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is the medical specially focused on improving over all quality of life for patients and
family facing serious illness. Emphasis is placed on intensive communication.
A key benefit of palliative care is that it looks at the patient as a whole in order to meet
the individual needs of each person and family.
Relieve symptoms such as pain, shortness of breath, fatigue, constipation, nausea, loss of
appetite and difficulty of sleeping.
It helps patient gain the strength to carry on with the daily life.
1.Palliative Care
- may be provided at anytime during persons illness, even from the time of diagnosis.
- can take place as curative treatment.
2. Hospice Care
- provides palliative care. However, hospice is focused on terminally ill patients.
- people who are no longer seek treatment to cure them.
NURSING THEORIES APPLICABLE TO CONCEPT IN PALLIATIVE CARE
Involves problem solving.
The unique function of the nurse is to assist the individual, sick or well, in the
performance of those activities contributing to health or its recovery that he would
perform unaided if he had the necessary strength, will, or knowledge.
Person- one who has physical , emotional or social needs. The recipient of nursing care
JEAN WATSON
A caring environment accepts a person’s as he is and looks to what the person may
become.
Forming humanistic.
Instilling hope.
CARE – hands on
1967- Dame Cicely Saunders found the first modern Hospice in London and introduces
the concept in the U.S while lecturing at Yale.
1982- congress passed the medicare hospice benefit under medicare Part A.
1990- WHO defines Hospice and Palliative care to set International Standards.
1990- Congress passed the patient self-determination Act. Giving patients the right to
advance directives and choices in their medical care.
1994- first nurses are certified as Hospice Specialists through the National Board of
Certification of Hospice Nurses.
1997- HNA becomes the Hospice and Palliative Nurses Association.
2000- NHO becomes the National Hospice and Palliative Care Organization.
End-of-Life care may last moments or months depending on the circumstances and
the setting in which patient dies.
It may involve complex drug regimen and near constant symptomatic care, or it
may involve only honest, compassionate conversations with family members.
Either way have acted to ease a patient’s transition from life to death.
Palliative care seeks to prevent and relieve suffering and to enhance the patient’s
quality of life.
Seeks to ease all aspects of suffering, not just the physical ravages of the disease or
disability.
Palliative care provides support and care for persons facing life-threathening illness
across setting.
The goal of interdisciplinary team is to work with patients to identify their specific
needs and health goals.
Use of interdisciplinary team is likely the key to addressing the many needs of the
dying and their families.
When palliative care succeeds, the patient dies what we call a “good death” free from
avoidable distress and suferring in keeping with his family’s wishes, and according to
accepted clinical and ethical standards.
• Interdesciplinary Team
Symptoms like dyspnea, nausea, vomiting, restlessness, agitation, fear and so on.
4. Holistic Care
5. Volunteer Support
They are trained as many as 30 hours of education in all aspects of hospice care.
6. Hospice setting
7. Bereavement Support
8. Control
The patient and family have the right to choose where end of life is delivered.
Caring for people in this phase of life acknowledges their experience and gives them a
feeling of personal wholeness and value.
Doctor: Usually acts as the care team leader; makes treatment plans and decides on
medication and dosing; may consult with other doctors such as pain specialists or
radiation oncologists.
The doctor may be available to make home visits or may supervise the cae plan
without actually seeing the patient.
assist with pain management and other side effects of cancer or its treatment.
may act as a liaison with the rest of the team. When people are enrolled in home
hospice programs, nurses visit them at home several times a week and sometimes more
than once a day.
Social worker: Helps with financial issues; arranges family meetings; assists with the
discharge from the hospital to home or hospice care
Hospital chaplain or other spiritual advisor: Counsels the patient and family members on
religious and spiritual matters .
Physical therapist: Helps maintain movement and assists when mobility is impaired or
there are concerns regarding safety in the home
Grief and bereavement coordinator: Helps with planning memorial services and
counseling for the patient as well as family members.
Roles of Nurses
Nurse spends the most time with the patient and family.
A hallmark of quality palliative care is the collaboarative role that the nurse
develops with the physician and other interdisciplinary team members.
