Palliative Care

Introduction
PALLIATIVE
derived from the latin word pallium
meaning a cloak or cover.
To relieve without curing (Oxford
English Dictionary)
In its most literal use it refers to the
provision of active care for a person
whose condition is not responsive to
curative treatment.
An approach that improves the
quality of life of patients and their
families facing the problem
associated with life-threatening
illness, through the prevention and
relief of suffering by means of early
identification and impeccable
assessment and treatment of pain
and other problems, physical,
psychosocial and spiritual.
According to WHO definition,
Palliative care:
Provides relief from pain and other
distressing symptoms
Affirms life and regards dying as a
normal process.
Intends neither to hasten nor to
postpone death.
Integrates the psychological and
spiritual aspects of patient care.
Offers a support system to help
patients live as actively as possible
until death.

Offers a support system to help the
family cope during the patients
illness and in their own bereavement.
Use a team approach to address the
needs of patients and their families,
including bereavement counseling, if
indicated
Will enhance quality of life and may
also positively influence the course of
illness
Is applicable early in the course of
illness in conjunction with other
therapies that are intended to
prolong life, such as chemotherapy or
radiation therapy , and includes those
investigations needed to better
understand and manage distressing
clinical complications.
The objectives of palliative care are
therefore:
- To palliate physical symptoms, alleviate
disease and maintain independence for
as long and as comfortably as possible;
alleviate isolation, anxiety and fear
associated with advancing disease;
provide as dignified a death as possible;
and support those who are bereaved.
Unlike hospice care, palliative
medicine is appropriate for patients
in all disease stages, including those
undergoing treatment for curable
illnesses and those living with
chronic diseases, as well as patients
who are nearing the end of life.
Palliative medicine utilizes a
multidisciplinary approach to patient
care, relying on input from
physicians, pharmacists, nurses,
chaplains, social workers,
psychologists and other allied health
professionals in formulating a plan of
care to relieve suffering in all areas of
a patient's life. This multidisciplinary
approach allows the palliative care
team to address physical, emotional,
spiritual and social concerns that
arise with advanced illness.
Hospice services and palliative care
programs share similar goals of
providing symptom relief and pain
management.

Palliative care services
can be offered to any patient without
restriction to disease or prognosis,
and can be appropriate for anyone
with a serious, complex illness,
whether they are expected to recover
fully, to live with chronic illness for an
extended time, or to experience
disease progression. Hospice care
under the Medicare Hospice Benefit,
however, requires that two
physicians certify that a patient has
less than six months to live if the
disease follows its usual course. This
does not mean, though, that if a
patient is still living after six months
in hospice he or she will be
discharged from the service.
Palliative nursing was introduced
by a specialist nursing group the
Palliative Nursing Group in 1989. it
is now a widely used term in the UK
and is recognized as a distinct
nursing specialty with diploma,
undergraduate and post graduate
degree programmes.
The role of palliative nursing is to
assess needs in each of the areas and
to plan, implement and evaluate
appropriate intervention. It aims to
improve the quality of life and to
enable a dignified death.
Palliative intervention concerns
intervention when the disease is not
curable

History and Development of
palliative care
Palliative care began in the hospice
movement and is now widely used
outside of traditional hospice
care. Hospices were originally places
of rest for travellers in the 4th
century. In the 19th century a
religious order established hospices
for the dying in Ireland and London.
The modern hospice is a relatively
recent concept that originated and
gained momentum in the United
Kingdom after the founding of St.
Christopher's Hospice in 1967. It was
founded by Dame Cicely Saunders,
widely regarded as the founder of the
modern hospice movement.
The hospice movement has grown
dramatically in recent years. In the
UK in 2005 there were just under
1,700 hospice services consisting of
220 inpatient units for adults with
3,156 beds, 33 inpatient units for
children with 255 beds, 358 home
care services, 104 hospice at home
services, 263 day care services and
293 hospital teams. These services
together helped over 250,000
patients in 2003 & 2004. Funding
varies from 100% funding by
the National Health Service to almost
100% funding by charities, but the
service is always free to patients.
Hospice in the United States has
grown from a volunteer-led
movement to improve care for people
dying alone, isolated or in hospitals,
to a significant part of the health care
system. In 2005 more than 1.2
million persons and their families
received hospice care. Hospice is the
only Medicare benefit that includes
pharmaceuticals, medical equipment,
twenty-four hour/seven day a week
access to care and support for loved
ones following a death. Most hospice
care is delivered at home. Hospice
care is also available to people in
home-like hospice residences,
nursing homes, assisted living
facilities, veterans' facilities, hospitals
and prisons.
Indications:

