Palliative Care Assessment
VBMC TRAUMA CARE SERVICES GUIDELINE
Palliative Care Assessment
· Identify
pre-existing advanced directives early (in the trauma bay or within 24 hours of
admission)
· Initiate
the assessment on admission and complete within 24 hours
· Hold
a structural family meeting as soon as possible, but definitely within 72 hours
of admission, and every 3-5 days thereafter
· Provide patient and family prognosis which includes the risk of death and the expected functional and cognitive recovery
Goals of Care Conversation
· Hold
conversation as soon as possible and within 72 hours of admission
· Ensure
all therapy during hospitalization is concordant with the patient’s preferences
and ultimate goals
· Document
discussion with detail
· Time-limited trials can be considered when seriously ill patients, their surrogates, or providers face difficult decisions about initiating major new interventions or continuing life-sustaining treatments in the face of poor or uncertain prognosis
End-of-Life Care
· DNR
or DNI orders do not preclude treatment or the delivery of care with curative
intent
o Document
reconsideration of DNR/DNI orders around the time of surgery
· Withdrawal
of life support does not imply withdrawal of “care”
o Focus
shifts to eliminate patient pain, anxiety, and suffering
o Remove
all unnecessary equipment, monitors, and restraints
o Silence
all alarms
o Create
peaceful environment for patient and family
o Inform
family about the dying process
o Allow time for rituals
Special Considerations for Geriatric
Patients
· Complete
a frailty screen on admission for all patients 65 years or older
· Presence of frailty should trigger palliative care processes, including identification of advance directive and GOC conversation
Special Considerations for Pediatric
Patients
· Decision-making
for older children and adolescents needs to include patient assent
· Bereavement care for the family poses challenges and should involve the pediatric palliative care team
Special Considerations for Spinal Cord
Injury
· Provide
patient and family data supporting prognosis and maximal functional outcomes
after spinal cord injury, specific to the level or injury, to guide discussions
related to advance care planning
· Provide patients with high spinal cord injury, who wish to pursue WOLST, access to mental health specialists and rehabilitation specialists with expertise in spinal cord injury. Involve the specialists in the conversation to better inform decision making.
Special Considerations for Traumatic
Brain Injury
· GCS
is an accurate predictor of death from TBI, but is less useful in predicting
functional cognitive outcome in survivors
· Focus conversation on potential cognitive and functional outcomes to determine their compatibility with the patient’s goals of care and/or advance directive.
Supporting the Health Care Team
· Palliative
care team can provide support to health care providers
· Stress
management training and education is available
· Debrief with staff
Clinical Documentation
· Identification
and contact information of family or surrogates
· Status
of advanced directives, POLST, and DNR/DNI status if known at time of admission
· Any
cultural or religious preferences
· Identification
of patient’s other health care providers who may be an invaluable source of
health status
· Prognostication/frailty
assessment
· What,
if any, emotional and informational support was provided for the family and
patient
· Any goals of care or focused decision-making discussions