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GRIEF AND LOSS

Loss Death and Dying (Kozier)
- It is a universal experience that occurs
throughout the lifespan. AGE BELIEFS
- Something of value is gone.
Infancy to 5 No clear concept of death
y/o It is reversible, temporary sleep
Grief
- It is a form of sorrow involving feelings, Understands death is final but
5 - 9 y/o
thoughts and behaviors caused by can be avoided
bereavement. Death is inevitable
- Total response to emotional experience related 9 - 12 y/o
Understand own mortality
to loss.
12 - 18 y/o Fears a lingering death
Responses to loss are strongly influenced by one’s
cultural background. 18 - 45 y/o Attitude is influenced by religion

The grief process involves a sequence of affective,
cognitive and psychological states as a person 45 - 65 y/o Experience peak of death anxiety
responds to and finally accepts a loss.
65 ↑ Death is multiple meanings
Bereavement
- Subjective response to by loved ones.
Death
Mourning - end of life
- behavioral response - full cessation of vital actions
- Permanent state in the field of biology
- all living things eventually die
Stages of Grieving (Kubbler-Ross)
Attitudes about Death and Dying
Denial refuses to believe - Present generation may be unaware of feelings
- Prolonging life
the individual resists the loss and - Common fears
Anger - Behaviors of health care professionals
may “act out” feelings.
the individual attempts to make a
Bargaining deal in an attempt to postpone the
reality of loss. DENIAL
- “No, not me…”
overwhelming feeling of loneliness
Depression Intervention
and withdrawal from others.
o do not interfere unless it becomes
the individual comes to terms with destructive
loss, or impending loss, o do not support denial; conversations
Acceptance psychological reactions to loss to should include reality
the loss cease, and the interaction o continue to teach and encourage self-care
to other people resumed. activities

ANGER
- “why me?”
- expression of emotion

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- Increase in chest fluids
- Grunting and moaning on expiration
- Skin changes
Intervention
o give space allowing them to rail and below,
the more the storm blows the sooner it will Nursing Responsibilities in Death and Dying
blow itself out - Nurses need to take time to analyze their own
o try not to respond in “kind” feelings about death before they can effectively
o when anger is destructive, it must be help others with terminal illness
addressed directly. Remind the person of - The major goals for the dying clients are:
appropriate and inappropriate behavior. » to maintain PHYSIOLOGIC and
PYCHOLOGIC support
BARGAINING » to achieve a dignified and peaceful death
- “yes me, but…” » to maintain personal control
- attempts to negotiate
Intervention Loss and Death RESPONSIBILITIES
o spend time with patients - Provide relief from loneliness, fear and
o discuss importance of valued objects and depression
people. - Help clients maintain sense of security
- Help clients accept losses
DEPRESSION - Provide physical comfort
- the inevitability of the news eventually (and not
before time) sinks in and the person reluctantly
accepts that it is going to happen.
Intervention
o be available
o don’t attempt to cheer person up
o find out any religious support

ACCEPTANCE
- restful time, but not necessarily happy
- often begin putting their life in order, sorting
out wills and helping others to accept the
inevitability
Intervention
o plan care to allow the person with whom
patient is comfortable to care for him or her
o it is important that you don’t withdraw

Signs and Symptoms of Approaching Death
- May have increased hallucinations
- Decreased appetite
- May have temperature spikes
- Incontinent for stool and urine 24 to 72 hours
prior to death
- Pain may be more intense
- Restlessness is common 12 to 24 hours prior
to death
- Changes in respiratory status

