Lorelei Sawchuk, RN, MN, CHPCN(C)Nurse Practitioner & SupervisorPalliative Care ProgramRoyal Alexandra HospitalEdmonton, AB780-735-4038Lorelei.Sawchuk@albertahealthservices.ca

24th Annual Palliative Care ConferenceEdmonton, AB

C1, C2…Continuing the Conversation: What is CRITICAL in providing comfort care?

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Conflicts of Interest Declaration

• None

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Objectives

• Utilizing the RMC Goals of Care Designation, the healthcare professional working at a patient’s beside will be able to:– Translate the care needs of palliative patients

designated as C1 or C2 level of care

“What is expected and what do I do when C1 or C2 care is prescribed?”

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Advanced Care Planning & Goals of Care Resources

• Conversations Matter Video Series• Conversations Matter Guidebook• Healthcare Professionals

– Goals of Care Order Form– Advanced Care Planning Tracking Record– Quick Reference Pocket Card

http://www.albertahealthservices.ca/3917.asp• E-Learning Modules

http://www.albertahealthservices.ca/4254.asp

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Purpose of Goals of Care Designations

• To reflect a patient’s values & beliefs regarding: – Care to receive– Location of care

Alberta Health ServicesAdvance Care Planning: Goals of Care Designation (Adult) PolicyRMC: Understanding the Goals of Care Designations

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Where & How We Choose to Die

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Common Symptoms at End of Life

• Pain• Tiredness (Lack of Energy)• Drowsiness (Feeling Sleepy)• Nausea• Lack of Appetite• Shortness of Breath (Dyspnea)• Depression (Feeling Sad)• Anxiety (Feeling Nervous)• Wellbeing (How you feel overall)

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Common Hospital Interventions• Imaging: Xray, CT, MRI…• Intravenous• Oxygen• Blood Tests• Medication

– Pills– Needles

• Vital Signs• Rehabilitation• Repositioning in bed• Toileting

– Voiding & bowel movements• Nutrition

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Overview of RMC

• R– Medical care & interventions include resuscitation

followed by ICU to cure or control of illness• M

– Medical & interventions to cure or control health condition without resuscitation or ICU

• C– Medical care & interventions without cure or control

of health condition– Maximal symptom control & maintenance of function Alberta Health Services

Advance Care Planning: Goals of Care Designation (Adult) PolicyRMC: Understanding the Goals of Care Designations

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Dialysis

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C Level of Care• Medical care & interventions focused on comfort• Care aimed at maximum symptom control &

maintenance of function without cure or control of illness• C1: Transfer may be possible to better understand or

control symptoms including surgery• C2: Physical, psychological & spiritual care anticipating

imminent death (hours to days). Do not usually transfer for care needs

Alberta Health ServicesAdvance Care Planning: Goals of Care Designation (Adult) PolicyRMC: Understanding the Goals of Care Designations

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Surgery

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Painful Bone Metastasis

• Radiation

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Pleural Effusions

• Thoracentesis

• PleurX

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Ascites

• Paracentesis

• Abdominal PleurX

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Infections

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M2 vs C1: The Role of Antibiotics

• http://www.albertahealthservices.ca/ps-1023351-acp-faq-clinical.pdf

• “By way of example, a person with an M2 designation who develops a new pneumonia would receive treatment aimed at cureof the pneumonia, but only in the current location of care. A person with a C1 designation who develops pneumonia might seek treatment that would relieve potential pain, dyspnea and distress, whether or not the treatment could fully resolve the pneumonia. Sometimes antibiotics would be contemplated for such a patient, with the sole intent of relieving symptoms.”

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Transfusions

• How would this help?• What would the

concerns be?

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Intravenous

• Antibiotics

• Diuretics

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PICC Lines

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Blood Tests

• Always ask…will this make the person more comfortable in easing symptoms

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Blood Glucose Management

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Less Painful Pokes

• IM or Subcut • EZ Set Butterfly

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HDC Pneumothorax

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How thirsty are you?

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Artificial Hydration

Why?• Prolong life?• Can improve comfort by

preventing toxic effects caused by pain medication

• Can ease the worries of the family

Why not?• Prolong life?• Decrease phlegm (respiratory

secretions)• Decreases breathing problems

from heart failure & fluid in the lungs (pulmonary edema)

• Reduce swelling (edema)• Does not help a dry mouth • Does not help thirst if mouth is

well cleaned and moistened

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Hypodermoclysis (HDC) “Clysis”

• IV fluids given through a small needle into the fatty (subcutaneous tissue) just under the skin

• Little worry if accidentally pulled out

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By Mouth

• By spoon• By sponge• By straw• Sips• At risk

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Mouth Care

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Artificial Nutrition

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Management of Agitation

• Restrain (yourself)• Calmness• Chemicals

– Haloperidol– Methotrimeprazine– Midazolam

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Oxygen

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Medication

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Medication Review• Acetaminophen 650 mg po QID• Centrum Forte 1 tab po Daily• Enalapril 10 mg po BID• Folic Acid 5 mg po Daily• Heparin 5000 units SC q12H• Lasix 40 mg po QAM• Metformin 850 mg po BID• Morphine ER (Long acting) 60 mg

po BID• Pantoprazole 40 mg po daily• Peg 3350 packet 17G po QAM• Prednisone 7.5 mg po Daily• Rosuvastatin 10 mg po Daily• Vitamin B6 25 mg po QHS

• Maxeran 10 mg po/SC Q6H PRN• Morphine 5 mg SC Q4H PRN• Zopiclone 3.75 mg po QHS PRN

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Vital Signs

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Skin Care

• Resposition• Resist

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Voiding

• Bathroom• Commode• Bedpan• Incontinence products• Texas condom catheter for men• Foley catheter• Monitor for urinary retention!

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Bowel Care

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Peace & Privacy?

• Preference• Communication!

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Summary

• Goals of Care are– Not contracts – Conversations– Opportunities to share concerns and wishes

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Lorelei Sawchuk, RN, MN, CHPCN(C)Nurse Practitioner & SupervisorPalliative Care ProgramRoyal Alexandra HospitalEdmonton, AB780-735-4038Lorelei.Sawchuk@albertahealthservices.ca

24th Annual Palliative Care ConferenceEdmonton, AB

C1, C2…Continuing the Conversation: What is CRITICAL in providing comfort care?