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HOSPICEHOSPICE TEL HASHOMERTEL HASHOMER

HOSPICEHOSPICE TEL HASHOMERTEL HASHOMER

TEL AVIV UNIVERSITYSACKLER SCHOOL OF MEDICINE

SCHOOL OF CONTINUING MEDICAL EDUCATION

- אוניברסיטת תל אביבהב”ס לרפואה ע”ש סאקלר

בית הספר ללימודי המשך ברפואה

ASSOCIATED WITH ISRAEL CANCER ASSOCIATION בסיוע האגודה למלחמה בסרטן בישראל

ISRAELISRAEL

Dr. M. Bercovitch

Dr. M. Bercovitch

Dr. M. Bercovitch

Dr. M. Bercovitch

STRUCTURE

Dr. M. Bercovitch

MEDICAL DIRECTOR

PHYSICIAN

PSYCHOLOGIST – 1 -½ part time

SOCIAL WORKER- 1 – ¼ part time

PHYSIOTHERAPIST- 1 – ½ part time

SECRETARY - 1

VOLUNTEERS - 25

*Night shifts- physicians from geriatric department

HEAD NURSENURSES – 15 – part timeNURSING AIDES –5 – part time

25 patients –30Km – surrounding the hospital

PHYSICIAN ½ part time

HEAD NURSE - 1

NURSES –3 –1/2 part time

SOCIAL WORKER – ½ part time

SECRETARY ½ part time

VOLUNTEERS

WORKING AS CONSULTANTS

ON CALL: 24 hours/dayweekends and holidays

HOME CARE HOSPICE

Dr. M. Bercovitch

OTHER ACTIVITIES

Dr. M. Bercovitch

RESEARCH & TEACHING

Medical Research & Information Center

Physician4 volunteers

Nursing Teaching Center

THE CIRCLE OF LIFE

““HOPE ALONGSIDE HOPE ALONGSIDE DEATHDEATH””

Dr. M. Bercovitch

IN THE HOSPICE

37 YEAR OLD MAN BORN IN YEMEN

EMIGRATED TO ISRAEL 1962

MILITARY SERVICE

PROFESSION - AGRICULTOR

NO HISTORY OF SIGNIFICANT

MEDICAL PROBLEMS

MR. E.M

1997 - RECCURENCE OF THE DISEASE IN THE LT THIGH

EXCISION OF THE TUMORCHEMOTHERAPY

CHEMOTHERAPYEXCISION OF THE TUMOR

CHEMOTHERAPY

SUPERIOR VENA CAVA SYNDROME DUE

TO HICKMAN CATHETER THROMBOSIS

1998 - RECCURENCE OF THE DISEASE IN PELVIS INOPERABLE

PRESENT MEDICAL HISTORY

1995 - DG.- LT POPLITEAL MIXOID LIPOSARCOMA

METASTASES TO: LUNG, BONES, LIVERCHEMOTHERAPY

ENCEPHALOPATHY DUE TO CHEMOTHERAPY

1999 - July - LT LOWER ABDOMINAL MASSCHEMOTHERAPY

- September - CLINICAL DISEASE PROGRESSIONSACRAL ROOT COMPRESSION

CAUDA EQUINA SYNDROME

- October - RADIOTHERAPY DISCHARGED HOME

MCR UNO 1000mg X 1/Day TREATED WITH:

