Palliative Care

Palliative Care

  • Palliative care is a term derived from Latin palliare, "to cloak.“
  • Palliative care is a multidisciplinary approach and specialized medical care for people with serious illness.
  • The goal of therapy is to improve the quality of the life.
  • It’s focused on providing patients with relief from the symptoms, pain, physical stress, and mental stress of a serious illness.

Definition

  • A World Health Organisation 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." (WHO)
  •  Palliative care teams specialize in treating people suffering from the symptoms and stress of serious illnesses such as cancer, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), kidney disease, Alzheimer’s, Parkinson’s, Amyotrophic Lateral Sclerosis (ALS) and other chronic disorders.

Goals of Palliative Care

  • Relieve pain and other symptoms.
  • Prevent suffering
  • Address emotional and spiritual concerns, of patients and caregivers.
  • Honoring patient preferences
  • Coordinating care.
  • Improving quality of life during illness.

Issues Addressed in Palliative Care

Palliative care can address a broad range of issues, integrating an individual’s specific needs into care. The physical and emotional effects of cancer and its treatment may be very different from person to person.

  • Physical-Physical symptoms such as pain, fatigue, loss of appetite, nausea, vomiting, shortness of breath, and insomnia can be relieved with medicines or by using other methods, such as nutrition therapy, physical therapy, or deep breathing techniques.
  • Emotional and coping-Depression, anxiety, and fear that can be addressed through palliative care. Experts may provide counseling, recommend support groups, hold family meetings, or make referrals to mental health professionals.
  • Practical-Patients may have financial and legal worries, insurance questions, employment concerns, and concerns about completing advance directives. For many patients and families, the technical language and specific details of laws and forms are hard to understand.
  • Spiritual- An expert in palliative care can help people explore their beliefs and values so that they can find a sense of peace or reach a point of acceptance that is appropriate for their situation.


Models of Palliative Care

  • Hospice Care – A well-established program to provide patients with a prognosis of six months or less. As delineated within the Medicare Hospice Benefit, these services can be provided in the home, nursing home, residential facility, or on an inpatient unit.
  • Palliative Care Programs – Institutional based programs in the hospital or nursing home to serve patients with life-threatening or life-limiting illnesses. Occur in hospital settings (academic, community, rehabilitation) and skilled nursing facilities. Provide services to patients anywhere along the disease continuum between initial diagnosis and death.
  • Outpatient Palliative Care Programs – Occur in ambulatory care settings to provide continuity of care for patients with serious or life-threatening illnesses.
  • Community Palliative Care Programs – Occur in communities as consultative teams who collaborate with hospices or home health agencies to support seriously ill patients who have not yet accessed hospice.

PRINCIPLES OF PALLIATIVE CARE MANAGEMENT

  1. Scope of care- Includes patients of all ages with life-threatening illness, conditions or injury requiring symptom relief from physical, psychosocial and spiritual suffering.
  2. Timing of palliative care- Palliative care should ideally begin at the time of diagnosis of a life threatening condition and should continue through treatment until death and into the family’s bereavement.
  3. Patient and family centred care- The patient and family constitute the unit of care which should be managed as a whole.
  4. Holistic care- Palliative care must endeavour to alleviate suffering in the physical, psychological, social and spiritual domains of the patient in order to provide the best quality of life for the patient and family.
  5. Multidisciplinary care- A multidisciplinary team approach is essential to address all relevant areas of patient care.
  6. Effective communication- Good communication skills (including listening, providing information, facilitating decision making and coordinating care) are essential tools in palliative care and healthcare providers must develop this in order to provide effective palliative care.
  7. Knowledge and Skills- Palliative care is active care and requires specific management for specific conditions.
  8. Seamless care- Palliative care is integral to all healthcare settings (hospital, emergency department, health clinics and homecare).

Barriers to Palliative Care

  • Lack of awareness among policy makers, healthcare professionals, and public.
  • Cultural and social barriers.
  • Misconceptions about palliative care, for example, some consider that palliative care is only meant for cancer or AIDS patients.
  • Misconceptions regarding use of opioids in care and pain relief.

Role of Nurse in Caring for a Terminally III Patient

Nurses' responsibility to provide appropriate nursing care to avoid patients' suffering as much as possible.

1. Assessment- Frequent assessment is required to assess patient's daily condition. However, the frequency of assessment may vary depending upon client's stability and the client may be assessed at least four times a day. If changes are observed, the number of times the assessment is done may be increased.

2. Physical care- Physical changes are evident during the dying process. Therefore, it is nurses' responsibility to monitor these changes and provide appropriate interventions.

Eg.

Pain

  • Administration of pain medication.
  • Don't ignore pain or delay pain medication.
  • Opioids are essential for pain management.

Dyspnea

  • Administration of oxygen reposition the client by providing side position or elevating the head end.
  • Perform suctioning as indicated.
  • Opioids can relieve distressing symptoms

Skin

  • Monitor for breakdown and implement certain interventions to prevent the breakdown.
  • Check for any discoloration.
  • Assess body temperature.

Dehydration

  • Provide plenty of fluids orally, but don't force the client to eat or drink.
  • Perform oral care regularly.
  • Apply moisturizers on lips to lubricate them

3. Psychological care- It is nurses' responsibility educate the patient and his/her family about the to illness and the changes that it brings to their lives. 

  • The nurse must assess for signs of anxiety and depression.
  • Privacy must be provided to the family and client to have quality time and share feelings.
  • The client is most likely to feel fear and nurses must monitor the same.
  • The client is most likely to feel hopeless. Nurses can support the client in order for them to feel optimistic, listening to the client and maintaining effective communication, allowing the client to express his/her feelings regarding illness and future outcomes. 

4. Cardiac and circulatory care

  • Decreased blood perfusion- Discoloration of skin, evidence of cyanosis. Check SpO2 and provide oxygen to patient as prescribed.
  • Decreased cerebral perfusion- Decreased levels of consciousness. Presence of drowsiness and disorientation. Assess the Glasgow Coma Score (GCS) and report to physician.
  • Decreased Cardiac output and Intravascular volume-Tachycardia, Hypotension, Assess blood pressure  and inform the physician.

5. Urinary care

  • Insert Foley's catheter if needed.
  • Keep the patient clean and dry.

6. Food and liquids

  • Decreased intake of food and water or other fluid, which may cause reduction in weight.
  • Provide oral care. Don't force food or fluids.

 7. Respiratory care

  • Provide oxygen therapy as prescribed.
  • Educate the family that alterations in respiration are normal in a dying patient.

8. Other care-

Provide family education that these signs of impending death are normal. Provide oxygen therapy as prescribed

Conclusion

  • Access to appropriate care and support at the end of life is a basic human right
  • Timely, targeted and team based palliative care must be provided to improve the outcomes
  • Palliative care- Adding life to years
     

 

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