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The only way for the person to reconcile with these feelings is to talk to someone willing to 5-10 y/o final but can be avoided listen .The new reality: irrational.Medication is more effective in the context of a . autonomy and self-control fears death 12–18 In the Social Level fears and fantasizes avoidance y/o .Understand that you may experience grief .Nurses have to be strong to control their . useful .Need to evaluate his life as meaningful. TAKING CARE OF THE DYING PERSON important. difficult . DEATH CONCEPTS preparation to die immobility and inactivity. . act as a liaison with the outside world In the Intellectual Level .“why” . Nursing staff must treat the dying person without fear.The role of the nursing staff is fundamentally . and to keep their distance .Responds to the persons need in a physical.Accept the physical and mental state he is in spend his last days. encounters and person experiences a “social death”.Need of emotional withdrawal co-exists with increased attitude awareness y/o the need of belonging to an accepting and supportive social environment 45–65 accepts mortality . and interact with him as a . and functioning death.Chronic pain: interrupts normal everyday feelings to be able to tolerate pain.Provide physical comfort .Biological needs. wishes .Nursing staff should stand by him without being supportive judgmental.Feelings of anger. illness.Help accept losses In the Psychological Level .Provide relief from illness.Nursing staff has to comprehend and the 1–5 y/o and unrelated action responsible person to express these feelings for action . which is above 65 fears sometimes more painful than the actual death Interventions D.Show him that they will not abandon him person who LIVES . psychological.Emotional and social withdrawal 18–45 . the multiple meanings.Support has to respond to the person’s need for understands own mortality and 9–12 y/o safety.Help clients maintain sense of security . fear and depression holistic intervention .Pain is a subjective experience . let him decide where he wants to . social and intellectual level Nursing Responsibilities . depression are part of a wider process of “anticipatory grief”.Acute pain: usually temporary . Supportive 3 .Nurses need to take time to analyze their own In the Physical Level feelings about death before they can effectively .When family/medical nursing staff keep their y/o distance in order to protect themselves. reduction and control of pain help others with terminal illness . unfair. encourage relatives to be close to him. sadness.

ASSISTED SUICIDE Assisted Suicide Death with Dignity or Murder? .when it is a doctor who helps another person to kill themselves Euthanasia . and means to take his What is Assisted Suicide? or her own life with the intention that they will . (Belgium. The voluntary decision to terminate life has suffering. Nazi regime excused their criminal deeds as B. their life .The word Euthanasia originated from the Greek Euthanasia by Action language: eu means “good” and Thanatos . Provide structure and continuity .someone provides an individual with the information. physician . . and gave no consent .when the person who is killed made no request been decriminalized.intentionally causing death by not providing recovery. and equal human rights.General term for helping a patient to terminate be used for this purpose. This made the Netherlands the first country in the world to formally sanction mercy killing. guidance. Non-voluntary Euthanasia . In the Netherlands voluntary euthanasia has . . unbearable and incurable . ill. necessary and ordinary (usual and customary) care or food and water Voluntary Euthanasia .when the person who is killed has requested to . Encourage participation compassion.Another word for euthanasia is mercy killing injection. But it has not always been people’s choice continuous. Under the new law. The act of euthanasia today is understood as . old or of mind different ethnic group.intentionally causing a person’s death by means “death” performing an action such as giving a lethal . . called “euthanasia” THESE ARE NOT EUTHANASIA 4 . This criminal regime murdered millions of o The patient must be judged to be sound of people because they were disabled. been misused during the human history. o A request to die must be made voluntarily.Majority of assisted suicide are requests from Physician Assisted Suicide severely or terminally ill patients . Oregon) . Listen and encourage termination of “worthless lives” D. euthanasia is administered termination of life on request only to patients who are in a state of . Allow expression and provide safety . This is against the humane nature of love and A. The crimes committed in the past are one of the be killed reasons why termination of life on request is a criminal act in almost all States of the world. These are other requirements as well: especially between 1933 and 1945 during the o A second opinion from an external German Nazi regime in Europe.Euthanasia literally means ‘good death’ and generally aims to hasten the death of people Euthanasia by Omission who suffer severely without any hope of . Murders committed for these reasons were also independently and persistently.A.

Mandates Health Division Review. Makes it mandatory that a second opinion by a provide a benefit to the patient. Voluntary .Patient administers the treatment 12. Montana » Not all pain or situations are controllable » Legal in Netherlands » There are safeguards » Humane » Patient self-determination OREGON’S DEATH WITH DIGNITY ACT 1. Physician-Assisted Suicide 11. 4. IMPACT 2. . Belgium » Sin . Does not authorize mercy killing or active 1. » In 47 states terminally ill patients cannot choose to end their suffering 5 .Euthanasia would legalize euthanasia » Illegal in the United States.Patient consents to treatment » A cry for help 4.Physician prescribes the treatment 9. Makes it mandatory that a 15-day waiting period occurs after the first oral request. Allows cancellation of the request at any time.Against . Requires a written request by the patient.Physician does not administer the part. Active euthanasia. Excludes nonresidents of Oregon from taking . 2. Requires the patient give a fully informed.For » Legal in Oregon.Patients life. 3. TYPES OF EUTHANASIA 15. Provides for psychological counseling if either of the patient’s physicians thinks the patient needs counseling.Physician-Assisted Suicide . when they have been shown to 6. . Euthanasia request to receive the medication. Makes it mandatory that 48-hours (2 days) TYPES OF ASSISTED SUICIDE elapse after the patient makes a written 1. Canada » Murder » Legal in Netherlands. endanger life.Administering treatment to end life 2. treatment to the patient 10. too burdensome or is unwanted. voluntary decision. Punishes anyone who uses coercion on a . treatment 13. be necessary. Requires two oral requests by the patient. Applies to the last 6 months of the patient’s . Not commencing treatment that would not 3. Washington. Mandates participating physicians are licensed in Oregon. 7.Physician directly administers the patient to use the Act. be ineffective. . qualified physician be given that the patient 2. Recommends the patient inform his/her next of .1. Involuntary » Suicide intent is not permanent .Withholding from treatment to end life CONTROVERSY 3. Withdrawing treatment that has been shown to has fewer than 6 months to live.Patient is unable to consent to treatment » Depressed » Financial obligation to families » Pain is controllable LEGALITY » Legalizing physician-assisted suicide .Physician prescribes the treatment kin. 8. The giving of high doses of pain-killers that may 5. Passive . 14.

