C1, C2…Continuing the Conversation:
What is CRITICAL in providing comfort care?
Lorelei Sawchuk, RN, MN, CHPCN(C)
Nurse Practitioner & Supervisor
Palliative Care Program
Royal Alexandra Hospital
Edmonton, AB
780-735-4038
[email protected]
24th Annual Palliative Care Conference
Edmonton, AB
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 Services
Advance Care Planning: Goals of Care Designation (Adult) Policy
RMC: 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
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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
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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) Policy
RMC: 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 Services
Advance Care Planning: Goals of Care Designation (Adult) Policy
RMC: 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-faqclinical.pdf
• “By way of example, a person with an M2 designation who
develops a new pneumonia would receive treatment aimed at cure
of 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?
Why not?
• Prolong life?
• Can improve comfort by
preventing toxic effects caused
by pain medication
• Can ease the worries of the
family
• 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
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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
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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
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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
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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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C1, C2…Continuing the Conversation:
What is CRITICAL in providing comfort care?
Lorelei Sawchuk, RN, MN, CHPCN(C)
Nurse Practitioner & Supervisor
Palliative Care Program
Royal Alexandra Hospital
Edmonton, AB
780-735-4038
[email protected]
24th Annual Palliative Care Conference
Edmonton, AB
46