Nursing care allow patient and family to grow in the dying experience.
the nurse is the primary conduit for information, critical assessments, and
evaluation of the patient and family goal s within the interdisciplinary team.
• Clinician
• Educator
• Researcher
• Collaborator
• Consultant
• Presence
Is a nursing intervention that can be describe as a gift of self in which the nurse
is available and open to situation.
2. Compassion
3. Touch
For a dying patient touch can be both a healing and life affirming act.
Convey to a patient that he is safe to freely express any concerns and needs.
5. Dignity or Honesty
Patient expect the nurse to be honest.
The patient and family deserve honesty regarding the day to day effects of the
medical treatment.
6. Assisting in Transcendence
In end-of-life care it refers to patient developing a sense of meaning and peace that
keeps his suffering and death from being meaningless.
At the highest level of nursing care you can provide emotional support that let the
patient experience self-transcendence( a sort of triumph in death ).
the specialty ;
These are authoritative statements described by the Hospice and Palliative Nurses
Association for the nursing profession inorder to;
Identify the responsibilities for which palliative and hospice care nurses are
accountable.
Standards reflect the values and priorities of palliative care nursing and provide
the framework for the evaluation of practice.
• Divisions of Standards
• STANDARDS OF CARE
Refers to the basic level of care that should be provided to all hospice and
palliative care patients and families.
• Standards of Rerformance
• Keeping promise
3. Respecting persons
Utilitarianism- a moral theory that asserts there is only one basic principle. The
principle of utility which declares that ought always to produce the greatest possible
balane if value over disvalue for the greatest number of persons.
Ethical Concepts:
Self governance
• The patient’s capacity for rational reflection must be significantly impaired. This
autonomy condition must be clinically determined and substantiated.
• It is reasonable to assume that the patient will at the later time with recovery of
capacity for rational reflection.
Patient should be assumed to have the capacity to make decisions for themselves
unless there is clear evidence.
• The patient understands treatment or lack of treatment can affect their quality
of life.
If the patient lacks the capacity to make informed choices, other means must be
identified for surrogate decision - making.
b. NON-MALEFICENCE
The principle of maleficence is understood as requiring clinicians to
intentionally avoid patient unnecessary harm or pain, whether psychological or
physical.
4 conditions be met before an act with both good and bad consequences may be morally
justified:
• The individual must sincerely intend only the good and not evil.
d. There must be a proportionately grave reason for permitting the evil effect, that is
there must be a favourable balance between the good and the evil effect of the action.
Example:
• Respiratory depression is not the means by which the pain relief is obtained.
4. The relief of pain and the related reduction of suffering combined to provide
sufficiently important reason or proportionately greater good than the harm that is
incurred respiratory distress and likely death.
8. JUSTICE
The equitable distribution of potential benefits and tasks; determining the order in
which clients should be cared for.
ETHICO-LEGAL CONSIDERATION
2. Providing consideration
3. Maintaining confidentiality
4. Relieving pain
5. Withrawing treatment
Legal Consideration
Peace of mind for the patient that his wishes will be carried out even if he can’t
communicate.
Clear directions for family and significant others about the patient wishes.
2. Advance directives
Is a written document ( living will ) recognized by state law that provides directions
concerning the provision of care when a client is unable to make his or her own
treatment choices.
It includes the living will, the durable power of attorney, and directive for organ
donation.
Living will- an advance directive lists of the medical treatment that a client chooses
to omit or refuse if the client becomes unable to make decisions and is terminally ill.
States have their own requiremens for executing living wills , but generally two
witnesses, neither of whom can be a relative or physician, are needed when the client
signs the living will.
2. If you are currently physically ill, obtain information regarding the expected progress
of your disease.
3. Discuss with your physician the expectation of your treatment and the risk of
undergoing those treatments.
4. Make sure your family and significant others are familiar with your value system and
spiritual beliefs.
6. Document the types of treatment you would and would not like to receive if you can
no longer communicate you wishes.
7. Prepare several copies of the document and give one to your physician, your attorney
and your chosen surrogates. Keep a copy in hand for emergency or future health care
providers.
