:<5yo:
rate
<5yo:>5yo:
5mg;10
>5yo:
5mg;
mg210
) mg2)
Rectaldiazepam
diazepam0.3
0.3mg
mg11--0.5
0.5
Rectal
3
3
mg/kg/dose
mg/kg/dose
Load PB 20 mg/kg/dose
At 1 mg/kg/min not to exceed
exceed 25mg/min
25mg/min
Max actual dose: 1000 mg 7,7, 88
However:
Whether the seizure is
controlled or not:
Pulse oximetry
OR
Midazolam 0.3 mg/kg/dose Buccal 1,3 Qualifier : If patient has
0.2 mg/k/dose IV4, 5
epilepsy and is on maintainance
AEDs (PB/PHT /VPA )  give
booster at 5mg/kg/dose ( if
possible get assay before
booster )
•Investigate for underlying etiology
of seizure
•Refer to Neurology Service STAT
30 – 60 mins
If seizures persist
Add Pb at 5 – 10 mg/kg /IV
(total of 30mg/kg)9
If sz are controlled
Maintain PB IV 5 mg/kg/day in two
divided doses. First maintainance
dose 12 hours after loading
If seizures persist give either PHT or
VPA :
a. Load PHT at 20 mg/kg/IV . If
seizures persist may give additional 5
– 10 mg/kg IV. Do not exceed 30
mg/kg
rate 1mg/kg/min; max 25 mg/min
Max actual dose: 1000 mg 10
Maintain PHT 5mg/kg/day in two
divided doses. Start maintenance 12
hours after loading
When giving PHT IV , flush IV line with
2cc Normal saline or plain distilled
water before and after giving PHT
Always make sure that the IV line is
in place
Child >2 years old
b. IV Valproic Acid loading dose (20 30 mg/kg)1
Rate of infusion : 3mg/kg/min
If seizures are controlled Maintain 5-6
mg/kg/dose q 6 hours
(CAUTION : can cause hepatotoxicity)
If no seizure maintain PHT / VPA
60 mins
If seizures persist despite
Benzodiazepines and maximal loading
doses of PB ,and PHT / VPA  Refractory
Status epilepticus
- hook to EEG monitor if available
1. Load with IV midazolam 0.2 mg/kg IV
bolus followed by IV
Infusion. Start at 2ug/kg/min , increase
by 4ug/kg/min q 5mins until seizure
stops or maximum of 24 ug/kg/min is
reached.
Preparation:
Dilute 3 mg/kg in 50 ml D5W wherein 1
ug/kg/minute is equivalent to 1 ugtt/min
2. Refer to Anesthesiologist
Propofol 1 – 2 mg/kg/iV bolus over 5
minutes followed by 5 – 10 mg/kg/hr IV
infusion1
Thiopental 5- 20 mg/kg IV to be infused
not faster than 25 mg/min followed by
0.5 – 3 mg/kg/hr IV infusion
Up titrate GA until EEG shows burst
suppression
Considering tapering GA after 12 hours
of burst suppression
Refer to Neurology Service
Stand by ventilatory support. Be ready to intubate and admit to ICU.
