PALLIATIVE CARE:

DEFINITION : Palliative Care was defined by the World Health Organization (WHO) in 2002 as An approach that improve the quality of life of patients and their families facing a problem associated with life threatening illness

Palliative care is 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. Palliative care:

SCOPE
Palliative care (pronounced pal-lee-uh-tiv) is specialized medical care for people with serious illnesses. It is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness whatever the prognosis. The goal is to improve quality of life for both the patient and the family.

Palliative care is provided by a team of doctors, nurses, and other specialists who work together with a patient's other doctors to provide an extra layer of support. It is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment.

A World Health Organization statement describes palliative care as "an approach that improves the quality of life of patients and their families facing the problems 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." More generally, however, the term "palliative care" may refer to any care that alleviates symptoms, whether or not there is hope of a cure by other means; thus, palliative treatments may be used to alleviate the side effects of curative treatments, such as relieving the nausea associated with chemotherapy.

The term "palliative care" is increasingly used with regard to diseases other than cancer such as chronic, progressive pulmonary disorders, renal disease, chronic heart failure, HIV/AIDS, and progressive neurological conditions. In addition, the rapidly growing field of pediatric palliative care has clearly shown the need for services geared specifically for children with serious illness.

PHILOSOPHY:

Communication with patient and family members , using the team approach to address the needs of patient

Competent and compassionate management of pain & other symptoms through outpatient, daycare and indoor care.

Provide relief from complex pain and other distressing symptoms Integrate the psychological and spiritual aspects of patient care psychosocial support, psychological assessment and intervention, all dimensions: emotional, social, spiritual of patients and their family members.

Offer a support system to help patients live as actively as possible until death Offer a support system to help the family cope during the patients illness and in their own bereavement Symptom control Psychological support for patients and families/carers End of life care Advice and support for healthcare professionals caring for patients with a life-limiting illness We provide education and training, research

ELEMENTS OF PALLIATIVE CARE

Elements in the broad conceptualization of end-of- life experience can be thought of in 4 categories: fixed elements, modifiable elements, interventions, and outcomes. Some of what the patient brings with himself or herself cannot change; in fact it would not be desirable to change some aspects. Knowing and accommodating these fixed characteristics, the clinician may then focus on a persons modifiable dimensions. Then the task is to identify the patients expectations and needs, and deliver the appropriate care interventions, whether directly by the clinician or through other aspects of the system. Together these elements of need and care combine to determine the overall experience of the dying processthe outcomes by which the health care system and society must measure our performance.

1)Fixed characteristics of the patient Race Ethnicity and culture

2)Modifiable dimensions Pain and other physical discomfort Psychological and cognitive symptoms Social relationships and support Economic demands and caregiving needs Hopes and expectations Spiritual, cultural, and existential beliefs

3)Health system interventions Family and friends Communities Professionals Societal institutions

4)Outcomes Objective measures Satisfaction

GLOBAL AND INDIAN PERSPECTIVE OF PALLIATIVE CARE

Provides relief from pain and other distressing symptoms; Affirms life and regards dying as a normal process; Intends neither to hasten or 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; Uses a team approach to address the needs of patients and their families, including bereavement counselling, 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.

QUALITY OF LIFE ISSUES : Physical pain and suffering: Although most physicians have training in pain management and alleviating distressing symptoms, it is widely recognized that pain is undertreated and some symptoms are poorly controlled; therefore, even though the psychologist may not be an expert in physical symptomology, the degree to which physical pain as well as other aspects of suffering are involved in the person's decision making must be reviewed. Comorbid psychological conditions: Disruptions of thought and affect caused by the following conditions may not be severe enough to make a person incapable of making decisions, but they can significantly affect decision making as well as impair quality of life (note: the psychologist may utilize appropriate standardized assessment tools as long as the instruments can be justified because of a need

to document a condition the professional has detected and are not used merely to rule out hypothetical problems):
o o o o o

Clinical depression and other mood disorders, Clinical anxiety disorders (including acute stress disorder and posttraumatic stress disorder), Early-stage dementia, Fluctuating states of delirium and/or psychosis, Personality disorders (note: the presence of a diagnosable personality disorder would not disqualify a person's end-of-life decisions; however, awareness of such a diagnosis would help the professional put other aspects of the discussion into the appropriate context),

Substance abuse (including accidental or purposeful abuse of/dependence on prescribed medication);

Other psychological issues: In addition to formally diagnosable conditions, there are a host of other issues associated with the individual himself or herself that need to be reviewed:
o o o o o

Ambivalence or rigid thinking, Fears (e.g., of pain, loss of mental status), History of actual and perceived trauma and loss (including traumatic head injury), Hopelessness and despair, Internalization of societal rejection (e.g., self-hatred due to sexual orientation - "internalized homophobia"; internalized low sense of entitlement in women),

Religious, spiritual, and existential beliefs, expectations, experiences, and values; sense of personal meaning and fulfillment in life; philosophy of life and life values; assumptive world components;

Fear of loss of control/loss of autonomy/loss of dignity: Research has indicated that these issues are the primary reasons given by people who want to take an action that may impact the timing of death and therefore they deserve careful exploration; Financial concerns: Issues associated with the cost of medical care may play a role in end-of-life choices so a discussion of the degree to which monetary matters are a part of the decision is important. (Note: there is some debate in the literature about whether the presence of financial concerns should disqualify a person's decisions. For some this is perceived to be a form of societal coercion while for others it is a natural consideration that may be seen as altruistic. It will be up to the professional, perhaps after peer consultation, to determine whether any financial concerns that are present are impairing the dying person's judgment);

Cultural factors: As reviewed earlier, people of diverse backgrounds hold differing attitudes toward various end-of-life decisions so exploring ways in which culture may be affecting decision making must be included in the review:
o

Cultural expectations and traditions associated with decision making, end-of-life issues, and values,

Impact of personal characteristics, such as age, ethnicity, gender, economic status, and disability;

Review possible underlying issues: Resolution of the following issues, if present, should not be expected, nor required. These areas are listed because of their potential for decreasing quality of life and impacting relationships:
o o

Is the request for assistance in dying a form of communication and what is being communicated? Is there a "split in the experience of the self" such that the person wants the sick part of the self to die but the healthy part to live? If so, what impact is this having on the decision making?

How is the person's ego functioning and related issues (e.g., coping and defense mechanisms, frustration tolerance, character scripts, locus of control and processing, cognitive style and biases, problem-solving skills, and ways of managing psychosocial transitions) affecting the decision?