2. Open communication including not only patients and family members but also all relevant
health professionals will facilitate informal decision-making.
3. Listening to the patient’s own story.
- Including past and present life experiences, will assist the professional to understand the
impact of symptoms from the patient’s perspective.
- This model allows members to share information through discussion and working together
to formulate goals.
- The task at hand determine who take the leadership role, rather than the most senior
member of the team assuming leadership.
• Evaluation
- established the cause if the symptoms includes taking a history including general trends
and recent changes.
- attention should be performed and investigations carried out is appropriate, given an
individual’s prognosis & goals of care.
- a PE should be performed & investigations carried out if appropriate given an individual’s
prognosis & goals of care.
2. Explanation
- explanation about care & treatment options is vital to the delivery of effective care &
empowers patients and cares to be involved as equal partners in the decision-making process.
- information about the disease process & significance of symptoms should be provided to
patients when they need it & not at a time convenient for the professional included in the care.
3. Management
- builds on the assessment process.
- first stage is to identify the cause & determine what is reversible or treatable.
4. Monitoring
- will not only determine the efficacy of interventions but also facilitate regular re-
assessment of the security of the symptoms and impact on the patient.
5. Attention to detail
- this can perhaps have the most significant ramifications for the patient if done badly.
- throughout the process of symptom management the missing of details by health
professionals can have done consequences.
MANAGING PAIN IN PALLIATIVE ASPECT OF CARE
PAIN
- is an unpleasant sensory and emotional experience associated with actual or potential
tissue damage.
pt. become withdrawn, unable to focus and their whole personality can appear to be
changed as their quality life diminishes.
Three Types of Pain Response:
• Neuropathic pain
- caused by the damage of nerve fibers resulting to the injury of the spinal cord or brain.
associated in pt. with tumor compression, infiltration of peripheral nerves, nerve roots or
other type of spinal cord pain that occurs as a result of neurologic injury
Describe pain as “lancing”, a constant dull ache with a vice like quality or as a paroxysms
of burning or electrical-shock-like sensation.
2. Somatic pain
- is described as aching and dull, increased by movement, and able to be localized to the
injured area
• Pain arises from skin, bone, muscle, connective tissue, and blood vessel.
ex.: Arthritis and bone metastasis
3. Visceral pain
- can be aching, but can also feel like squeezing and cramping.
- can be localized to superficial tissues and radiate to a larger area of skin muscle.
ex.: pain of myocardial infarction
ASSESSING CHARACTERISTIC OF PAIN
• LOCATION
• INTENSITY
- pt. should be asked to quantify their pain using a subjective rating scale
3. QUALITY
MC GILL PAIN QUESTIONARE
- is a well-tested widely used instrument to elicit patient’s verbal description of pain.
4. PAIN
- some pain may always be present and is termed baseline pain.
6. EFFECTS on LIFE
- the following questions are useful to determine how pain may impact spiritual life:
Have your beliefs changed since you started to live with pain?
Has the pain affected your spiritual beliefs or your relationship with GOD?
5 W’s TO ASSESS PAIN:
W2 – words to describe
W3 – when does the pain occur? What is the pattern during the day?
W5 - whole
PALLIATIVE MANAGEMENT OF PATIENT IN PAIN
COMFORTING PAIN
THERE ARE 5 INGREDIENTS FOR PAIN RELIEF:
1. Developing a caring relationship
2. Teaching
3. Anticipating comfort needs
Informing patients and helping them decide about using these therapies.
NON OPIODS
- ex.: acetaminophen or non steroidal anti-inflammatory drug.
Has few side effects
Side effects: hepatotoxicity and liver damage.
OPIODS
Patient with severe pain.
ex. Morphine
Side effects of morphine: Nausea and vomiting, pruritus, constipation, respiratory
depression, hallucination and sedation.
SIGNS AND SYMPTOMS OF OPIODS TOXICITY
1. Confusion
2. Myoclonic jerks
3. Pinpoint pupil
This maybe result of the cancer treatment itself, for example chemotherapy causing anemia
or radiation therapy.