12.10.99 - 29.11.99 - AT HOME

POOR GENERAL CONDITIONSEVERE PAIN IN SPINE AND BOTH LOWER LIMBS

GENERAL WEAKNESS

NECROTIC LT LEGBEGINNING NECROSIS OF THE LT FOOT

ABLE TO MOVE IN WHEELCHAIR

TREATED WITH :MCR UNO 1800mg X1/Day

SUMMARY UNTIL ADMISSION

TO OUR HOSPICE

RELATIVELY YOUNG PATIENT WITH

METASTATIC POPLITEAL MIXOID LIPOSARCOMA

TREATED FOR 5 YEARS BY SURGERY,

CHEMOTHERAPY WITH RAPIDLY INCREASING

INTENSITY OF PAIN IN HIS GANGRENOTIC

VERY HIGH DOSES OF MORPHINEWITHOUT PAIN RELIEF

LT LOWER LIMB AND TREATED WITH

DIAGNOSES

INTRACTABLE PAININTRACTABLE PAINPOPLITEAL MIXOID LIPOSARCOMAPOPLITEAL MIXOID LIPOSARCOMA

METASTASES TO THIGH - LEFTMETASTASES TO THIGH - LEFT PELVIS PELVIS

LUNGLUNG

LIVERLIVERABDOMENABDOMEN

SURGERY - RECURRENTSURGERY - RECURRENT

SACRAL ROOT COMPRESSIONSACRAL ROOT COMPRESSION

CAUDA EQUINA SYNDROMECAUDA EQUINA SYNDROMES/P CHEMOTHERAPY S/P CHEMOTHERAPY

ON ADMISSIONON ADMISSION29/11/199929/11/1999

MODERATE GENERAL CONDITION

PULSE: REGULAR, 70 /min,

FULLY ALERT, NORMAL COGNITION

PUPILS: EQUAL, DIAMETER 3mm

AUSCULTATION: FEW CREPITATIONS

ABDOMEN: ABSENCE OF PERISTALTIC SOUNDSLEGS: PITTING OEDEMA IN RT LOWER LIMB 3+

PARTIAL GANGRENE OF LT LEG & FOOT

POSTSURGERY SCAR IN POSTERIOR ASPECT - NAD

BREATHING 18 /min

NEUROLOGICAL: FULLY ALLERT & COOPERATIVE NORMAL COGNITION NORMAL SPHINCTER COMPETENCE MUSCULAR STRENGTH -NORMAL

THE GOALS IN THE INITIAL STAGETHE GOALS IN THE INITIAL STAGE

RAPID PAIN CONTROL WITH ORAL ANALGESISRAPID PAIN CONTROL WITH ORAL ANALGESIS

DISCHARGEDISCHARGEDISCHARGEDISCHARGE

PROBLEMS SOLUTIONS

WEAKNESS BLOOD TRANSFUSIONS (PC)

FATIGUE

DRYNESS OF

THE MOUTHSusp. NYSTATIN

CONSTIPATION LACTULOSE & BISACODYL

3/3

3/3

RESOLVED

DIFFICULT PROBLEMS DIFFICULT PROBLEMS

EPISODES OF DROWSINESS

PAIN - VAS - 10/10

LACK OF AWARENESS ABOUT THE STAGE OF THE DISEASE

PROGNOSIS AND THE TRUE MEANING OF HOSPICE

ADMISSION.

PATIENT NAME: EM ADM. DATE: 0 ID#: ### ASSESSED BY: Dr. M.BNOTES: Mixoid liposarcoma Karnofsky on Admission 0 10 20 30 40 50 60 70 80 90 100

DATEHospital. Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

1098

V 7A 6S 5

43210

###

MORPHINE (mg) 140 0 180 0 240 0 125 0 200 0 60

MO Way of Admin. PO PO PO EP EP PO100 100 200 200 100 200 200 50 200 200 240 100 100 280 500 500 100

RESQUE DOSES 150 90 300 200 150 150 200 200 200 240 300 300 100

150 200 150 200 200 125 240 100 300 500

Resque doses PO PO PO PO PO PO PO IM PO PO PO PO PO PO PO PO PO

Way of PO PO PO PO PO PO PO PO PO PO PO PO PO

administration PO PO PO PO IM PO IM PO PO

Sleep (0 - 3) 1 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3Karnofsky (0-100) 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

Mobility (0 - 4)3) 40 40 40 40 50

PAIN TYPE BONES NEUROPATHIC VISCERAL OTHER

COANALGESICS NSAIDS ANTIDEPRESANTS ANTICONVULSANTS STEROIDS

Dose (mg)

NEUROGARSEDATIONDRUG CHANGE

AREDIANERVE BLOCKEPIDURALNEUROSURGERY

WHAT TO DO

AFTER UNSUCCESSFUL AFTER UNSUCCESSFUL

PAIN CLINIC INTERVENTIONPAIN CLINIC INTERVENTION

CONSCIOUS SEDATIONCONSCIOUS SEDATION

CORDOTOMYCORDOTOMY

PATIENT,FAMILYPATIENT,FAMILY

IDTIDT

CORDOTOMYCORDOTOMY

FREE OF PAIN WITH GANGRENOUS LLL

FREE OF PAIN WITH AK AMPUTATION

CONSENSUS

STAGING OF THE DISEASE

AMPUTATIONAMPUTATION

WEDDINGWEDDING

REHABILITATION

GERIATRIC

DEPT.

IV ANTIBIOTICS

BEGINNING 0F REHABILITATION

HOSPICE14.01.00 - 21.01.00

DISCHARGE...

PAIN RELIEF

PHYSIOTHERAPY

SEXUAL CONSULTATION

REHABILITATION - PROSTHESIS

MCR 40mg

4.01.01 - 21.07.01

… 7 MONTHS AFTER… 7 MONTHS AFTER

POOR GENERAL CONDITIONSEVERE PAIN IN SPINE AND RT LOWER LIMB

GENERAL WEAKNESS

ABLE TO MOVE IN WHEELCHAIR

PROGRESSIVE GENERAL DETERIORATION

21.07.01

DEATH ….

THE SUCCESSFUL CARETHE SUCCESSFUL CARE

WHAT IS WHAT IS

IN AIN A

PALLIATIVE CARE UNITPALLIATIVE CARE UNIT

THE SUSSCCESSFUL CARE IN PCU IS: THE SUSSCCESSFUL CARE IN PCU IS:

GOOD SYMPTOM CONTROL

GOOD PSYCHOSOCIAL SUPPORT

GOOD SPIRITUAL SUPPORT

SHOULD FACILITATE THE SUCCESSFUL PLANNING SHOULD FACILITATE THE SUCCESSFUL PLANNING

AND ACHIEVEMENT OF THE GOALS OF THE PATIENT AND ACHIEVEMENT OF THE GOALS OF THE PATIENT

AND FAMILY DURING THE TERMINAL PERIOD.AND FAMILY DURING THE TERMINAL PERIOD.

All above

GOOD INTERDISCIPLINARY &

MULTIDISCIPLINARY COLLABORATION