Immediate palliative care is indicated
for patients with any serious illness
and who have physical, psychological,
social, or spiritual distress as a result
of the treatment they are seeking or
receiving. Palliative care increases
comfort by lessening pain, controlling
symptoms, and lessening stress for
the patient and family, and should not
be delayed when it is indicated.

Palliative care is not reserved for
patients in end-of-life care and can
increase quality of life and lengthen
the patient's life.
In some cases, medical
specialty professional
organizations recommend that
patients and physicians respond to
an illness only with palliative care
and not with a therapy directed at the
disease. The following items are
indications named by the American
Society of Clinical Oncology as
characteristics of a patient who
should receive palliative care but not
any cancer-directed therapy.


1. Patient has low performance status,
corresponding with limited ability to
care for oneself
2. Patient received no benefit from
prior evidence-based treatments
3. Patient is ineligible to participate in
any appropriate clinical trial
4. The physician sees no strong evidence
that treatment would be effective

These characteristics may be
generally applicable to other disease
conditions besides cancer

Palliative Care in Hospitals
The team initially included a
chaplain, a social worker, a nurse and
a two part-time voluntary doctors.
It operated as an advisory service
and was able to facilitate a level of
symptom control that enabled many
patients to be discharged home
earlier than anticipated.

Palliative Care in the Community
At the beginning of the 20
th
century,
the majority of the people died at
home.
The number of people who now die
at home has fallen to19% with 23%
dying from cancer.
Field and James (1993) indicated that
the experience of patients dying in
their own homes appeared to vary
widely, partly because homes and
families differs in terms of social,
psychological and spiritual make up
and partly because of the nature ,
conduct and availability of support
given to unpaid carers.

Field and James (1993) also noted
that should a person choose to die at
home and receive adequate support ,
they might have up to 25 different
paid carers visiting their home
during the course of their terminal
illness.
Communication and coordination of
their care becomes inadequate,
leading to fragmentation of care
between health carers such as
doctors, nurses and home helps.
Day Care
Day hospices-new in UK.
These are units normally based in
hospices, where patients with
advancing disease can attend on a
day basis.
Staff usually comprise nurses and
paramedics, such as occupational
therapists and physiotherapists,
assisted by volunteers.
Purpose:
- To provide care for relatives as well
as social and therapeutic benefits for
the patient.

These can range from craft activities
through aromatherapy to direct care
such as a wound dressing or a bath
They viewed their aims as fivefold, to
provide:
Stimulation and enjoyment
through activities, focusing on the
individuals needs and choices and
encouraging self-esteem.
Social support and help to alleviate
feelings of isolation and depression
Respite for carers
Basic nursing where appropriate,
to aid and improve physical well-
being
Rehabilitation by adapting the
patients physical and social
environment so that independence
can be maintained for as long as
possible.
Care homes
- another area where palliative care is
practised.
A nursing home/care
homes, convalescent home, skilled
nursing facility (SNF), care home, rest
home or intermediate care

provides a
type of residential care. They are a
place of residence for people who
require continual nursing care and
have significant deficiencies
with activities of daily living. Nursing
aides and skilled nurses are usually
available 24 hours a day.
Residents include the elderly and
younger adults with physical or
mental disabilities. Residents in a
skilled nursing facility may also
receive physical, occupational, and
other rehabilitative therapies
following an accident or illness. Some
nursing homes assist people with
special needs, such
as Alzheimer patients.