1. PNA Epilepsy Council Recommendations for the Treatement
of Status Epilepticus in Children more than 2 months old and
Adults
2. The Harriet Lane Handbook 15th Ed, 2000
3. ILAE. Status Epilepticus. www.ilae.org
4. Arif, H. Treatment of Status Epilepticus. Seminars in
Neurology 2007
5. EFNS Guidelines in the Treatment of Status Epilepticus 2006
6. Kalviainen, R. Status Epilepticus Treatment Guideline.
Epilepsia 2007
7. Panayiotopoulus, CP. A Clinical Guide to Epileptic Syndromes
and their Treatment. 2010
8. Phenobarbital. www.epilepsy.com
9. The Harriet Lane Handbook 16th Ed 2002
10. Bauer, L. Applied Clinical Pharmacokinetics. Ch 10.
Phenytoin. 2008
 Define
subclinical status
epilepticus and the role of EEG
Note: patient has depressed sensorium
-- on-convulsive status needs to be distinguished
from increased ICP
Definition of non convulsive status epilepticus (SE)
-- ANSWER: “enduring epileptic condition with
reduced/altered consciousness, behavioral, and
vegetative abnormalities, or merely subjective
symptoms, without major convulsive movements“
Role of EEG:
-- ANSWER:
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Status epilepticus is a medical emergency that
requires rapid and vigorous treatment to prevent
neuronal damage and systemic complications
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Admission of such patients to an intensive care
unit setting and meticulous hemodynamic
monitoring is mandatory
Guidelines for the Evaluation and
Management of Status Epilepticus
G.M. Brophy et al
Neurocritical Care Society
Status Epilepticus
Guideline Writing Committee
2012
Non-invasive airway protection
and gas exchange with head
positioning
Immediate
(0-20 min)
Maintain airway patency,
avoid snoring, administer
02
Intubation ( if airway comproMised or elevated ICP
Suspected)
Immediate
(0-10 min)
Establish secure oxygenation and ventilation
Vital signs : 02 sat, BP, HR
Immediate
(0-2 min)
Establish and support
baseline VS
Vasopressor support of BP
If SBP <90 or MAP < 70
Finger stick blood glucose
Immediate
(5-15 min)
Immediate
(0-2 min)
Support CPP
Peripheral IV access
Immediate
(0-5 min)
Establish medication route
1. Emergent initial AED tx
2. Fluid resuscitation
Diagnose hypoglycemia
1. Stop seizure
2. Establish euvolemia
Urgent SE control tx with AED
Immediate after initial
AED given (5-10 min)
Stop seizure
Neurologic exam
Urgent (5-10 min)
Evaluate for mass lesion,
acute intracranial process
Triage lab test panel
Immediate (5 min)
Diagnose life threatening
metabolic condition
Refractory SE tx
Urgent (20-60 min
after 2nd AED)
Stop seizures, tx strategies
based on individual patient
response and AED concentrations
Urinary catheter
Urgent (0-60 min)
Evaluate systemic circulation
Continuous EEG
Urgent (15-60 min)
Diagnostic testing
Urgent (0-60 min)
Evaluate for mass lesions,
meningitis, encephalitis
Urgent (0-60 min
Measure and control ICP
Evaluate for NCSE if not
waking up after a clinical
seizure ceases
CT
LP
MRI
Intracranial pressure monitoring
(depending on clinical
presentation)
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After diazepam, patient continued to have seizures
lasting for more than 5 minutes. He was loaded
with Phenobarbital with a loading dose of 20
mg/kg/dose, then maintained at 5 mg/kg/day.
Post-ictal exam: wt- 17 kg.
 PE: BP 125/80 CR- 128 RR-16 Temp- 38.1 C
◦ No dermatosis; Pinkish palpebral conjunctiva,
anicteric sclerae, no CLN palpated, clear breath
sounds, distinct heart sounds, no murmur; no
hepatosplenomegaly; full and equal pulses, no
cyanosis.
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Neuro exam
Stuporous, stertorous breathing
No eye opening, minimal withdrawal to pain
Pupils 2-3mm EBRTL, normal fundoscopy
(-) corneals, (-) Doll’s
(+) withdrawal to pain bilaterally, with extension of
the right extremities on pain stimulation
◦ (+) Babinski bilateral
◦ (+) nuchal rigidity
◦ He was intubated using a 4.5 tube at level 15
and was hooked to the mechanical ventilator.
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Upon admission to ICU:
◦ VS, NVS, I/O were monitored
◦ NPO; venoclysis was started
◦ The following labs were done.
NV
Protime
14.1 secs.
Control
13.8 secs.
INR
1.03
CBC
Results
Hb
85
120-180 g/L
Hct
0.292
0.37-0.54
Prothrombin 1.02
ratio
RBC
6.12
4-6 x 1012/L
activity
96%
WBC
15.7
4-11 x 109/L
aPTT
29.4 secs.
seg
74
50-70%
Normal
28 secs.