Rest with family standards in specialist palliative care in the UK.Palliative care is an approach that improves the disease at any time during the disease quality of life of patients and their families trajectory.WHO 2002  when they have unmet needs and are . psychological. specialty in UK since 1987. 2002) Terminologies . care. 1. Palliative care strives to help individuals and their families: . widely regarded as » Offers a support system to help the family the founder of modern hospice movement.Palliative medicine has been recognized as a their own environment. by Dame Cicely Saunders. cope during the patient‘s illness and in . Palliative Care Introduction » Affirms life and dying as a normal process. and » cope with loss and grief during the illness Quality end-of-life care requires: and bereavement.Supported by physicians. their beliefs. nurses. and psychosocial and spiritual.Enhance the control of patients over their care is an umbrella organization for setting . PALLIATIVE CARE . patients are faced with a monumental decision . . Palliative care aims to relieve symptoms and 1. » In the 3 states that have legalized person and/or family living with a life physician assisted suicide. effect a cure’ (Macpherson. life closure and the dying process. » Many healthcare and human service spiritual and practical issues and workers would be and have to be involved associated expectations. physical.Appropriate control of pain and symptoms . The modern hospice is a relatively recent » Integrates the psychological and spiritual concept that originated and gained momentum aspects of patient care. in the United kingdom after the founding of St. not to prepared to accept care. Palliative Care may: Definition of Palliative Care » complement and enhance treatment of the . » prepare for. which . . social. It was founded live as actively as possible until death. through the prevention and » Palliative care may be provided to relief of suffering by means of early individuals: identification and impeccable assessment and  with any diagnosis treatment of pain and other problems. Autonomy improve the quality of living and dying for a 6 . hopes and in physician-assisted suicide cases against fears.Avoid inappropriate prolongation of dying . . or become the total focus of facing the problem associated with life.Palliative care is developing as an areas of » Provides relief from pain and other special clinical competence throughout the symptoms. needs. Healthcare and Human Service Workers » address physical. world. The National Council for Palliative Care. .‘to mitigate the sufferings of the patient.  regardless of age. in Australia and » Source: National Council for Palliative Care New Zealand since 1988 and more recently in (2002) Canada. threatening illness. terminally ill threatening illness. and social published its current definition in 2002 NCPC workers definition of palliative care. and manage. » Offers a support system to help patients Christopher‘s hospice in 1967.