How are the person's specific strengths, skills, and assets, vulnerabilities, and liabilities influencing the decision-making process?

Are rage, revenge, and helplessness involved in the process and what do they represent to the person?

Are guilt, shame, self-punishment, and atonement affecting the quality of life and the end-of-life decision?

Is the person viewing life as having already come to an end and how is this impacting the decision-making process and review?

Overall quality of life: Generally speaking, how good does the individual believe his or her quality of life is at the present time, what does he or she envision for the near future, and what could change the present and prospective quality of life for the better? Other issues to explore: If these issues have not already been discussed, the following topics deserve consideration:
o o o

Has the person been suicidal in the past? How long has the person been thinking about his or her end-of-life options? How long ago was a decision made?

Why was the decision made when it was and, if there is a significant time gap between when the decision was made and when the review is being conducted, why is the discussion being held now?

If the person was going to follow through with the end-of-life decision, when would action take place and why then?

The person's social support system. Consideration of significant others: How has the presence or absence of significant others impacted the person's decision making:
o

Review the beliefs the person has about the potential impact on the significant others (including those yet-to-be-born), if any, of a particular decision,

If the individual insists there are no significant others, including friends, discuss the degree to which this isolation (and, possibly, loneliness) may be amenable to change and the effect such a change might have on a decision,

Examine the degree to which concerns about being a burden on others (physically, emotionally, financially, etc.) are influencing the decision; Involvement of significant others: Discuss the presence of significant others in the client's life and consider suggesting that, if possible, they become involved in the decision-making process in some way:

If the individual is unwilling to have significant others involved, review the reasons for this decision and discuss the impact their lack of involvement may be having on his or her decision making,

If the person is willing to have significant others involved but has not included them to this point, discuss how such involvement will occur and how this plan impacts the review,

If the dying person is uncertain about involving significant others, discuss the issues until some decision can be made and then follow the first two bullets in this item, depending on which is most appropriate given the decision made,

If significant others have been involved, find out what the dying person believes took place in the discussions and whether there is any unfinished business,

Review if there has been any direct or indirect, subtle or overt, actual or perceived, pressure from significant others on the decision-making process; Interviews with significant others: Consider reviewing at least the following issues related to the terminally ill person with members of his or her support system; if any areas of concern arose during the interview with the ill individual, ask about them in this section as well:

o o o o o o o o o

Current functioning, Recent changes in physical, mental, or emotional health, Medical and psychosocial history, especially psychological problems and substance abuse/mis-use, Typical pattern of adjusting to loss, change, and illness, Personality style, Reasons for considering particular options and the significant other's reactions to these reasons, Areas of unfinished business, Extent of financial concerns of all involved, Other issues of concern related to the interviews with the dying person (e.g., if the dying individual's response to questions about his or her fears of dying and death need clarification or raised concerns in the professional, questions about this area can be asked of the significant others).

Systemic and environmental issues. The goal here is to explore for the presence of any pressures from outside sources that may be impinging on the person's decision making. 1. Indirect external coercion: To what extent are pervasive societal conditions and attitudes negatively impacting the individual's life and, perhaps, causing him or her to feel as if there are no satisfactory options that will provide for a decent quality of life, such as:
o

Negative biases toward older persons, persons with disabilities, women, members of minority ethnic groups,

Lack of funding for basic health care needs, inadequate resources for persons with chronic and disabling conditions, poorly trained professional caregivers, and other problems;

2. Direct external coercion: Pressure to make a particular decision may be subtle or overt, may be actually occurring or merely a perception of the individual, could occur intentionally or accidentally, for example:
o

Are health care providers, administrators, and/or insurers/payers pressuring the client to make a decision that will cut expenses, open up space, or for some other reason?

Has a medical provider suggested scaling back treatment or offered some specific options, leading the person to believe he or she has been given up on or abandoned by professional caregivers.

COMMUNICATION SKILL The person with palliative care needs may be very ill, weak and fatigued and may have high levels of distress. The individual and their relatives and carers may feel powerless. It is hard to listen to someone elses suffering and can raise emotions or fears within the health and social care worker themselves. Remember

It must be difficult for you

t done much but people often feel better for talking, A problem shared......

What is Communication Communication is the exchange of information whenever two or more individuals are together communication is taking place. Communication means different things to different people and there are many methods of communication some of which are more effective than others

Objectives : a)Understand how to communicate with a range of people, carers and staff on a range of matters in a form that is appropriate to them and the situation b) Recognise the need for timely communication c) Understand the range of skills and interactions that underpin effective communication. d) Understand the impact communication has on the well being of the person receiving care, their relatives and carers e) Understand how to constructively manage barriers to effective communication. Be able to change form/style of communication and monitor effectiveness of own communication. f) Demonstrate knowledge of culture and ethnicity issues that can impact on communication styles, expectations and preference. Able to access appropriate resources to aid communication. g) Reflect on their own communication skills and involve other appropriate persons as necessary. h) Demonstrate awareness of the principles and aims of caring for people with complex needs. (I.e. physical, psychological, social and spiritual complex needs) i) Understands the importance of giving clear explanations and gaining permission prior to carrying out any activity, and to understand the reporting procedures if permission is not obtained.

j) Understands how to keep accurate and complete records consistent with legislation, policies and procedures Effective Listening in Communication One of the best ways to communicate with people is to stop talking and start listening; but listening is more than not talking. Listening means not only hearing what is being said but also attempting to understand what lies behind the words spoken. The good listener recognises that the other person has something constructive to offer and seeks to discover what it is, even though their thoughts may be unclear. Effective listening requires a continuous determined effort to pay attention to the speaker and to his/her words. Listening is not easy and not the same as hearing. The process of listening could be broken down further into 4 distinct but interrelated components

Listening by definition isnt a natural process; it refers to paying attention, remembering and understanding the content of what the speaker has said. Hearing or passive listening however is a natural process as one doesnt have to learn to hear. Listening is by far the most important of all communications skills. It does not come naturally to most people, so we need to work hard at it; to stop ourselves 'jumping in' and giving our opinions. Passive Listening Passive listening is the process of emptying the mind. The listener must not allow themselves to make judgements or question the other person. This is difficult to achieve and requires constant practice. Active Listening Active listening is the process of listening to others in order to understand their ideas, opinions and feelings and to demonstrate you have understood. Tips for active listening

ow you understand

Potential Barriers to Active Listening

Inevitably there are barriers to active listening. some of the major barriers these may include.