lympho
16
20-44%
mono
10
2-9%
platelet
552
150-450 x 109/L
ESR
12
<15
mm/Hr
CRP
10.4
<6 mg/L
Blood
chemistry
BUN
Urinalysis
2.3
2.9-9.3 mmol/L
color
Yellow
turbidity
Hazy
ph
6
Sp. gravity
1.02
pus
2-3
RBC
0-1
+
creatinine 29
80-115 umol/L
Na
131
135-145 mmol/L
K
4.5
3.6-5.5 mmol/L
Ca
2.33
2.2-2.55 mmol/L
TP
80
62-80 g/L
albumin
34
38-54 g/L
Amorphous
urates
globulin
46
22-34 g/L
bacteria
+
A/G
0.74
1.1-2.2:1
albumin
-
Sugar
++
ABG: ph-7.47 pCO2- 29.1 pO2- 207 HCO3- 21.1 O2 sat- 99% BE-(-1.7)
CXR: Bilateral pneumonia with consolidation,
left; hyperaeration and lymphadenopathies
•
Diagnosis is based on the neuro evaluation
(+)
(+)
(+)
(+)
depressed sensorium – stuporous
seizure
Babinski
nuchal rigidity
– Anatomic
Cerebral hemispheres, gray and white matter, and
meninges
– Etiologic
Subacute CNS infection
-- most probably TBM rule out bacterial meningitis,
fungal, less likely viral
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CSF studies
◦ To include opening and closing pressure
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Neuroimaging
◦ Because of the depressed sensorium, seizure, and
the subacute state, it would be best to do
neuroimaging prior to lumbar puncture
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What diagnostic tests would you request to
confirm your diagnosis?
Neurology
◦ CSF studies
◦ Neuroimaging
◦
Neuroradiology
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What neuroimaging would be appropriate in this
case?
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criteria
based on stability, need for contrast, etc
Discuss the results of the CT
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Neuroradiologist to give his comments and
impression with differential diagnoses.
CT scan of the head
◦ Ill-defined hypodensity is seen in the left basal
ganglia with mass effect on the ipsilateral ventricle.
◦ Ventricles are dilated.
◦ Meningeal enhancement is noted, particularly in the
basal cisterns.
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Neurology
◦ Based on the CT, give your impression.
◦ Recognizing signs of increased ICP
◦ How would you manage the elevated OP?
 Pharmacologic: decompressants, steroids
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ICU
◦ Other pharmacologic agents: Totilac, hypertonic
saline
◦ Non-pharmacologic: correction of blood gas,
elevate head, fluids, hyperventilation
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Neurosurgery
◦ Would you do shunting in this patient?
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Open forum
The mainstay of therapy for patients with
increased ICP is the maintenance of optimal
hemodynamic and respiratory support to
ensure adequate oxygenation and perfusion
of the brain.
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Emergency Management of Increased Intracranial Pressure
Alexander Fraser Pitfield, MD, Allison B. Carroll, MD, and
Niranjan Kissoon, MD
Pediatric Emergency Care & Volume 28, Number 2, February
2012
Acute
management
Post-Resuscitation
management
Emergency Management of Increased Intracranial Pressure
Alexander Fraser Pitfield, MD, Allison B. Carroll, MD, and
Niranjan Kissoon, MD
Pediatric Emergency Care & Volume 28, Number 2, February
2012
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Initial resuscitation
Seizure control
Sedation and Analgesia
Hyperventilation
Hyperosmolar therapies
Initial imaging
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Initial resuscitation
•
Airway protection for
patients with GCS < 8
•
Maintain normal
oxygenation and ventilation
•
Maintenance of systolic BP
greater than 5th % for age
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Seizure control
•
Prompt recognition and
treatment of both
convulsive and nonconvulsive seizures to
avoid increased metabolic
rate which can precipitate
increased CBF and
increased ICP
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Sedation and
Analgesia
•
•
•
Judicious use of sedatives and
analgesics prevents transient
increases of ICP caused by pain
and agitation
Balanced sedation to maintain
BP and, if possible, facilitate
assessment of neurological
status
Neuromuscular blockade may be
necessary to minimize metabolic
demand
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Hyperventilation
• Although hyperventilation is
NOT routinely
recommended, its short
term use for patients with
active evidence of cerebral
herniation is considered
acceptable emergency
management
