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Michael and Carol

Michael and Carol. Karen Glaetzer Nurse Practitioner – Palliative Care Southern Adelaide Palliative Services Lecturer (B) – Flinders University. Michael. 39 year old man with cerebral palsy and intellectual impairment Lives with parents Carol and Donald

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Michael and Carol

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  1. Michael and Carol Karen Glaetzer Nurse Practitioner – Palliative Care Southern Adelaide Palliative Services Lecturer (B) – Flinders University

  2. Michael • 39 year old man with cerebral palsy and intellectual impairment • Lives with parents Carol and Donald • Presented to local medical surgery March 07 with headache • CT showed – posterior fossa lesion • Thought to be GBM • Excision and biopsy – histology inconclusive • Developed thyroid mass • Obstruction and tracheostomy • Histology – Medullary Ca Thyroid

  3. Michael • Treatment options – Surgery, XRT, Chemo • Family declined • 4 month hospital admission • First seen in ICU, family wanted to explore home care options • Prognosis thought to be 2 weeks • Arrangements made for transfer home • No regular GP • Palliative Care Plan and Crisis Orders

  4. Carol • Mother of Michael • Diagnosed with large breast mass 2 months ago • Currently undergoing chemo pre mastectomy • Keen to have Michael return home • Went on to have mastectomy, then further chemo and radiotherapy

  5. NP Role • Case Coordination role • Organised local GP • Visited fortnightly or weekly in later stages • Clinical/Psychosocial assessment • Support to parents • Reviewed and titrated medications as required (dexamethasone and analgesia) • Phenytoin levels as needed – eventually changed to Clonazepam so monitoring not needed • Arranged in home respite for when Carol having chemo and radiotherapy

  6. Outcome • Michael died at home 9 months after discharge from hospital • Cared for at home by his parents • Did not require any hospital admissions • Was seen twice by GP in 9 months, no other medical contact • Carol presented 2 days after Michael’s funeral with a pleural effusion

  7. Outcome • Admitted for drainage and further staging • Found to have widespread lung metastases • Went home for 3 weeks • Did not want to put her husband through another death at home • Died at Daw House 5 weeks after Michael • Bereavement follow up provided to Don

  8. Tessa

  9. Tessa • 80 year old lady • Lives with husband and son • Presented with 2-3 week history of weight loss and abdo pain • CT showed AAA, pancreatic mass and liver metastases • Emergency AAA repair and biopsy of mass – adeno ca pancreatic primary • Reviewed by Oncology – declined chemotherapy • Referred to Palliative Care Service

  10. Tessa • Assessed through Triage Process • Sent appointment for NP Clinic • First seen 11/8/09 • Seen with husband and daughter • Full history taken, physical and psychosocial assessment • Still independent • Not needing any increased community supports at this stage

  11. Issues Identified/Outcomes • Constipation an issue – gave advice • Only using Endone 5mg once daily • Concerned by 3 stone weight loss – referred for Megesterol/Dexamethasone Study • Arranged referral for Wheelchair • Follow up appointment 6 weeks

  12. Second Appointment • 22 September 2009 • Came with husband • Stable • Completed Megesterol Study • Now taking Endone 3 times a day – commenced on Oxycontin 10mg bd • Physical Examination – right calf swelling, warm and tender • Sent for Ultrasound – DVT confirmed – commenced Clexane

  13. 3rd Appointment • 1 December 2009 • Increasing pain - Oxycontin increased to 20mg bd • Appetite poor • Obvious weight loss • Problems with constipation - Movicol • Epigastric mass larger • Continues on Clexane – mild ankle swelling • Family still managing care

  14. 4th Appointment • 2 March 2010 • Pain increasing – needing to take regular breakthrough in afternoons – Oxycontin increased to 20mg tds • Appetite slightly improved • Further weight loss evident • Showering with husband nearby • Still not requiring any additional home supports • Discussed respite options, but declined • Next appointment 2 months

  15. OPD Clinics • Opportunity for regular review • Needs based • Strengths identified • Encourages independence • Empowers individuals to take control • Resource efficient Essentials: • Constant reinforcement about what might happen and contingencies • Opportunity to respond with a home visit if/when the need arises • Communication back to GP and other relevant providers

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