Fears

BODY LANGUAGE Body language is a term for communication using body movements or gestures instead of, or in addition to, sounds, verbal language or other communication. It describes all forms of human communication that are not verbal language. This includes the most subtle of movements that many people are not aware of, including winking and slight movement of the eyebrows. In addition body language can also incorporate the use of facial expressions.

Positive body language shows you are interested in what the person is saying. Tips for positive Body Language Relaxed Body Position- (though dont slump) this helps put the other person at ease as you look friendly and helpful. If you appear tense you may seem unreceptive or nervous. Open Posture -by standing at a slight angle to the other person so that you dont seem threatening and if the other person is sitting try and match their position by also sitting. Lean Slightly Forward-as a sign of involvement, but dont overdo it or you will invade their personal space. Eye Contact-should be appropriate (normally there is more eye contact as the other person is talking). Two extremes of inappropriate eye contact would include diverting the eyes or staring. If you look down or away too often it may indicate tension or boredom where as staring may be interpreted as aggression. In some cultures regular eye contact (70%) can either be seen as offensive or even flirtatious, particularly female to male eye contact

Responding Responding may be defined as the ability to give appropriate feedback to the message received either verbally or non-verbally. It involves the processes of listening and attending. It is argued that at the heart of good effective interpersonal communication is the skill of responding with accurate understanding. Listening without responding may be seen as passive listening. By responding appropriately you demonstrate that you understanding the individuals needs and feelings, and values what has been said. Verbal Responding This relates to all activities that make some kind of verbal statement e.g.

o Open questions Example: How are you feeling? o Closed questions Example: Are you feeling better? tanding o Reflecting Example: Am I right in thinking you would prefer to be called Bob? o Echoing Example: You said you are called Brian, but prefer to be called Bob? Non-Verbal Responding Generally most non-verbal responding tends to accompany some form of verbal responding. This includes:

Silence When thinking about how we communicate we shouldnt forget silence. Silence can be a very powerful tool. Silence in every day conversations can be awkward but when caring for people who may wish to discuss sensitive issue silence has an important role. Try not to jump in to avoid periods of silence. Touch Touch can be a powerful form of communication, it can convey warmth and empathy but it can also be patronising or condescending e.g. a pat on the head or worse a pat on the bottom! Touch is a very individual thing; some people are more tactile than others. Think about your own circle of family and friends, there is probably a wide range of occasions when it would be comfortable to touch or be touched by different people. Are you a naturally tactile person? As health and social care workers we are familiar with touching people intimately as part of our work but others may not be. Touch is not always appropriate; you would be surprised if your bank manager held your hand even if it was bad news! We need to be mindful of cultural and sexual factors when considering touch as a form of communication, what is acceptable for you may not be for the other person.

Communication Role in Health and Social Care Settings Communication is an essential aspect of our everyday role. It is a vital element of the role of all health and social care staff. The literature identifies a number of key characteristics in the process of communication when helping and counselling individuals these include; genuineness, empathy, warmth and acceptance. Genuineness To be truly genuine means to be authentic and be able to express what one feels for example what you see is what you get. As health and social care staff we often have to try and deal with difficult situations. It is easy to hide behind a uniform or a role. It is easy to forget sometimes that it is alright to say I dont know. Inevitably at sometime people with palliative care needs and/or their families may say, you dont know how Im feeling and unless we have been in a similar situation we probably truly dont! Empathy Empathy is the ability to recognise and understand how another person feels. An empathic response indicates that if placed in similar circumstances you would have similar feelings. There are two components of empathy, recognising the feelings and then communicating to the speaker that you understand and acknowledge how they feel. It does not mean you share their feelings, this is sympathy. You can show empathy through gestures, facial expressions, appropriate touch and words. Examples That must be difficult for you. Im not surprised you feel anxious. I imagine you were very frightened This is not wrong; it indicates that you are trying to understand how the other person feels which is better than ignoring it. Avoid saying, I know how you feel because you dont, you can only try to imagine how another person feels. Warmth By being warm a person will usually come across as genuine. Being warm doesnt have to mean being demonstrative and overenthusiastic especially if that isnt your normal way or style of behaving. It does however, mean respecting another person, who they are and what they stand for. To a person with palliative care needs experiencing warmth from others is extremely important. As health and social care staff we have our own agendas, beliefs and values which can affect the way we respond and act with others. Acceptance Acceptance means taking the whole of a person not just the bits we like i.e. warts and all. It is virtually impossible to be totally acceptable. As health and social care staff our role requires us to try and accept other people without judgement. Awareness of ourselves and our character will make us more aware of others.

Other key characteristics include

Warmth, acceptance, genuineness and empathy add a humanistic dimension to communication (Rungapadiachy, 2003).

HOME CARE
Home care for the sick is the oldest form of health care. Today, a wide range of health and social services can be given in the home. Whether a person is being treated for cancer, is recovering from it, or has advanced disease, home care can be an option. Through home care you can get expert, compassionate health care in your home instead of in a hospital or other facility.

Types of home care agencies Many providers offer home care services, including:

Home health agencies Hospices Homemaker and home care aide agencies Staffing or private-duty agencies Medical equipment and supply companies Home infusion or pharmaceutical (medicine) companies

Home health agencies If you need skilled home care services, they will usually be given by a home health agency. The same agency may offer different kinds of home care services through nurses, therapists, social workers, homemakers and home care aides, medical equipment and supply dealers, and volunteers. Some agencies limit their services to nursing and 1 or 2 other specialties. If care is needed from more than one specialist, the home health agency will set up a team to provide care that covers your needs. Because home health agencies hire and supervise their personnel, they assume liability for all care. Home care services are usually available 24 hours a day, 7 days a week, though most home services are done during the day when possible.

