Transcript 1. Palliative Care Consult

Palliative Care
Consultation
Elizabeth Whiteman, MD
James Davis MD
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
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
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
Key Components to effective
consultation
• Initial Contact
• Patient Assessment
• Written Note
• Follow-Up
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
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
Palliative Medicine
• The active” total care” of patients
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With chronic disease
With reversible /curable disease
With palliative treatment plan
With disease not responsive to treatment
With ongoing symptoms
Near end of life
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
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)
Patient Assessment - cont’d.
• Perform pertinent exam
• Look for common secondary issues:
malnutrition, weakness, anorexia,
delirium, spiritual suffering
The Palliative Examination
• – Symptoms
▫ Pain
▫ Shortness of Breath
▫ Nausea, Vomiting
▫ Dry mouth, secretions
▫ Constipation, diarrhea
▫ Anorexia
▫ Fatigue
▫ Depression/Anxiety
Rate
• Pain 0-10
▫ Factors that improve or make worse
• Dyspnea
▫ Rest, ambulation
• Mental status: depression, Assess for delirium if
appropriate
Additional problems may need
further assistance
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Spiritual
Social
Ethical
Discharge plan
Facilitate communication
Resources
Goals of care
Prognosis
Legal : advance directives/POLST, wills
The Written Note
• Consulting Physician
• Reason for consultation
• Problem List
• Recommendations
• Discussion
Consulting Physician
Write the name of the
physician who called and
SURE
name
the Attending Physician
I need advice
could you help?
Sure
I need advice
could you help?
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.
History/ Current Problems
• List problems that relate to the reason for
consultation first.
• Summary syndromes related to diagnosis or
symptoms.
Past Medical history
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List pertinent current diagnosis
Recent interventions, treatments
Coexisting medical conditions
Any surgical history especially related to disease
Medications
• List all current medications
• Note any past medications on hold
Allergies
• True allergies
• Side effects from medications
▫ Eg: nausea from certain medicine
▫ Eg: lethargy or insomnia
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, drugs
▫ Advance directive or primary contact in event of
emergency
Review of Symptoms- Palliative
focus
• Pertinent 14 point review of systems
• Palliative care assessment
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Anxious/nervous
Sad/Depressed
Dyspnea
N/V
Fatigue
Consciousness
Stool Pattern
Spiritual/Emotional Distress
Other
Functional Status ECOG
Physical exam
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Vitals
General
HEENT: oral exam, NG tubes
Lungs
CV, vascular
Abdomen
Extremities
Skin-decubitus ulcers, skin rashes, discoloration
Muscle tone, motor function, contractures
Psych: depression, anxiety, delirium
Labs, tests
• Pertinent labs
• Radiologic studies
▫ X-rays
▫ CT/ MRI/ PET
• Other: swallow studies, EMGs etc.
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 Status
• Goals of care, include patient’s primary contact
in event of emergency
• Social-caregivers, family support
• Plan for follow up
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.
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
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
References
• Weissman, D, Consultation in Palliative
Medicine, Arch Internal med, Vol 157, Apr 14,
1997.