Eating and talking may also increase breathlessness, so measure should be taken to
minimize the effort required during mealtime.
Turn on the fan in an oscillating mode. Provide information to the visitors and folks about
this matter.
Sitting upright in a supported position or leaning slightly forward resting arms on a table
may be of benefit.
If patient is fearful, the presence of someone at the bedside or the use of a night light may
be of some help
Accupressure
Placebo effect of treatment
Occupational therapy
PHARMACOLOGIC MANAGEMENT:
1. Bronchodilator
2. Steroids
3. Nebulized furosemide
4. Opiods
5. Used of sedation
The manifestation appeared is azotemia with elevated urea, creatinine, and uric acid level.
Signs and symptoms are tachycardia, postural hypotension, reduced skin turgor and dry
mucous membrane.
Fluid deficits at the end of life are associated with cognitive impairment and altered
behavior.
Hypodermoclysis
- process of introducing fluid through subcutaneous infusion in hospice and palliative
setting.
- contraindicated in pt with bleeding disorder or generalized edema
- butterfly needle is use
- inserted subcutaneously in the thighs, outer arm, abdomen, in bedridden pt.
Inexpensive
Lasts 5 to 7 days
• Psychostimulants
- such as methylphenidate (Retalin, Concerta) to boost energy
- subcutaneous injection of epoetin alpha (Epogen, Frocit) increase hemoglobin and
hematocrit.
b. Promoting sleep, improving nutrition, reducing the burden of other symptom managing
decreased energy.
-recommendation of assistive equipment, occupational and physical therapy
- nurse can encourage period of rest and activities to restore emotional energy, such spending
time with family, surrounding oneself with nature, listening to music or meditating.
c. Teaching the families and caregiver.
PALLIATIVE CARE OF PATIENT WITH IMPAIRED SKIN INTEGRITY
• Pharmacological Intervention
Be aware that the high dose of the dopamine antagonist alone or in combination can cause
extrapyramidal effects like akathisia and dystonia.
Eat small amount slowly and sip small amount of fluid frequently
c. Alternative intervention
Ages 4 to 6 years
Age 12 to Adolescent
Signs of grieving:
• Somatic symptoms
- difficulty sleeping and eating, bed wetting, headache, stomach ache
b. Psychological symptoms
- separation anxiety, loneliness, guilt, fear that others will die, fantasizing about death,
learning difficulties and school problems.
c. Behavioral symptoms
- crying, emotional outburst, temper tantrums, extreme shyness, dis interest in playing,
demand for attention, overdependence and aching out.
RE-GRIEF PHENOMENON
- revisit grief periodically as they develop
Nursing Intervention for Ages 3 to 5 years
Strengthening the parent’s ability to provide support for the child by realizing the child’s
need to stay close to parent
• Referring for counseling those children with persistent difficulty playing; persistent fears;
aggressiveness; difficulty separation from the parent; preoccupation with dying; and
regression in toilet training, eating or sleeping.
• Joining with the parents to inform them of the parents’ illness when death is imminent.
• Not being surprised by a child's brief episodes of mourning alternate with desires desire to
return to normal activities
• Involving teachers
• Encouraging participation in rituals after death and activities that remember parent
• Referring for counseling those children who do not return to previous levels of functioning
in school activities and peer relationship
Adolescent 12 to 14 years old
• Allowing them to help but limiting caregiving tasks that may be excessively burdensome to
a child so young
• Referring for counseling those teens with clinical depression, suicidal thoughts, fears and
phobias, refusal to attend school, injury, regression to childish behavior, and somatic
symptoms that do not disappear.
• Referred.
Using play with grieving children
• Dolls, action figure, puppets
• Toys that re-create life, such as doll house, telephones, doctors kits
• Aggression releases activities like beating drum, punching bags, kicking balls, running, and
hammering
• Construction toys
• games
Using creative arts with grieving children and adolescents
• Drama
• Making collages
Using Children’s Literature
• Evaluate the book for its fit with the particular children and select titles that fit individual
needs.