Hospice care This type of care involves a core team of skilled experts and volunteers who provide all-around medical, psychological, and spiritual care when cure is no longer possible. Hospice care is usually based at home so that families take part in the patients care. Trained hospice professionals are on call 24 hours a day. They help the family care for the patient, help ensure that the patients wishes are honored, and keep the patient as functional and free from pain and other symptoms as possible. They also help support the family through this time. Many hospice programs are Medicare certified and licensed according to state requirements. Homemaker and home care aide agencies These agencies help patients by preparing meals and helping them bathe, dress, and keep house. They may also sit with patients who cannot be left alone for medical or safety reasons. This is sometimes called companion service. Some states require that these agencies be licensed and meet certain standards of care. Pharmaceutical and infusion therapy companies These companies deliver medicines, equipment, and nursing services for people who need intravenous (IV) fluids, nutrition, or treatments at home. They also give special feedings through tubes that are placed in the stomach or intestine (tube feedings). Nurses teach patients and family members to give these medicines, fluids, or feedings in the patients home. They often stop in to be sure everything is working well, and you can call them if there are problems. Some pharmaceutical and infusion therapy companies are certified by Medicare. Durable medical equipment and supply dealers These companies provide products ranging from breathing machines (respirators), oxygen tanks, wheelchairs, and walkers, to catheter and wound-care supplies. They deliver these products, install or set them up, and teach patients and caregivers how to use them. Most of these companies do not give physical care to patients, but a few offer pharmacy and infusion services. They may provide a nurse to give medicine and tube feedings to patients and teach the patient and family the proper way to give these on their own. Some offer respiratory therapy services to help patients use breathing equipment. Those that bill Medicare must meet federal minimum standards. Some states require that these companies be licensed. Staffing registries/private-duty agencies Private-duty agencies provide people with nursing, homemaker, home care aide, and companion services. In most cases, these agencies are not licensed or regulated by the government. Staffing registries often serve as employment agencies for home care nurses and aides. They match the provider with the patient and collect a finders fee.

Independent providers These are individual nurses, therapists, aides, homemakers, and companions who are privately employed by those who need their services. The patient or family must recruit, hire, and supervise the provider. The patient or family pays the provider directly.

Types of home care services are available;

Nursing care A highly skilled registered nurse (R.N.) can be very helpful to a cancer patient at home and can help relieve the burden on family members. With home care, a nurse comes into the home, looks at the care needs you and your family have, and sets up a plan of care along with the doctor. Services may include the care of wounds, ostomy care, giving intravenous (IV) treatments, giving and supervising medicines, and watching for side effects. Your care plan may also include giving supportive care, like pain control, as well as health teaching and emotional support. The needs of both the patient and the family are covered. Physical therapy Physical therapists can help you to regain the use of impaired or weakened muscles. They also work with you to improve the range of motion in joints and learn to use any special equipment needed for daily activities. Occupational therapy An occupational therapist can help you with problems that keep you from doing activities of daily living. An occupational therapist will look at what you can do, and then teach you new ways to do daily tasks, like eating, bathing, dressing, and household routines. If special equipment is needed, you will be taught to use it. With the therapists help, you can learn to do more things on your own. Speech therapy If you cannot talk the way you used to, a speech therapist can help you communicate again by teaching special techniques and helping you practice. They may also help if you have problems swallowing. Social workers Social workers look at social and emotional factors that affect patients. They serve as case managers for patients with complex needs and help find sources of help in the community. This can include helping the family look for financial help when needed. They also counsel patients on coping with the demands of illness, family conflicts, and grief that affect the patients care.

Home health aides/home care aides With the help of an aide, you can better handle personal care, such as getting in and out of bed, walking, bathing, and dressing. Some aides have had special training and are qualified to give more complex services if supervised by a registered nurse. Homemaker/attendant care A homemaker can perform light household tasks for you, like laundry, meals, housekeeping, and shopping. These services are done to help maintain your house rather than give health care. Some agencies assign a home health aide these tasks along with health services. Volunteers A volunteer from a community organization, a home care agency, or hospice can sit with you, give emotional support, and help with personal care, paperwork, and getting to and from doctor visits. Others Home care services may also include some of these:

Nutrition support and help with diet Medical equipment and supplies Lab and x-ray studies Pharmacy services Respiratory therapy Transportation Home-delivered meals Problem-solving or other help by phone Dentists, clergy, specialist doctors, and other health professionals Emergency alert or safety monitoring systems

Types of services are available for patient with cancer Much of the care given to people with cancer is done in an outpatient setting, which includes home care. In many ways, home care for the person with cancer is no different than the home care that is given to people with other kinds of illness. Home care services could include all of the services listed above. Skilled nursing might involve an oncology nurse specialist, who is an expert in cancer care. Many of these same services are also offered as part of hospice care.

Some of the home care services needed by a person with cancer might include:

Chemotherapy Immunotherapy or biologic therapy (which use different parts of the bodys immune system to fight cancer or lessen the side effects of some cancer treatments)

Blood products (transfusions) Pain management Antibiotic treatment Nutritional support Anti-emetic therapy (treatment for vomiting) Hydration (giving of fluids, usually IV or through a feeding tube, for patients who cannot drink enough liquids)

All of these infusion therapy services are offered by most home care agencies. For many people, these services can be given in the home.

WHO PAYS FOR HOME CARE?

Home care services can be paid for by:
1) 2) 3)

Patient and family (out of pocket) Public third-party payers such as Medicare, Medicaid, and the Veterans Administration (VA) Private third-party payers such as health insurance companies and managed care plans

1)Patient and family (out of pocket) For services that are not covered by insurance, one may choose to pay out of own pocket if they can afford it. 2)Public third-party payers To qualify for the Medicare Home Care Benefit Most Americans over age 65 are eligible for the federal Medicare program. Some people under the age of 65 may be eligible due to disability. To qualify for home care, a person with Medicare must meet all of the following:

Your doctor must decide that you need medical care at home and make a plan for your care at home. You must need at least one of the following either part time or on and off: skilled nursing care, physical therapy, speech-language therapy, or occupational therapy.

You must be homebound and unable to leave the house without help. To be homebound means that leaving home takes a good deal of effort. But leaving home for medical treatment or short non-medical trips (such as for haircuts or religious services) do not usually disqualify you.

If you meet all the above requirements, you may be eligible for services provided by a Medicare-certified home health agency. Depending on your condition, Medicare may pay for:

Skilled nursing visits Physical, occupational, and speech therapies Medical social services Medical equipment and supplies

If one of these skilled services is needed, home care aide services may also be provided as part of home care for the illness. The doctor who refers you for home care must sign off on your plan of care and review it regularly. Except for hospice care, the services you get must be part-time and provided through a Medicare-certified home health agency in order to qualify for payment. For more information on Medicare and home care, you can order the booklet, Medicare and Home Health Care by calling Medicare, or you can read it on their Web site. Not all home care agencies are certified to provide care to people with Medicare. Those that are certified have met federal requirements for patient care. This allows them to provide home health services to patients covered by Medicare and Medicaid. Due to legal requirements, the agencies must report to Medicare, and their services are watched and controlled. Medicare also covers hospice services for people with cancer who are expected to live for 6 months or less. For hospice coverage, you are not required to be homebound or in need of skilled nursing care. Call Medicare or visit their Web site to find out more about the Medicare Hospice Benefit To qualify for Medicaid coverage of home care States are required to provide health services to people who get money from federally assisted income programs, such as Social Security and Temporary Assistance for Needy Families (TANF). Others who may qualify for Medicaid help include categorically needy people. These are people who meet the income and resource requirements for TANF but who are not getting it (for example, certain children under the age of 21, and some elderly, blind, and disabled persons whose income is below certain levels).

