Palliative Care & Home Care Collaborative Assessment

Nursing Assessments are a valuable part of the care plan when patients are at home. Please forward nursing assessment information to the Palliative Care Nurses after visits.

Edmonton Symptom Assessment System (ESAS)

• Should be patient driven however if patient unable (confused, language barrier, decreased LOC, or refuses) nurse can make general assessment and indicate on form.
• ESAS reviews the most common symptoms experienced by patients at end of life.
• If patient cannot provide an exact number, try asking if symptom is mild (0-3) moderate (4-7) or severe (8-10).
• See ESAS Policy CLI.5910.SG.001 for more details.
• All symptoms are important to assess. We look for correlations between symptoms.
  Ex: Anxiety and pain both being high; nausea being high when the patient is constipated; poor appetite when nausea is high

Pain

• Common symptom experienced by our patients.
• A thorough pain assessment is a key component to our assessment.
  • Is the patient taking regular scheduled pain meds?
  • How many breakthrough doses of opioids are taken in a 24-hour period?
  • Does the patient feel his/her pain is being adequately managed with the current regimen?
  • Contact the palliative nurse if:
    • The pain is not well managed
    • There is a new kind of pain
    • The severity of pain has had a sudden onset
    • The pain has caused sudden changes in mobility
    • The patient has used 5 or more breakthroughs in a 24-hour period

Bowel Assessment

• All patients taking opioids are at high risk of developing constipation, a difficult and serious side effect resulting in hospitalization if not addressed.
• Patients not eating well or not eating at all will still produce stool and should be emptying their bowels at minimum every 3 days.
  • Ask about date of last BM
  • Ask about the amount and consistency of last BM. (NB: seeping of liquid stool can often be a symptom of severe constipation)
  • Listen for bowel sounds
  • Is the patient passing gas?
  • Is the patient using laxatives? Are laxatives available in the home?

Psychosocial Needs

• Palliative Care involves care of the patient and the family/caregivers.
• Ask if there are any questions or concerns. You may not have all the answers and it is OK to tell them you do not know the answer. Reassure them that you will forward their concerns/questions to the Palliative Care Nurse.
• Palliative Care Nurses can enlist the support of the Palliative Care Social Workers for any psychosocial, coping or support needs.
• It may be necessary to go over some of the basic signs and symptoms of the dying process. (See Topic 8, 9(1) and 9(2))
• Reassure family/caregivers that the changes that occur as a person approaches death are a normal part of the dying process.

Trajectory of Change

• The rate of change in a patient’s condition is a good assessment in determining the patient’s prognosis. If the patient is changing month to month, prognosis is measured in months. If the changes are happening week to week, it would be weeks. When changes occur day to day, prognosis can be measured in days. Over the last day or two, changes can occur from one hour to the next.
• It is important to recognize the rate of decline in order to initiate a change in medication route, provide prescriptions for injectable medication, orders to home care for subcutaneous line insertions and medication preparation. It is easier to get this organized early and having the medications available in the home, rather than rush to accomplish this in a time of crisis.
• When patient and family goals of care are to stay home, it is important that they have what they need to manage in the home setting. This includes medications, equipment, and home care support. If you identify that there needs to be more resources in the home, discuss with the Palliative Care Nurse. For increases in homecare supports or equipment, discuss with the appropriate member of the home care team.
• Notify the Palliative Care nurse if you see the patient’s condition deteriorating quickly.

The Palliative Care Program consistently uses the ERIK (Emergency Response Information Kit). Once completed, copies of the Health Care Directive and the Notification of Anticipated Death at Home letter (NAD) are placed in the ERIK. The ERIK kit is to be placed on the fridge. If you sense that things are changing quickly with the patient, check the ERIK to confirm the NAD is in place. If there is no NAD contact the Palliative Care Nurse ASAP to put it in place.

Contact the Palliative Care Nurse if:

• There are unmanaged symptoms
• New symptoms
• Significant deterioration
• Concerns related to family/caregiver coping
• Concerns related to care needs
• Medication supplies are running low and there are no refills available on prescription

Contacting the Palliative Care Nurse:

The community Palliative Care nurses work part-time. If it is not their scheduled work day and you need support from a Palliative Care Nurse or have questions, please call their phone. The voicemail message will indicate which other Palliative Care Nurse is working and is covering that day. The covering nurse will be able to answer questions. The Weekend Urgent On-Call Number for Palliative Care Phone Support outside of Monday – Friday 8:30 am – 4:30 pm business hours is 204 346 7021
To ensure effective communication between Home Care and Palliative Care Nurses, updates to and from both teams are encouraged after assessments/nursing visits.