Needs of basic palliative care.First hospice care . Caregiver India. .M. services in India.It can be estimated that approximately 60% of family. or palliative care services have access to such volunteers.Cancer Relief India (CRI) a UK charity . support workers. World 10. and Devesa. with over 80% presenting at stage III and . Bereavement . giving care and support for everyone who dies. They [usually] do not have formal training.1986 .Formal caregivers are members of an .“the state of having suffered the death of ESTIMATION someone significant” (CPCA. and are not accountable to NEED OF PALLIATIVE CARE norms of conduct or practice.0 . .provide education to doctors and .1994 – Pain and palliative clinic at Calicut.Whomever the person says is his or her . esteem .Annual deaths globally: 56 . experiencing cancer pain every year.governed” (CPCA.Issues that patients and caregivers mutually agree require attention in the plan of care. the dying need partners.8 .“anyone who provides care” IV. They may care. The family may include relatives. S. emotional.3 23.Annual deaths in developing countries: 44 and regard . .1994 . more than four million organization and accountable to defined cancer patients would benefit from palliative norms of conduct and practice.Care givers are people who are willing to incurable need palliative care and listen to ill persons and responds to their approximately one million people are individual experiences (Twycross R 2003). NEED OF PALLIATIVE CARE .Estimated numbers needing palliative care: 33 . F. Developing Countries 5.8 with WHO and Govt of India . .4 9. friends and pets. Parkin.Size of problem.6 6.To treat individuals with respect.aim is to propagating palliative care in India along with 7 . (CPCA.I. spiritual) experienced in anticipation of. 2001) who would need palliative care (in millions) 4. Dignity . 4–66 outside influence and direction.Annual deaths in developed countries: 12 5. people who would benefit from the availability 7.0 6. Cancer burden in the year 2000.Indian association of Palliative care Developed Countries 4. Bray. Two thirds of patients with cancer are . Grief close companions.Cancer Burden: global picture founded ..One million cases of cancer occur each year in 3.Since death also affects family members and 6. . Estimated number of people family members or friends. then a conservative figure might be 100 million during and after a loss. Family . 2.3 17. Milestones in Palliative Care in India .6 15. They may be .S. .“Shanti Avedana Ashram” – at Mumbai. perhaps one to two persons .According to WHO. “the state of being self. 2001).1990 . Less than one percent of those who need be professionals. The global picture. D.Reactions (physical.. (2001).Number of new cancer cases (in millions) nurses in palliative care and providing pain and 2000 2020 2050 symptom relief for cancer patients.Informal caregivers are not members of an organization.Thinking and acting independently without European Journal of Cancer 37.2001) . behavioral.

People Have the Right to Choice serious illnesses. recognizes that . (NNPC) has a network of 150 such clinic . . 85 nurtures the physical. Philosophy of Palliative Care . It focuses on providing » Each person is an autonomous and unique patients with relief from the symptoms.Guwahati Pain and palliative care death is a normal part of life and strives to Society. Oxford Brookes University. facilitating education initiatives and drug diagnosis. The word ‘palliative’ has its origins in the Latin Proposed Norms of Practice for Hospice Palliative word ‘pallium’ meaning to cloak or cover. beliefs and practices.Can support. developmental state. . individual with the right to participate in and stress of a serious illness—whatever the informed discussion related to care and to 8 . religious values. or comfort care. 2001 . The all die on our own terms.We believe in creating an environment that supported by 10. The goal is to improve quality of life availability. . intellectual. 1999 . policy emphasis the community based .Palliative. clinical services and research or spiritual. activities which are linked at several levels involving volunteers in the community. for both the patient and the family. Even today.Neighborhood Netwrok in Palliative care person. Psycho oncology in India . and readiness to deal with the dying process .Access is Foundational appropriate description. as chronic. progressive pulmonary disorders. chronic heart failure. symptoms for a considerable time before the person seeks help. cultural and renal disease. The Canadian Palliative Care Association (2001) . .From the start of a serious or terminal illness.integrated services . pain. spiritual and social with regard to diseases other than cancer such needs of patients and families.000 trained volunteers. (first palliative care . 25. approach to palliative care and considers home practitioners reduce the burden on family based care as the corner stone of the palliative caregivers by identifying and providing for the care services. 2008 . psychological. In the Care context of how cancer was perceived and poorly diagnosed from the middle ages until perhaps We believe: the latter half of the 20th century. to complete the diploma in palliative nursing at . prepare patients and their families so we can .CRI and Cancer Relief Macmillan Fund with WHO facilitated training of doctors and nurses in palliative care. » It is sensitive to personal. Care is Patient-Focused » Palliative cares strives to meet the .first palliative care policy in Kerala.To give people with life limiting illnesses a home in north India) reason to hope and a feeling of greater self- . social linking training. needs of you and your family.first nurse from India sponsored by CRI confidence and dignity.000 patients at any point. which respects the dignity and worth of each . Delhi. emotional. HIV/AIDS. The term “palliative care" is increasingly used physical. 1993-95 .We embrace a holistic approach to care giving. it is an . there are » Palliative care services should be available many cancers that grow unseen and without to all who require care. Palliative care (pronounced pal-lee-uh.These needs may be physical. 2001 .tiv) is specialized medical care for people with . 1997 . and progressive neurological conditions. social and doctors and 270 nurses looking after about spiritual wellbeing of those in our care.