Under federal Medicaid rules, coverage of home health services must include part-time nursing, home care aide services, and medical supplies and equipment. At the states option, Medicaid may also cover audiology (hearing services); physical, occupational, and speech therapies; medical social services; and hospice. Department of Veterans Affairs Different types of services are available in different areas of the United States. Most Veterans Affairs (VA) regions pay for skilled home care and hospice, although the VA may not directly provide these services. The veteran must be referred by a VA doctor and meet medical requirements to qualify for skilled home care or hospice. The Social Services department of your closest VA medical facility should be able to answer questions about eligibility in your area. Older Americans Act (OAA) The OAA provides federal funds for state and local social service programs that help frail and disabled older people to stay independent in their communities. This funding covers home care aides, personal care, household chores, escort, meal delivery, and shopping services for people aged 60 and older with the greatest social and financial need. These services are often provided through a local area Agency on Aging. The OAA was reauthorized by Congress from 2006 through 2011. To find your local Agency on Aging, you can contact the National Association of Area Agencies on Aging. Social Services Block Grant Programs Each year states get social services grants from the federal government. Part of the money is usually used for programs that offer home care aide and homemaker services. Patients can contact their state health departments or local area Agency on Aging Community organizations Some community groups, along with state and local governments, help pay for home health and personal care. Depending on a persons eligibility and financial need, these groups may pay for all or part of services. Hospital discharge planners, social workers, local offices on aging, the United Way, and your American Cancer Society are excellent sources for information about whats offered in your area.

3)Private third-party payers Commercial health insurance companies Most private insurance policies include some home care service for short-term needs, but benefits for long-term care vary from plan to plan. Be sure to ask about your insurance coverage not only for home care, but also for home hospice care. Managed care organizations These group health plans sometimes cover home care services. Managed care organizations that have contracts with Medicare must provide the full range of Medicare-covered home health services available. Coverage may be limited to doctor-directed medical services and treatments, but your choice of agency is restricted. Be sure to ask about your plans coverage. Private pay or self-pay If insurance coverage is not available or does not cover all the care that you need, you and your family can hire providers and pay for services yourself.

HOSPICE CARE
"You matter because of who you are. You matter to the last moment of your life, and we will do all we can , not only to help you die peacefully, but also to live until you die." --Dame Cicely Saunders Hospice is a philosophy of care. The hospice philosophy or viewpoint accepts death as the final stage of life. The goal of hospice is to help patients live their last days as alert and pain-free as possible. Hospice care tries to manage symptoms so that a person's last days may be spent with dignity and quality, surrounded by their loved ones. Hospice affirms life and neither hastens nor postpones death. Hospice care treats the person rather than the disease; it focuses on quality rather than length of life. Hospice care is family-centered -- it includes the patient and the family in making decisions. This care is planned to cover 24 hours a day, 7 days a week. Hospice care can be given in the patient's home, a hospital, nursing home, or private hospice facility. Most hospice care in the United States is given in the home, with family members or friends serving as the main hands-on caregivers. Because of this, a patient getting home hospice care must have a caregiver in the home with them 24 hours a day.

Hospice care is used when you can no longer be helped by curative treatment, and you are expected to live about 6 months or less if the illness runs its usual course. Hospice gives you palliative care, which is treatment to help relieve disease-related symptoms, but not cure the disease; its main purpose is to improve your quality of life. You, your family, and your doctor decide together when hospice care should begin.

Hospice care services

Many features of hospice care set it apart from other types of health care. A team of professionals In most cases, an interdisciplinary health care team manages hospice care. This means that many interacting disciplines work together. Doctors, nurses, social workers, counselors, home health aides, clergy, therapists, and trained volunteers care for you and your family. Each of these people offers support based on their special areas of expertise. Together, they give you and your loved ones complete palliative care aimed at relieving symptoms and giving social, emotional, and spiritual support. Pain and symptom control The goal of pain and symptom control is to help you be comfortable while allowing you to stay in control of and enjoy your life. This means that discomfort, pain, and side effects are managed to make sure that you are as free of pain and symptoms as possible, yet still alert enough to enjoy the people around you and make important decisions. To learn more on this topic, please see our document. Spiritual care Since people differ in their spiritual needs and religious beliefs, spiritual care is set up to meet your specific needs. It may include helping you look at what death means to you, helping you say good-bye, or helping with a certain religious ceremony or ritual. Home care and inpatient care Although hospice care can be centered in your home, you may need to be admitted to a hospital, extended-care facility, or a hospice inpatient facility. The hospice can arrange for inpatient care and will stay involved in your care and with your family. You can go back to in-home care when you and your family are ready.

Respite care While you are in hospice, your family and caregivers may need some time away. Hospice service may offer them a break through respite care, which is often offered in up to 5-day periods. During this time you will be cared for either in the hospice facility or in beds that are set aside for this in nursing homes or hospitals. Families can plan a mini-vacation, go to special events, or simply get much-needed rest at home while you are cared for in an inpatient setting. Family conferences Regularly scheduled family conferences, often led by the hospice nurse or social worker, keep family members informed about your condition and what to expect. Family conferences also give you all a chance to share feelings, talk about what to expect and what is needed, and learn about death and the process of dying. Family members can find great support and stress relief through family conferences. Daily conferences may also be held informally as the nurse or nursing assistant talks with you and your caregivers during their routine visits. Bereavement care Bereavement is the time of mourning after a loss. The hospice care team works with surviving loved ones to help them through the grieving process. A trained volunteer, clergy member, or professional counselor provides support to survivors through visits, phone calls, and/or letter contact, as well as through support groups. The hospice team can refer family members and care-giving friends to other medical or professional care if needed. Bereavement services are often provided for about a year after the patient's death. To learn more on this topic, please see our documents, Volunteers Hospice volunteers play an important role in planning and giving hospice care in the United States. Volunteers may be health professionals or lay people who provide services that range from hands-on care to working in the hospice office or fundraising. Staff support Hospice care staff members are kind and caring. They communicate well, are good listeners, and are interested in working with families who are coping with a life-threatening illness. They are usually specially trained in the unique issues surrounding death and dying. Yet, because the work can be emotionally draining, it is very important that support is available to help the staff with their own grief and stress. Ongoing education about the dying process is also an important part of staff support.

