Tuesday, December 23, 2014

A Day In The Life: Palliative Care

day in the life palliative care
I have one day left of my second (shortened!) week of palliative care. Because I'm taking next week off for my winter vacation, I won't get a full four weeks on this rotation, but I'm sure I'll still learn lots! Last week and this week have been spent doing palliative care new outpatient consults at the cancer institute. When I return from holidays, I'll have six days of inpatient palliative care at another hospital. Here's what a typical day of outpatient palliative care looks like for me:

0830 h: I arrive at the palliative care office in the cancer institute, "borrow" whichever desk isn't in use, and get organized by looking at the schedule for the day and starting to look through those patients' charts. 

0900 h: The palliative team (nurses, pharmacist, staff physician, and me) meet to run through the lists of new consults (usually two for the day), ward patients, outpatient follow-ups (mostly by telephone; some in-person), and new referrals to be triaged, and come up with a work plan for the day.
cross cancer institute palliative
palliative team meeting room
0910 h: I spend the next 50 minutes looking through the charts of the two new patients, making notes on their histories, treatments, investigations, etc. In addition, I go through the detailed palliative triage assessments, noting the current issues that I'll need to focus on.

1000 h: I walk upstairs to see the patient, taking a history, completing the palliative assessment forms, and performing a physical exam.
cross cancer institute ward
the exam room with its shape-conforming mattress (which we're not supposed to tuck sheets under!)
palliative assessment forms
lots of palliative assessment forms, which I fill out with the patient
1100 h: I walk back downstairs to the palliative care office to present the patient to the staff physician. We spend the next twenty to thirty minutes discussing the issues and coming up with a management plan -- which the wonderful staff take as an opportunity to do a bit of teaching and are patient with answering my questions/entertaining my suggestions.

1130 h: The staff physician and I go back upstairs to discuss our plan with the patient. At this time we also discuss goals of care. We return downstairs to write prescriptions, which are faxed to the patient's pharmacy.
cross cancer institute
at least I'm getting some exercise walking up and down these stairs all day!
1200 h: I have a quick lunch (I've returned to packing the laziest lunch ever: a peanut butter sandwich) at my desk while getting my notes/forms together to dictate.

1205 h: I start dictating the new patient consult.

1300 h: I finish dictating (second only to geriatrics consults, palliative consults are the longest ever). I'm already running late for the second new patient so hurry upstairs to see them. As with the 10 am patient, I do a history, palliative assessment forms, and physical exam.
esas-r
more forms...this one is the ESAS-r (Edmonton Symptom Assessment System - revised), created locally and used widely!
1400 h: Back to the palliative care office to review the second patient with the staff and come up with a management plan.

1430 h: Back upstairs to share said plan with the patient and discuss goals of care.

1500 h: Dictate...

1600 h: Finished dictating. Time to edit my dictations from yesterday, which always takes longer than expected given their novel-esque nature.

1700 h: Home

Days in palliative care are busier than I'd expected. Although we only see two new consults, they are complicated patients, each with multiple challenging issues. It takes some extra time to discuss things like psychosocial issues, hospice, goals of care, wills, and personal directives. Depending on the patient's stage of disease, the consult may proceed quite slowly, secondary to patient confusion, drowsiness, or mobility issues. In our once weekly multidisciplinary new patient consult clinics, one consult can take up to six hours, with the patient seen in turn by a nurse, dietician, occupational therapist, respiratory therapist, speech language pathologist, social worker, psychologist, spiritual care provider, pharmacist, resident, and staff physician.

Palliative care is an interesting and challenging area of medicine that I hadn't been much exposed to during medical school. My main goal for the rotation is to become more comfortable with prescribing pain medications -- and fortunately I'm getting more familiar every day with selecting and dosing opioids. I'm also getting to know anti-emetics and laxatives a whole lot better, which is sure to come in useful on every other rotation to come. I appreciate having just two consults a day, as it allows me to spend time being thorough with each one, so that I can get the most out of it in terms of learning (while hopefully also benefitting the patient!).

pallium palliative pocketbookStudy Resources
  • The Pallium Palliative Pocketbook -- This little spiral-bound pocket guide, kindly given to me by one of the palliative care physicians, is a well-organized reference for quickly looking up management and medications.
  • BC Palliative Care Guidelines -- I was given a thin spiral-bound book in medical school summarizing palliative care management by topic (e.g. pain, dyspnea, etc.), which is a good readable overview that I still have with me in residency. Though I've been unable to find an online version of this specific book, many health jurisdictions do post guidelines online, such as these palliative care guidelines from BC.


  • Have you done a palliative care rotation?
    Have you come across any helpful palliative care resources?

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