by Josh Tipple
Dealing with palliative care patients, especially when on-call, can be difficult and will require you to think hard about your decisions. But fear not as Josh delivers yet another great article to help you through the most daunting situations. Part of the Physio On-Call series.
You never know what will be coming your way when you are working on-call, dealing with palliative care patients in a call out can really get pulses going. Palliative care can be really daunting when you initially encounter it, but there should be a lot of people involved in the patient’s care and you should use that to your advantage. I found it very beneficial to attend calls to palliative care patients when I started on the rota, there is a lot to learn just by coming in and doing simple things like positioning and advice to nurses, helps with clinical reasoning and getting used to these cases.
One thing I always struggled with in these situations was what treatments should be used and what should be withdrawn. There is not a completely right or wrong answer to this, every time will be different, and different physio’s will make different decisions. As with any assessment in respiratory medicine make sure you approach these cases with a good structure and get as much information as you possibly can before you formulate treatment plans; then clearly document your reasoning. As I mentioned previously, the whole MDT should be involved in the care of these patients so use them to inform decisions and to ensure that your treatment plan is in line with the patients’ best interests.
In palliative care your main role will be with symptom management and comfort (caveat - not in all cases), therefore there may be some treatments that are not very comfortable which you may think about stopping if they are not effective. Equally there may also be times when you are called-in to see a patient that is new to the hospital and you need to make a decision on the best treatments to manage their symptoms and make them comfortable, so there may be things you want to add.
I used to like to plan my treatment using a heartbeat as the basis, basically when the line goes up, what treatments would I add to the situation, and when the line goes down, what treatments should I remove from the situation. I’ll explain more below.
Consider the treatments the patient is currently on. Do they have enough O2? Is there a positioning regime in place? Has suctioning been tried? Etc…
Just thinking of a list like this may give you the answer to your treatment plan straight away. For instance, following a positioning and suctioning regime that the ‘day-physio’ has advised may be all that is needed to manage the call out. Also, if there has been no intervention, that’s a pretty good indication to come in and begin management. It would also give you a good idea of whether there is scope for further treatment or if the patient is already maxed on physiotherapy intervention.
Think about what other therapies you can offer. Linked to the previous point, how much more do you think you can do for the patient, is there likely to be any improvement in their situation?
Obviously if this is a completely new patient who has not been reviewed before, there would be a lot you can offer - and you can hopefully provide treatment that can benefit the patient. On the other hand, there may be nothing else that you can offer. In this case consider whether you can provide comfort to the patient and help manage their symptoms. You would also want to consider whether there are any adjuncts to treatment that you would want to explore.
Think about what therapies you should take away. If they are invasive and not effective, should we be persisting with them?
This should always be done in discussion with the medical team, stopping treatment is a viable option but it should always be made with the patient’s best interest in mind. For instance, if the patient is being suctioned regularly and copious secretions are being removed, but the effects are very short lived, stopping suctioning should be discussed with the medical team. Consider the comfort of the patient; this decision should be made as a team and not as an individual as the risk / benefit analysis can be very difficult to weigh up on your own (especially if you’re new to the on-call rota).
In this instance having clear clinical reasoning behind your treatment options will help you and when you document the session be sure to clearly explain why you are ceasing a treatment option.
What do you need to follow up on?
A quick email to the inpatient team/lead to let them know that you have been called in is always advisable for call outs, but when dealing with palliative patients there needs to be a little more detail. Things to consider:-
- The resus status of the patient
- Changes in the treatment regime (e.g. humidified O2/increased O2)
- If you did stop any treatments, explain why
This is by no means an exhaustive list but it will give you an impression of what to include.
Hopefully, this makes sense; remember this is only part of the puzzle. Palliative care will require you to think hard about your decisions. Visualising a heartbeat might give you a bit of inspiration to think about what can help and what can’t.
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