intends neither to hasten nor to postpone . serve.integrates the psychological and spiritual utmost respect. hospice. shortness of breath.Palliative care is the specialized medical care » We are accountable to ourselves. such as chemotherapy patient and family. family. each for people with serious illness. Palliative care never » Patient. acute . The needs and preferences of the intended to prolong life. enhance formal and informal caregivers’ well-being is integral to a successful . choose the best possible options and » The provision of ongoing support to outcomes based on that information. continuing care centers. are imperative to maintain and advance . . dissemination and . . . On-going Education is Essential considered options. regional program and to the public we nausea and other distressing symptoms. » Patient information is treated with the . in hospitals or on a tertiary palliative care conjunction with other therapies that are unit. education is important to the maintenance and enhancement of the quality of . to our individual sites. Collaborative Leadership is Advantageous coordination amongst all involved » The development and maintenance caregivers and programs/services. Service is Coordinated palliative care programming. Accountability is demonstrated through SCOPE Outcomes . » Palliative care affirms life. Euthanasia and physician assisted suicide are not . » Care choices should be guided by quality of life as defined by the patient. Quality of Life Guides Decisions palliative care.is applicable early in the course of illness. Resources Influence Program Quality expertise and effective interactions. to the .offers a support system to help the family cope. Research Leads to Advancement in Care » The development. process. as well as the resources or radiation therapy. Team members must aspects of patient care adhere to this principle. Care Setting Is Important . Team Work Is Essential integration of research are critical to » Palliative care is a network of services most palliative care. . . Confidentiality is Central death. Dying is Part of Life palliative care program. other.provides relief from pain. » Palliative care is provided in a patient and .uses a team approach to address the needs of family focused environment in the most patients and their families. caregiver and public intentionally hastens death.affirms life and regards dying as a normal through measurable goals. » Adequate resources. effectively delivered by an interdisciplinary team who rely on shared knowledge. » A palliative care program should promote continuity of care across settings and . Accountability is demonstrated . . available. .will enhance quality of life. are taken into consideration. . appropriate care setting such as the home.offers a support system to help patients live as actively as possible. Caregiver Well-Being Is Fundamental 9 . responsibly managed.

.Uses a team approach to address the needs of patients and their families including bereavement. nurse and social empowerment to adjust funding from insurers relief andand the support the government. Through education of care providers.Helps then in gaining access to needed health stage of the disease or the need for other care providers & appropriate care settings. can be provided along with curative treatment. aspects of patient care.Provides relief from pain and other distressing unavoidable suffering therapists. Massage . .Offers support system to help the family to cope during the patient’s illness and in their own bereavement.e as a part of the life cycle. Support Effective palliative care requires a broad AIMS AND PRINCIPLES OF PALLIATIVE CARE Honesty multidisciplinary approach that includes the .Enhance the quality of life. therapies Involving various kinds of trained providers in . suffering . . . pharmacists. resources. It begins when illness is diagnosed. and Improve the Avoid the avoidable Quality of Life Wellbeing also involves giving support to the family.Builds ways to provide excellent care at the end age and at any stage in a serious illness and of the life. . . psychological. it can be successfully implemented . and social Symptom Psychologica distress.Three essential component of palliative care: different setting tailored to the needs of the patient and his or her family . team.Integrates the psychological and spiritual Teamwork even if resources areand Partnership limited. mind and spirit. nutritionists. . Relief Hope l . .Partnership between the patient and the care GOALS OF PALLIATIVE CARE providers. if indicated. extra layer of support.Intends neither to hasten nor post pone death. counseling. work palliative care specialists.Achievement of the best possible quality of life .Death accepting but also life enhancing. Palliative care is still sometimes defined as solely being for people with cancer. It is appropriate at any . Palliative care for children is the active total care of the child's body. The core team includes doctor.Offers a support system to help patients live as community health centers and even in actively as possible until death. Palliative care is provided by a team of doctors. Health providers must evaluate and alleviate a child's physical.Respect the likes and dislikes.Adds life to days and not days to life. but palliative care is more often now defined as 10 . appropriate health policies Building and adequate Capacity: . goals choices of family and makes Openness use of available community the dying person. . children's homes. nurses and other specialists who work together .Supports the need of the family members for patients and their families regardless of the .Concerned with healing rather than curing. symptoms.Affirms life & regards dying as normal process with a patient‘s other doctors to provide an i. Promote Comprehensive Comfort Care . chaplains and others may also be part of the . in . It can be provided in tertiary care facilities.MAIN AIMS . and continues regardless of whether or not a child receives treatment directed at the disease. may also positively influence the course of a patients illness. including the needs of children. .Patient centered rather than disease focused. .

