EH Palliative Care Template SW

Palliative Care Nurse Narrative/Interval History: “Palliative care is consulted in the setting of chronic obstructive pulmonary disease (COPD) exacerbation with declining functional status and uncontrolled dyspnoea as well as assistance with symptom management, advance care planning needs, and goals of care discussions in the context of serious illness.” 1. Present at consultation: “With express permission, the palliative care team met to review goals of care and advance care planning today with Sarah, the patient, and Mr. John Smith, her son.” 2. Hospital Course: “Palliative care is consulted in the setting of” - chronic obstructive pulmonary disease (COPD) exacerbation with declining functional status and uncontrolled dyspnoea “as well as advance care planning and goals of care discussions in the context of serious illness.” - Sarah, a 72-year-old female, presented with worsening shortness of breath over the past week, increased cough, and fatigue. Her dyspnoea is constant, 7/10 at rest, and exacerbated by any exertion. She reports difficulty sleeping due to breathlessness and has reduced her daily activities significantly. She has a long history of COPD, with previous hospitalisations for exacerbations. She uses salbutamol and tiotropium regularly but states they are less effective now. No previous palliative care involvement. Palliative Plan - Discharge to home with increased community palliative care support, including daily nursing visits for symptom management and assistance with personal care. Referral to hospice for further consideration if symptoms remain uncontrolled. Structure & Processes of Care - Patient education provided on understanding COPD progression, recognising symptoms of worsening dyspnoea, and the importance of adhering to her new medication regimen. Discussed non-pharmacological methods for dyspnoea management, such as pacing activities and pursed-lip breathing. Reviewed the purpose of palliative care in improving quality of life. - Discussed introducing hospice options as her condition progresses, outlining the differences between palliative care and hospice care, focusing on comfort measures and quality of life at end-of-life. Explained various care settings available through hospice. Physical Aspects of Care - Assessment: Likely diagnosis of severe COPD with acute exacerbation, leading to refractory dyspnoea and functional decline. Rationale based on chronic respiratory disease history, acute symptom presentation, and limited response to standard bronchodilator therapy. Objective findings include oxygen saturation of 88% on room air, increased respiratory rate of 28 breaths per minute, and diffuse wheezing on auscultation. - Differential diagnosis: Congestive heart failure, pneumonia, pulmonary embolism. - Investigations planned: Chest X-ray to rule out pneumonia, arterial blood gas to assess oxygenation and ventilation, and echocardiogram to assess cardiac function. - Medical treatment planned: Start oral morphine sulfate 5mg every 4 hours as needed for dyspnoea, with expected outcome of reduced breathlessness. Potential side effects discussed include constipation (prophylactic laxative prescribed) and drowsiness. Continue current bronchodilator regimen. Steroid taper initiated for COPD exacerbation. - Non-pharmacological interventions: Referral to respiratory physiotherapy for breathing techniques and energy conservation strategies. Occupational therapy for adaptive equipment to ease daily activities. - Interventional procedures considered: None at this time, focusing on medical management and comfort. - Lifestyle modifications related to health management: Encouraged smoking cessation (patient reports she quit 5 years ago) and adherence to a low-salt diet to manage potential fluid retention. - Referrals: Community Palliative Care Team, Respiratory Physiotherapy, Occupational Therapy, Social Worker. - Follow-up appointments: Palliative care clinic review in 2 weeks to assess symptom control and re-evaluate goals of care. Psychiatric Aspects of Care - Assessment: Sarah reports feelings of anxiety related to her breathlessness and fear of suffocating. No formal psychiatric diagnosis, but situational anxiety noted. Rationale based on patient self-report and observed distress during acute dyspnoea episodes. - Non-pharmacological interventions for psychiatric conditions: Referral to a psychologist for anxiety management techniques, including mindfulness and relaxation exercises. - Follow-up appointments for psychiatric conditions: Psychology follow-up in 1 week. Social Aspects of Care: - Social history: Sarah lives alone in a ground-floor flat. Her son, John, lives 30 minutes away and visits weekly. She has a good relationship with her son and relies on him for shopping and transport. She enjoys gardening but has been unable to do so due to her breathlessness. She is a retired primary school teacher. Her main coping mechanism involves watching TV. No other significant social support. Housing is suitable, but she struggles with stairs even within her flat. - Dietary history: Reports good appetite but has lost 3kg over the past 3 months due to difficulty preparing meals and fatigue. Diet often consists of easy-to-prepare foods, sometimes skipping meals. - Environmental and occupational history: No current occupational exposures. Home environment is generally clean, but she finds it hard to maintain. No known ergonomic issues. - Detailed history of patient or family understanding of disease: Sarah understands she has a serious lung condition but expresses hope for recovery. Her son is more realistic about the prognosis but struggles to discuss end-of-life care with his mother. Both acknowledge the severity of her current symptoms. - Discussion about life meaning, strengths, challenges, values, hopes for the future, and important relationships: Sarah values her independence and spending time with her son. She hopes to be able to enjoy her garden again. She finds her declining physical abilities very challenging and expresses fear of becoming a burden. Her son is her primary emotional support. Spiritual Aspects of Care: - Spiritual history: Sarah identifies as Anglican but is not a regular churchgoer. She finds comfort in nature. Her beliefs do not significantly influence medical decision-making; her priority is comfort and maintaining dignity. Cultural Aspects of Care: - Cultural factors that impact healthcare experiences and preferences: No specific cultural factors identified that impact her healthcare experiences or preferences. She prefers direct communication and to be involved in all decisions. Care of the Imminently Dying: - Discussion or information regarding care for the imminently dying, expected changes, comfort measures, and family support: Initial discussion held with Sarah and her son regarding potential future decline and symptoms associated with end-of-life in COPD. Emphasised comfort measures, managing dyspnoea, and ensuring peaceful surroundings. Provided information on grief support for her son. Ethical & Legal Aspects of Care: - Discussion or information regarding code status and related documents or preferences: Discussed advanced care planning. Sarah currently wishes for full resuscitation but is open to revisiting this as her condition progresses. No formal advance directives in place yet. - Discussion or information regarding advance care planning documents and treatment preferences: Provided information on 'My Wishes' documents and Lasting Power of Attorney for Health and Welfare. Encouraged her to discuss this further with her son and her GP. She expressed a preference for comfort over aggressive interventions if her quality of life significantly deteriorates. - Discussion or information regarding ethical issues impacting care or decision making, including any safeguarding or reporting needs: No immediate ethical issues or safeguarding concerns identified. The team will support Sarah and her son in future decision-making regarding her care. “Consent for the use of AI-assisted tools for documentation was obtained from the patient and all other participants in the visit prior to this encounter. All questions were answered. Patient understands that they may decline the use of AI-assisted tools.”