Coordination of care The interdisciplinary team coordinates and supervises all care 7 days a week, 24 hours a day. This team is responsible for making sure that all involved services share information. This may include the inpatient facility, the home care agency, the doctor, and other community professionals, such as pharmacists, clergy, and funeral directors. You and your caregivers are encouraged to contact your hospice team if you are having a problem, any time of the day or night. There is always someone on call to help you with whatever may arise. Hospice care assures you and your family that you are not alone and help can be reached at any time.

Hospice care settings

Hospice care is defined not only by the services and care provided, but also by the setting in which these services are delivered. Hospice care may be provided in your home or in a special facility. Most cancer patients choose to get hospice care at home. In fact, more than 90% of the hospice services provided in this country are based in patients' homes. Before making a decision about the type of program that is best for you and your family, it is important to know all your options and what each requires. Your doctor, hospital social worker, or discharge planner can be very helpful in deciding which program is best for you and your family. Home hospice care Many, if not all, of the home health agencies in your community, as well as independently owned hospice programs, will offer home hospice services. Although a nurse, doctor, and other professionals staff the home hospice program, the primary caregiver is the key team member. The primary caregiver is usually a family member or friend who is responsible for around-the-clock supervision of the patient. This person is with the patient most of the time and is trained by the nurse to provide much of the hands-on care. It is important to know that home hospice may require that someone be home with you at all times. This may be a problem if you live alone, or if your partner or adult children have full-time jobs. But creative scheduling and good team work among your friends and loved ones can overcome this problem. Members of the hospice staff will visit regularly to check on you and your family and give needed care and services. Care begins when you are admitted to the hospice program, which generally means that a hospice team member visits the home to learn about you and your needs. Return visits are set up so that your needs can be reevaluated regularly. To handle around-the-clock patient needs or crises, home hospice programs have an on-call nurse who answers phone calls day and night, makes home visits, or sends the team member you may need

between scheduled visits. Medicare-certified hospices must provide nursing, pharmacy, and doctor services around the clock. Hospital-based hospices Hospitals that treat seriously ill patients often have a hospice program. This arrangement allows patients and their families easy access to support services and health care professionals. Some hospitals have a special hospice unit, while others use a hospice team of caregivers who visit patients with advanced disease on any nursing unit. In other hospitals, the staff on the patient's unit will act as the hospice team. Long-term care facility-based hospices Many nursing homes and other long-term care facilities have small hospice units. They may have a specially trained nursing staff to care for hospice patients, or they may make arrangements with home health agencies or independent community-based hospices to provide care. This can be a good option for patients who want hospice care but do not have primary caregivers to take care of them at home. Independently owned hospices Many communities have free-standing, independently owned hospices that feature inpatient care buildings as well as home care hospice services. As with long-term care facility hospice programs, the free-standing hospice can benefit patients who do not have primary caregivers available at home.

WHO PAYS FOR HOSPICE CARE?

Home hospice care usually costs less than care in hospitals, nursing homes, or other institutional settings. This is because less high-cost technology is used and family and friends provide most of the care at home. Medicare, Medicaid in most states, the Department of Veterans Affairs, most private insurance plans, HMOs, and other managed care organizations pay for hospice care. Also, community contributions, memorial donations, and foundation gifts allow many hospices to give free services to patients who can't afford payment. Some programs charge patients according to their ability to pay. Medicare hospice To get payment from Medicare, the agency must be approved by Medicare to provide hospice services. To qualify for the Medicare hospice benefit, a doctor and the hospice medical director (also a doctor) must certify that the patient has less than 6 months to live if the disease runs its normal course. The doctor must re-

certify the patient at the beginning of each benefit period (2 periods of 90 days each, then an unlimited number of 60-day periods). The patient signs a statement that says he or she understands the nature of the illness and of hospice care, and that he or she wants to be admitted to hospice. By signing the statement, the patient declines Medicare Part A and instead chooses the Medicare hospice benefit for all care related to his or her cancer. The patient can still receive Medicare benefits for other illnesses. A family member may sign the statement if the patient is unable to do so. Medicaid coverage In 1986, laws were passed to allow the states to develop coverage for hospice programs. Most states have a Medicaid hospice benefit, which is patterned after the Medicare hospice benefit. Private insurance Most private insurance companies include hospice care as a benefit. Be sure to ask about your insurance coverage, not only for hospice, but also for home care. Private pay If insurance coverage is not available or is not enough to cover all costs, the patient and the family can hire hospice providers and pay for services out of pocket. Some hospices provide services without charge if a patient has limited or no financial resources.

SOURCES OF HOSPICE CARE

Finding the hospice program that meets your needs may take some research, but it will be time well spent. You and your family should do this early in your care while you have the strength and ability to take part in the decision. Quality of care, availability of needed services, the types of services covered, staff training and expertise, and insurance coverage all need to be considered. Most communities have more than one hospice provider you can choose from. Here are some things to think about as you start your search: Local resources Your doctor or hospital discharge planner can help you find hospices in your area. Hospice care providers also are listed in the phone book. Your community may have information and referral services available through your American Cancer Society, an Agency on Aging, a local United Way chapter, the Visiting Nurse Association, or your place of worship.

State resources You may contact your state's hospice organization or its department of health or social services to get a list of licensed agencies. The state health department oversees certification of hospice services. Certification makes them able to get funding from Medicare and, in some states, also from Medicaid. Check the blue pages of your phone book for other resources in your area. National resources National organizations that deal with hospice care accreditation, treatment, and patient advocacy

ROLE OF NURSE IN PALLIATIVE CARE: Strategies for ensuring quality end-of-life care should be integrated into every nurses practice. These include: communicating openly, honestly and in a timely fashion maintaining comfort ensuring social support and care for caregivers applying the principles of palliative care ensuring that care is ethically, spiritually and culturally appropriate