to improve the quality of life for individuals with a life-limiting illness and their families. better understand your choices for treatment.The palliative approach is only provided in hospital type settings .The palliative approach is only provided to residents with cancer . psychological. ItComfort also helps T Intent you gain the strength . loss of appetite. shortness of breath. Palliative Treatment Care Time Course of Illness PC TEAM Potential members of the interdisciplinary team for D a palliative approach may include but not be PALLIATIVE E limited to: ACTIVE TREATMENT A CARE . by reducing their suffering through early identification.Aboriginal health workers Palliative/ depression. being for people facing a life. .Specialist nurses E nausea. difficulty A sleeping and . Palliative care focuses on symptoms such as . And it . Palliative care is not usually defined as improving communication so that you can being for people with chronic diseases such as Cure/Life.Chaplains/pastoral care workers 11 .The palliative approach costs more. social and spiritual needs MYTHS ABOUT PALLIATIVE CARE .Generalist nurses Cure/Life Prolonging D pain.You need to be a nurse to be able to provide the care Diagnosi Advance s d .Pharmacists ability to tolerate medical treatments.threatening helps you have more control over your care by illness.Residents will become addicted to pain relief drugs.Applying the palliative approach will increase Disease the care worker‘s work load .You need to be an expert to be able to provide EVOLVING MODEL OF PALLIATIVE CARE the care . physical. cultural.Trained volunteers and their coordinators H to carry on with daily life. Intent constipation.Care assistants T H . Prolonging Intent diabetes. fatigue. . assessment and treatment of pain. It improves your . Death Bereavement Palliative/Comfort Intent A PALLIATIVE APPROACH PALLIATIVE CARE MODEL Aims: .General Practitioners .

TIMING OF PALLIATIVE CARE . making. These includes appropriate and 3.Dietary counseling . of palliative care.nursing services. active .Specialist physicians The primary goal is to prevent and relieve . play. Emotional and Spiritual Support effective sharing of information.Home attendants • therapies. bowel and bladder problems. PRIMARY GOAL .Interdisciplinary team care. 3. social.is important for both the patient and family listening.Physical therapy 4. Require the expertise of various providers in order to adequately assess 2.Investigations and drugs continues through cure. music therapist.is vital for comfort and to reduce patients‘ distress. weakness. 7. COMPREHENSIVE CARE PALLIATIVE CARE PATIENT SUPPORT SERVICES Palliative care employs multidimensional assessment to identify and relieve sufferings Three Categories of Support: through the prevention or alleviation of 1. or until death and into . respected. achievement of best possible quality .Community/ palliative services sufferings imposed by disease and their . social and spiritual . Symptom Management and treat the complex needs of seriously ill .Recreation activity officers ELEMENTS OF PALLIATIVE CARE . pastoral counseling. condition or injury. INTERDISCIPLINARY TEAM sources of pain and relieve them with drugs Team work is an integral part of the philosophy and other forms of therapy.Psychologists/ psychiatrists treatment. home The uniqueness of each patient and family is health aide.Allied health practitioners 1.Specialist palliative service providers of life for patients and their families regardless . The patient family constitute the . mental confusion. distress.Physical. and effective communication with all 12 .Bereavement coordinators Patients of all ages experiencing a debilitating chronic or life threatening illness.Pain specialists . PATIENT POPULATION . art.Speech therapy life threatening or debilitating condition and . psychological.Managers of the stage of the disease or need for other .Occupational therapy It ideally begins at the time of diagnosis of a . determination of goals and in dealing with the emotional demands of preferences.Bereavement counseling unit of care. Pain Management physical. and difficulty breathing Effective communication skills are requisite in palliative care. PATIENT AND FAMILY CENTERED CARE medical. SERVICES PROVIDED BY PALLIATIVE CARE .involves treating symptoms other than pain patients and their families. 5. 2. assistance with medical decision critical illness.Durable medical equipment and supplies the family‘s bereavement period. COMMUNICATION SKILLS fatigue. Health care professionals and families can collaborate to identify the 6. such as nausea. . occupational. .