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Hyperosmolar
therapies
• Both mannitol and
hypertonic saline can be
given as a bolus if signs of
acute neurologic
deterioration or cerebral
herniation are present
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Hyperosmolar
therapies
• Currently, mannitol is the first
choice for a hyperosmolar
agent for use in patients with
increased IZCP, but several
authors have argued that
hypertonic saline might be a
more effective agent
• There is no concensus as to
appropriate indications for use,
the best concentrations, and
the best method of delivery
DOSE
MANNITOL
HYPERTONIC
SALINE
0.25- 1 g/kg of 20%
mannitol given over
10-20 mins
5-10 cc/kg of 3%
hypertonic saline given
over 5-10 mins
ADVANTAGES
Early effect of cerebral
Added benefit of
vasoconstriction and a
expanding
more sustained
intravascular volume,
reduction in cerebral which may supplement
edema
CPP
DISADVANTAGES
Hypotension
secondary to osmotic
diuresis, renal function
compromise
May cause abrupt
increase in serum Na
levels
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Maintenance of
Normoglycemia and
Normonatremia
• Hypoglycemia impairs
the energy supply to
disrupted neurons,
while hyperglycemia
increase oxidative
stress
• Serum sodium should
be maintained at least
above 135 mmol/L

Patient Position
• Maintain head at midline
and elevated at 30 degrees
to maximize cerebral
venous return which lowers
ICP without lowering CPP
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Temperature control
• Hyperthermia increases
cerebral metabolic
demand by 5% for every
1 ◦C elevation in body
temperature, which may
result in relative tissue
hypoxia
• Brain cooling
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Hyperosmolar
therapy
• Continuous infusion of
hypertonic saline is titrated
as needed to maintain ICP
less than 20 mmHg
• Ideally, maintain serum Na
not more than 160 mmol/L
and serum osmolarity no
greater than 320 mosm/L
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CSF Drainage
• Drainage of CSF may be
considered in patients with VP
shunts
• Lumbar drainage may be
considered in patients with a
functioning ventriculostomy,
open basal cisterns, and no
evidence of a major mass lesion
or shift on imaging studies

Mannitol and Dexamethasone was started.
Opening pressure
30 cm H2O
color
Straw-colored, clear
RBC
crenated
non-crenated
16.67 x 109/L
0.10
0.90
WBC
lymphocytes
10 x 109/L
100%
Sugar
1.10 mmol/L
(12% of RBS)
2.78-3.89 mmol/L
Protein
138.7 mg/dl
8-32 mg/dl
GS
(-)
AFB
(-)
India Ink
(-)
Culture
Negative after 5
days
TB PCR
negative
Normal value
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Infectious service
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◦
What specific CSF exam would you request for?
Other ancillary tests: CRP, ESR
TB work-up, work-up family
How would you manage this case?

Neurology (3-5 mins.)
◦ give basis for diagnosis
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Infectious (5 min)
◦ Current WHO recommendations
 (Tabulate recommendations of WHO, PPS, PIDSP, CNSP)
◦ Can you rule out bacterial meningitis based on the
CSF findings?
◦ Steroids
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Open forum (3-5min)
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Repeat LP was done
CT scan was repeated and it showed
progression of the hydrocephalus.
Neuroradiology
Neurosurgery- VPS
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On the 16th day of the hospital stay, patient
developed on and off low to moderate grade fever,
desaturations, apneic episodes. Septic work-up
was done.
CBC
Urinalysis
Hb
106
color
Dark yellow, cloudy
Hct
0.358
RBC
6.47
Pus cells
3-6/hpf
WBC
20.2
RBC
0-1/hpf
seg
76
Amorphous PO4
Few
lymphos
16
bacteria
Few
monos
1
albumin
Trace
eosinos
2
Sugar
+++
bands
6
++++
platelet
391
Budding yeasts
with hyphae
◦ Rpt CXR: consolidation of the right lower lung.
◦ Blood culture: negative
◦ Patient was shifted to Piperacillin-tazobactam, and
diflucan.
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There was difficulty weaning the patient
inspite of improving clinical and radiologic
findings of the lungs. Patient remained
vegetative with minimal eye opening, no
regard, with roving eye movements. He also
became quadrispastic.
Discussants: ICU, Infx (5 mins.)
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Patient was referred to Rehabilitation
medicine for PT and OT.
Medical management was continued. Patient
was eventually weaned off and extubated.