1)Effective communication is one of the foundational concepts that form the bases of hospice palliative care . Communicating effectively involves providing patients and their families with information so that they are able to make decisions about care, initiating discussions , about end-of-life care when the patient can actively participate, and facilitating discussions with patients and their families in a supportive and compassionate manner. 2)Hospice palliative care is aimed at relief of suffering and improving the quality of life for persons who are living with or dying from advanced illness, or are bereaved (1). Hospice palliative care is more focused than end-of-life care and can be provided along the disease trajectory where people need help with suffering and symptom management. It tends to be organized as a set of services. 3)The patient and family are treated as a unit of care and the family should be included in decision-making processes whenever possible 4)Patients and family members need to be informed so that they are able to make decisions, determine goals for care and establish present and future priorities for care. It is important to provide seniors and their caregivers with information so that they are able to make appropriate care decisions, but this information needs to be given incrementally so it is not overwhelming. 5)Nurses in all areas of health care play a key role in initiating discussions with patients about end-of-life decisions regarding care. In chronic disease, where patients slowly decline or their health status fluctuates, it is often difficult to determine when the end-of-life is approaching. Discussions with patients failing to improve in an intensive care setting need to take place at the earliest possible opportunity. In a document about promoting excellence in end of life care for individuals with amyotrophic lateral sclerosis (ALS), six triggers for initiating discussion about end-of-life issues were listed: the patient or family opening the door to discussions about end-of-life care evidence of severe psychological, social or spiritual distress or pain which requires high doses of analgesic the occurrence of dyspagia, requiring a feeding tube, dyspnea forced vital capacity of less than 50% loss of function in two body regions

6)Discussions with patients and their families about end-of-life care are challenging and difficult to initiate. How does the nurse talk about death and dying? Nurses need to explore their own attitudes, values and beliefs about issues surrounding death to improve communication and maximize end of life care 7)When assisting patients and families to make decisions about end-of-life care the nurse should: be clear and avoid euphemisms be specific about goals and expectations of treatment be willing to initiate and engage in discussion use the words the death and dying talk about hope, clarify goals and burdens of treatment and prognosis collaborate with other providers to give consistent information

BIBLIOGRAPHY: Books : Black.M.Joyes, Medical Surgical nursing, 7th edition, Saunders Publication Philidelpia. Pp 2416-2120. Brunner and Siddarth, Text book of Medical Surgical Nursing, edition 10th,Lippincott Publication.Pp 1234-1243. Woods Long Philip,Shafers Medical Surgical Nursing,7th edition, B.I. Publications Pvt. Limited New Delhi. Pp 866-876. Ghai O.P, Essential Paediatrics, edition 6th, CBS Publishers and distributors New Delhi, Pp 890-900. Wally and Wongs, Textbook of paediatrics Nursing, edition 6th, Mosbys publication, Pp 1432-1440. Lewis and Long, Texetbook of Medical Surgical nursing, 3rd edition, Mosby publication.Pp 2433-2444. Journal Articles 1. Abels, N, & Barlev, A. (1999). End of life decisions and assisted suicide. Professional Psychology: Research and Practice, 30, 229-234. 2. Baker, R. R., Lichtenberg, P. A., & Moye, J. (1998). A practice guideline for assessment of competency and capacity of the older adult. Professional Psychology Research and Practice, 29, 149-154. 3. Benbassat, J., Pilpel, D, Tidhar, M (1998). Patients' preferences for participation in clinical decision making: A review of published studies. Behavior Medicine 24, 81-87, 4. Blackhall, L.J., Murphy, S.T., Frank, G, Michel V, Azen S. (1995). Ethnicity and attitudes toward patient autonomy, JAMA 274, 820-5. 5. Blendon, R.J., Szalay, U.S., & Knox, R.A. (1992). Should physicians aid their patients in dying? The public perspective. JAMA, 267, 2658-2662. 6. Block, S. D.(2000). Assessing and managing depression in the terminally ill patient. Annals of Internal Medicine,132, 209-218. 7. Block, S.D., & Billings, J. (1995). Patient requests for euthanasia and assisted suicide in terminal illness: The role of the psychiatrist. Psychosomatics, 36, 445-457. 8. Bradley, J. Peiris, V, Wetle, T. (1998). Discussions about end of life care in nursing homes. J. American Geriatric Society 46, 1235-1241. 9. Breitbart, W. (1990). Cancer pain and suicide. Advances in Pain Research and Therapy, 16, 399-412.

10. Bursztajn, H. J., Harding, H. P., Gutheil, T., & Brodsky, A. (1991). Beyond cognition: The role of disordered affective states in impairing competence to consent to treatment. Bulletin of the American Academy of Psychiatry and Law, 19, 383- 388. 11. Chin, A. E., Hedberg, K., Higginson, G. & Fleming, D. (1999). Legalized physician-assisted suicide in Oregon - The first years experience. The New England Journal of Medicine, 340, 577-583. 12. Chochinov, H., Wilson, K., Enns, M., Mowchun, N., Lander, S., Levitt, M., & Clinch, J. (1995). Desire for death in the terminally ill. American Journal of Psychiatry, 152, 1185-1191. 13. Cicirelli, V. (1997). Relationship of psychosocial and background variables to older adults' end-of-life decisions. Psychology and Aging, 12, 72-83. 14. Dowdy, M, Robertson, C., Bander, J.A., (1998). A study of proactive ethics consultation for critically and terminally ill patients with extended lengths of stay. Critical Care Medicine 26(2), 252-259 15. Eliasson, A, Howard, RS, Torrington, K., et al (1997). Do not resuscitate decisions in the medical ICU: Comparing Physician and nurses opinions. Chest 111, 1106-1111. 16. Ersek, M. Kagawa-singer, M, Barnes, D, Blackhall, L & Koenig, B (1998). Multicultural considerations in the use of advance directives. Oncology Nursing Forum 23, 1683-1690. 17. Farrenkopf, T., & Bryan, J. (1999). Psychological consultation under Oregon's 1994 Death With Dignity Act: Ethics and procedures. Professional Psychology: Research and Practice, 30, 245-249. 18. Farberman, R. K. (1997). Terminal illness and hastened death requests: The important role of the mental health professional. Professional Psychology: Research and Practice, 28, 544-547. 19. Field, D., Copp, G. (1999). Communication and awareness about dying in the 1990s. Palliative Medicine, 13, 459-468. 20. Fishbain, D. A., Goldberg, M. G., Rosomoff, R. S., & Rosomoff, H. (1991). Completed suicide in chronic pain. Clinical Journal of Pain, 7, 29-36. 21. Fowler, F. J., Coppola, K. M., & Teno, J. M. (1999). Methodological challenges for measuring quality care at the end of life. Journal of Pain and Symptom Management, 17, 114-119. 22. Ganzini, L., Nelson, H. D., Schmidt, T. A., Kraemer, D. F., Delorit, B. A., & Lee, M. A. (2000). Physicians' experiences with the Oregon Death with Dignity Act. New England Journal of Medicine, 342, 557-563. 23. Goldblum, P., & Martin, D. (1999). Principles for the discussion of life and death options with terminally ill clients with HIV. Professional Psychology: Research and Practice, 30, 187-197. 24. Grassi, L. (1997). Psychiatric implications of euthanasia and assisted suicide in terminally ill patients. New Trends in Experimental and Clinical Psychiatry, 13, 127-132. 25. Grisso, T., & Appelbaum, P. (1995). Comparison of standards for assessing patients decisions to make treatment decisions. American Journal of Psychiatry, 152, 1033-1037.