It combines the residents humanistic approach with a scientific . emergency . . especially for their families. individuals involved in the care of patients and .Aid the ability to tolerate medical treatments rural communities. functional ability etc. home care. choices for care 11. outpatient and non-traditional .encouraging open and early discussion on .. providing opportunities. .Care is tailored to help the specific needs of the dept. 10.Not a “one size fits all approach” delivery system settings (hospital.reducing potential distress to residents and EMOTIONAL their families caused by a transfer to an acute care setting . their family in the decision making about their . Some of these are: .reducing the admission and/or transfer of residents to acute care facilities as care staff develop the skills to manage the palliative care . nursing homes. The palliative various diseases. free from financial burden. ability to experience happiness . offering the resident and family consistent and Team must be knowledgeable and skilled in continuous care providing care for the dying and the bereaved. all health care settings including .Helps patients gain the strength and peace of ages and patient populations. improved control of pain symptoms. CONTINUITY OF CARE ACROSS SETTINGS APPROACHES TO PALLIATIVE CARE Palliative care is integral to all health care .Helps patients to better understand their ethnicity. Physical wellbeing: Free of pain and care discomfort. Psychological well being: free from death and dying anxiety/fears.Since palliative care is utilized to help with environments such as schools. in a setting that is familiar to the resident 8. EQUITABLE ACCESS WHAT DOES PALLIATIVE CARE PROVIDE TO A Palliative care teams should work toward PATIENT? equitable access to palliative care across all .allowing for advance care planning etc.. Reflects whole aspects care. the care provided must fit the care team collaborates with professional and symptoms informal care givers in each of these settings. assisted living patient facilities. and regardless of race. all diagnostic mind to carry on with daily life categories. Social well-being: Purposeful life role. their families and the health care team. QUALITY IMPROVEMENT Palliative care services are committed to the PALLIATIVE CARE NURSING pursuit of excellence and high quality of care which enhances the quality of life. SKILL IN CARE OF THE DYING AND BEREAVED . . 13 .increasing the involvement of the resident and approach. 9. PHYSICAL BENEFITS OF PC Palliative approach offers many benefits to the SOCIAL SPIRITUAL residents. sexual preferences or ability to pay.

skilled management of pain and other . Spiritual well-being: feelings of hope.Observational skills and the intuitive ability to . . To use therapeutic comforting touch with .We also offer a variety of bereavement and .It is the most challenging of all competency COMMUNICATION SKILLS areas and plays a significant part in the The ability professional growth of those who choose to work in this field. . Hospice palliative care . To field and respond to sometimes profound or to life. and. PHYSICAL NEEDS .A small percentage of patients will need to be admitted to a tertiary palliative care unit for PHYSICAL CARE SKILLS severe and complex symptoms.The growth of the nursing role within these managed at home or in hospice.To work with families.They also help patients and families cope with families common changes such as loss of appetite. because that is the most appropriate response. as well as side effects of therapies. To discuss the imminent death of a relative with . bowel and bladder problems. perhaps nausea. . constipation.Most pain and other symptoms can be . counseling services to friends and family . must be done in a hospital. at a time of extreme vulnerability.. .The knowledge and skills necessary to deliver active. EMOTIONAL AND SPIRITUAL NEEDS . members before and after a patient‘s death. 14 . . To challenge colleagues who may wish to deny symptoms such as anxiety.Anticipating their needs. . breathing difficulties and confusion. Some teams has been dramatic and continues to treatments may require diagnostic tests that represent a much admired model of working. weakness.Teamwork skills natural consequence of working with dying and .Communication skills INTRAPERSONAL SKILLS .Nurses need to recognize and attempt to . To know when to say nothing. patients information.Care teams offer help with non-physical pain through counseling and spiritual support to manage the emotional.The health of the whole person is important in recognize signs hospice palliative care.Psychosocial skills understand personal reactions that occur as a .Palliative care professionals provide highly confidence.Physical skills .Advising doctors of the appropriate recognizes emotional and spiritual distress as prescription and dosage to manage pain important sources of suffering requiring .The advocacy role nurses have towards patients support in addition to physical symptoms. meaning . social and spiritual PSYCHOSOCIAL SKILLS impact An ability .Intrapersonal skills bereaved people and to be able to reflect on .Supporting them when appropriate PALLIATIVE CARE COMPETENCIES / SKILLS . TEAMWORK SKILLS .Putting them in touch with services and .Life closure skills how this affects care given in sensitive situations. hands-on care in whatever setting throughout a long period of illness. rhetorical questions about life and death .