He was discharged improved with the ff. PE
and NE:
◦ Awake, occasional smiling and crying
◦ Decreased spasticity on all extremities, but no
purposeful movement
◦ (+) Withdrawal to pain
◦ Bilateral Babinski
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Neurology- AEDs
Infectious- anti-koch’s
Rehabilitation med
Pediatric Palliative care
OPEN FORUM
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Diagnosis
Treatment
Complications
Long term care

On follow-up, patient has no regard, with
roving eye movement, smiles occasionally,
sits with support in his wheelchair (with
contraptions), fed per orem. He undergoes PT
3x a week, and OT 2x a week.
Objective
• To present a plan for the long-term care of
JBU
 Role of palliative care
 Output : Plan of care specific for the needs of
JBU when he goes back to the community
 Outcome: Quality of life (QoL)
Fever,
change in
sensorium,
Seizure
Diagnosis:
TB
Meningitis
Major
therapeutic
efforts 
Early
recovery
phase
Recovery
phase
Adjustment
to outcome
DISCHARGE
ADMISSION
JBU’s journey: Transition from health to ill-health
What do we know?
 JBU sustained significant neurologic deficits
 Vulnerability factors –
Respiratory problems
Feeding problems
Seizures
Mobility
Others:
•
•
•
•
Evidence of (severe) bulbar involvement (worsening swallowing, cough, gag reflex)
Severe hypertonia/spasms (Baclofen pump)
Severe visual impairment
VP shunt (with frequent need of review)
What is Pediatric Palliative Care
(PPC)?
• Active total care of child’s body, mind and spirit, and
giving support to the family
• It begins when illness is diagnosed, and continues
regardless of outcome of treatment.
• Evaluation and alleviation of child’s physical,
psychological and social distress
• Multidisciplinary approach, including the family and
use of available resources
• May be provided across health settings: hospital,
community health centers, home
WHO, 1998
Pediatric Palliative Care is NOT “Palliative care is end-of-life care.”
“Palliative care is doing nothing.”
“Palliative care starts when curative treatment
stops.”
• The American Academy of Pediatrics supports
an integrated model of palliative care in which
components of the program are introduced at
the time of diagnosis, whether or not the
outcome ends in cure or death.
Palliative Care and Hospice Care
Palliative care
• Anyone with serious illness
regardless of life expectancy
• Given together with curative
care
Hospice care
• Someone with an illness
with a life expectancy
measured in months not
years
• Treatments and medicines
aimed at relieving symptoms
The principles of treatment are the same.
Individualized blending of care
directed and at physical,
emotional, social and spiritual
needs of the child and family
with continuous re-evaluation
and adjustment
End-oflife
Hospice
Bereavement
care
Hope for a cure, life extension, a miracle
HOPE for comfort, MEANING…
STAGES OF PALLIATIVE CARE
S.Liben, et.al. Pediatric Palliative Care:
challenges and emerging ideas . Lancet 2008:
371:852-64
Never say “there is nothing we can do.”
• We cannot cure the incurable but we can control
many of the symptoms which cause distress.
• We cannot take away the pain of loss, but we can
stand with those who are grieving and share their
sadness.
• We do not have all the answers, but we can listen to
all the questions.
The Worldwide Palliative Care Alliance
Model of Care at the Cancer & Hematology Center
Quality of life (QOL)
Children with lifethreatening illness or
debilitating illness
Comprehensive care
with curative intent
YES
Emotional,
psychological, spiritual
well being
cure
Cancer and Blood
Center Medical and
Palliative care Team
NO
Continuous care –
community, home
Comprehensive care
with palliative
intent
Normal grieving and
bereavement
Appropriate use of
limited resources
INTEGRATED PEDIATRIC PALLIATIVE CARE MODEL
Categories of patients requiring palliative care
Category 1
Life-threatening conditions for which curative treatment may be
feasible but can fail.
e.g. cancer, irreversible organ failures of heart, liver, kidney
Category 2
Conditions where premature death is inevitable.
e.g. cystic fibrosis, Duchenne muscular dystrophy
Category 3
Progressive conditions without curative treatment options
e.g. Batten syndrome, mucopolysaccharidoses
Category 4
Irreversible but non-progressive conditions causing severe
disability, leading to susceptibility to health complications and
likelihood of premature death.
e.g. severe cerebral palsy, multiple disabilities such as following
brain/spinal cord injury, complex health care needs, high risk of an
unpredictable life-threatening event or episode
B. P. Himelstein, MD et.al. Pediatric Pallaitive Care
NEJM 2004;1752-62
How does palliative care for children differ from
palliative care for adults?