26. Grisso, T., & Appelbaum, P. (1998). Assessing competence to consent to treatment: A guide for physicians and other health professionals. New York: Oxford University Press. 27. Haghbin, Z., Streltzer, J., & Danko, G. P. (1998). Assisted suicide and AIDS patients: A survey of physicians attitudes. Psychosomatics, 39, 18-23. 28. Hertogh, C., & Ribbe, M. (1996). Ethical aspects of decision-making in demented patients: A report from the Netherlands. Alzheimer Disease and Associated Disorders, 10, 11-19. 29. Lee, M., & Ganzini, L. (1994). The effect of recovery from depression on preferences for life-sustaining therapy in older patients. Journal of Gerontology: Medical Sciences, 49, M15-M21. 30. Lewis, M., Pearson, V., Corcoran Perry, et al (1997). Decision making by elderly patients with cancer and their caregivers. Cancer Nursing 20, 389-397. 31. Meier, D. E., Emmons, C., Wallenstein, S., Quill, T., Morrison, R. S., & Cassel, C. K. (1998). A national survey of physician-assisted suicide and euthanasia in the United States. New England Journal of Medicine, 338, 1193-1201. 32. Moraso, G., Capelli, M., Viterbori, P., DiLeo, S., Alberisio, A., Constantini, M., Fiore, M., Saccani, D., Zeitler, G., Verzolatto, N., Tirelli, W., Lazarri, L., Partinico, M., Borzoni, G., Savian, C., Obertino, E., Zotti, P., Ivaldi, G. P., Henriquet, F. (1999). Psychological and symptom distress in terminal cancer patients with met and unmet needs. Journal of Pain and Symptom Management, 17, 402-409. 33. Pearlman, R., Cain, K., Patrick, D., Appelbaum-Maizel, M., Starks, H., Jecker, N., & Uhlmann, R. (1993). Insights pertaining to patients' assessments of states worse than death. Journal of Clinical Ethics, 4, 33-41. 34. Quill, T., Cassel, K. & Meier, D. (1992). Care of the hopelessly ill: Proposed clinical criteria for physician-assisted suicide. New England Journal of Medicine, 327, 1380-1383. 35. Rosenfeld, B., Breitbart, W., Sein, K., Funesti-Esch, J, Kaim, M. Krivo, S. (1999). Measuring the desire for death among patient with HIV/AIDS: The schedule of attitudes toward hastened death. American Journal of Psychiatry 156, 94-100. 36. Saunders, J.M. & Valente, S.M. (1993). Nicole: Suicide & Terminal Illness. Suicide and Life Threatening Behavior, 23(1), 76-82. 37. Saunders, J.M. (2000). AIDS, Nursing and Physician Assisted Suicide: Part I and II. Journal of Nurses in AIDS Care 11, 45-53. 38. Saunders, J.M. (1981). A process of bereavement resolution: uncoupled identity. Western Journal of Nursing Research 3, 319-336. 39. Schneiderman, L., Kaplan, R., Pearlman, R., & Teetzel, H. (1993). Do physician's own preferences for life-sustaining treatment influence their perceptions of patients' preferences. The Journal of Clinical Ethics, 4, 28-32.

40. Singer, P. A., Martin, D. K., & Kelner, M. (1999). Quality end-of-life care: Patients' perspectives. JAMA, 281, 163-168. 41. Stewart, A. L., Teno, J., Patrick, D. L., & Lynne, J. (1999). The concept of quality of life of dying persons in the context of health care. Journal of Pain and Symptom Management, 17, 93-108. 42. Straus, G. & Nelson, B. J. (1996). Palliative care enrichment in geropsychology fellowships. Educational Gerontology, 22, 775-780. 43. Sullivan, A. D., Hedberg, K., & Fleming, D. (2000). Legalized physician-assisted suicide in Oregon-The second year. New England Journal of Medicine, 342, 598-604. 44. Sullivan, M., Rapp, S., Fitzgibbon, D., & Chapman, C. R. (1997). Pain and the choice to hasten death in patients with painful metastatic cancer. Journal of Palliative Care, 13, 18-28. 45. Sullivan, M., & Youngner, S. (1994). Depression, competence and the right to refuse life saving medical treatment. American Journal of Psychiatry, 151, 971-978. 46. Valente, S.M. (2000). Oncology Nurses' difficulties with suicidal patients. Medicine and Law 19, 4. 47. Valente, S. M., & Trainor, D. (1998). Rational suicide among terminally ill patients. Association Operating Room Nurses 68(2), 252-265. 48. Valente, S. M. & Saunders, J.M. (1996). Case commentaries: assisted suicide and euthanasia. Journal of Pharmaceutical Care and Symptom Control, 3-4, 1-2. Net reference: www.google.com www. cancer palliative care.com www.nursing care of palliative patient .com www.apa.org Psychology Topics Death & Dying A.V. Aids: - L.C.D - O.H.P - Chart - Black board -Hand out -Flashcard

Name of topic: Palliative care and its management

Teacher/Guide: Mrs A Yonatan

Presented By : Siddhi Parmar Subject :Medical surgical nursing clinical speciality-II Hours :

Unit

Date

S.NO

CONTENT

PAGE NO.

1.

Objectives of the Topic

2.

Definition and,

3.

Scope

Philosophy

Concept and elements of palliative care

Global and Indian perspective of palliative care

Quality of life issues

Communication skill

Home care

10

Hospice care

11

Role of nurse in palliative care

12

Bibliography

13

A.V.Aids

General Objectives : At the end of the class the group will have depth knowledge about the palliative care and role of nurse in palliative care Specific Objective: At the end of the topic students will be able to:Define palliative care Describe the scope of palliative care State the philosophy of palliative care State the Global and Indian perspective of palliative care Enlist the Quality of life issues in palliative care Discuss the Communication skill in palliative care Explain about Home care in palliative care Explain about hospice care in palliative care Discuss the role of nurse in palliative care