• Ongoing physical, emotional, cognitive and spiritual
development
• Communicate differently
• Understanding of illness, death and dying depends on
stage of development
• Member of many communities : families,
neighborhood, school
How does palliative care for children differ from
palliative care for adults?
• Respond differently to therapies and drugs
• Unable to advocate for themselves
• Most life-threatening conditions are rare
 Majority are familial
 Unpredictable prognoses  require years of caregiving
• Parents bear heavy responsibility for the care 
decision-maker
• Child’s death affects the whole family
Pediatric Palliative Care Team Model at
Cancer & Hematology Center
• Palliative care team –
• Medical (Primary physicians, Specialists)
• Nurses
• Social worker
• Child life specialist
• Chaplain or volunteer
• Family*
• Palliative core team performs supportive functions
“The hallmarks of palliative care are
communication and coordination, plus
excellent medical and nursing care, to enable
the patient to progress to the next phase of
his/her care.”
http://www.capc.org/building-a-hospital-based-palliative-care-program/c.
Center for Advance Palliative Care
Communication – key element of
palliative care
• Developmentally appropriate and effective
sharing of information
• Active listening
• Determination of goals and preferences
• Assistance with medical decision-making
• Effective communication with colleagues
National Consensus Project for Quality Palliative Care (2009). Clinical Practice
Guidelines for quality Palliative Care, 2nd edition.
http://www.nationalconsensusproject.org
Communication Skills in Palliative Care
Advance
planning
Family
Conference
Recovery
phase
Therapeutic
phase
Diagnosis
Breaking bad
news
Multidisciplinary team
Advance Care Planning
• Identify decision makers
• Discuss illness trajectory
• Identify goals of care
• Discuss about issues regarding care (respiratory
care, nutrition/feeding, seizure control, mobility issues), or
concerns near end of life
DIAGNOSIS
“Navigating uncharted territory”
CRISIS
Feeling
abandoned
INTERVENTION
Living on a
plateau
Child’s death
DAYS
WEEKS
MONTHS
YEARS
Example - Plan of Care
Goals
To prevent
occurrence of
seizure
Interventions
Provide a list o
home
medications
By whom
Nurse
Instruct
Resident/Nurse
caregiver on
Phenobarbital –
amount,
schedule, side
effects and
reportable
conditions
Monitoring/
Indicator
Number of
seizure
occurring 2-4
weeks after
discharge
Phenobarbital
level
(therapeutic
range)
Outcome
Seizure-free for
the last 6
months
Example - Plan of Care
Goals
Interventions
By whom
Monitoring/
Indicator
Outcome
To provide
assistance to
family/patients
Referral to
local social
worker
Social worker
Availment of
20% discount
as PWD
Reduction in
drugs and
medical supply
expenses by
20%
To improve
range of
motions of all
joints to
prevent joint
stiffness and
allow
flexibility.
Referral to PT
for
rehabilitation
PT
Range of
motions of all
joints 40% of
normal
Improved
mobility of
extremities
allowing
minimum assist
with ADLs
Ethical Principles
• Beneficence
• “Child best interest.”
• Non-maleficence
• “Do no harm.”
• Autonomy
• Right to self-determination; Informed consent
• Justice
• Allocation of health care resources according to need
Children and young
people with palliative
care needs and their
families can access the
services they need
according to the
different stage of the
child’s condition
Specialist palliative care
services Tertiary
specialist pediatric care
and symptom control
A key worker will be
responsible for
ensuring joined-up
and coordinated
service provision.
Core palliative care services
These Form the majority of
services required by children and
young people with palliative care
needs and their families. E.g.
community nursing teams,
hospices, bereavement services,
sibling support
Universal services The foundations for a good
palliative care service includes services which are
available to all children and young people. E.g.
GPs, education, playgroups
“You matter because you are you and
you matter to the last moment of your
life. We will do all we can to help
you, not only to die peacefully, but to
live until you die.”
Dame Cicely Saunders