The intensity of pain increases or A GOOD LISTENER decreases according to the mood of the . She may have to become a person ABLE TO UNDERSTAND THE PAIN oriented nurse in order to give holistic care. NEUROPSYCHIATRY CONDITIONS 15 . patient for a long time if it makes the patient as ease. Body patient. muscle A GOOD COMMUNICATOR relaxants antispasmodics and . She needs to answer in . Activities like pain can be due to chemotherapy. . It could be acute or chronic. SKILLS NEED PALLIATIVE CARE NURSE . difference. as they perceive it.Nurses role was a supportive one with multiple dimensions. about the disease. Valuing. .‘Pain is what the patient says hurts’ (Twycross R 2003).Verbal expressions are always heard. Causes of language tells many things. work. Model of the supportive role in A COMMITTED PERSON palliative care was developed . in which the nurse enters into the . Pain management in tells us that area or the use of that specific patient includes modifications of the article gives him comfort and he is preparing pathological process by giving radiation himself for leaving this world. finding meaning and patient’s illness.Nurse allow them to ventilate their anxiety for . doing for. Palliative care is seen as the end of families.Such care has been described as a sacred makes to be at ease. antiepileptic us.Families and the patient needs to know the patient‘s intimate space and touches parts of truth as they may need to reorganize and adopt the body that are usually private their lives towards the attainment of more achievable goals. grief and crisis and helping them appropriately .This area is concerned with nursing behaviors you.Acute care nurse plays a pivotal role in clinician .Along with opioids and non-opioids are also coping with the present situation. (Fallowfield L J et al 2002). EMPATHETIC TO THE EMOTIONS (OF PATIENTS AND RELATIVES) LIFE CLOSURE SKILLS . comforting word from you which makes a › acupuncture. connecting. They may blame God for pain and all and skills that are crucial to patients and difficulties. realistic hopes and aspirations. the pain. and to me and pitch with the right attitude for › behavioral therapy can be used to reduce reaching out to the patient effectively. in right › relaxation therapy.A nurse needs to be honest with the patient bisphosphonates. dignity. Adjuvant includes corticosteroids. antidepressants. comprised of six .A Nurse stays with the patient or visits the intervoven dimensions. . She may have to stay with her preserving own integrity. when life is the road of care. used. patients many times during the course of the empowering. . Reacting to their anticipated close to an end and thereafter. › massage. sitting alone in an area of significance or using constipation.Your patient may need an extra minute or a › application of heat pads. physical or articles of a particular person who passed away psychological problems. and radiation therapy. chemotherapy or surgery. therapy.significant others.Patient and relatives may shout and scream at . communication in the ABLE TO RECOGNIZE ASSOCIATED acute are settings. She needs to use right word.Nurse teach the patient about non drug simple ways so that the patient and the methods include relatives can understand.

only .Catheter care PALLIATIVE CARE PLAN INCLUDES . Meeting physical needs & symptoms experienced by the chronically ill or dying management. altered about 10% receives any psychosocial therapy body image. Facilitating participation of significant others in THE PATIENT patient care.Managing the multiple symptoms commonly 2. › spiritual care › functional status support and PROMOTE SPIRITUAL COMFORT AND HOPE: rehabilitation . types of the grief.Assess the stage. Specialized nursing care related to infections are two major needs of cancer . prone to delirium.one third of cancer population PROVIDE PSYCHOSOCIAL CARE experiences some variety of distress . 16 . Educating family in basic nursing care. . . › care goals › symptom management MAINTAIN A COFORTABLE AND PEACE FULL › advance care planning ENVIRONMENT › financial planning ..It helps to relax. and sleep disturbances USE THERAPEUTIC COMMINICATION must be considered as a clinical .wound care . 4.(Barton Buake 2006). 6. the benefits and burden of treatment options. . change if the client does not get relief from the monitoring & relieving discomfort relaxation & prescribed regimen.bowel and bladder care desire to have specific food in consideration. .Lymph edema management patients. promote good sleep patterns › family support and minimize symptoms severity.Personal hygiene and protection from 8.Turning patient position frequently. uncertainty and (Vanchon M 2006). depression. . reassessing pain intervention. depression. suicidal . Preventing complications – preventing. isolation.Nutritional need – consider the taste and .They may have anxiety. Cancer patient with advance disease may signs and symptoms. ABLE TO UNDERSTAND THE PERSONAL NEED OF 7.Prevention of pressure sore . Monitoring & administering pain relief . and their values ROLE OF NURSE IN PALLIATIVE CARE and goals to preserve the autonomy of client. and severe anxiety. People who . powerlessness. Cancer related fatigue. and its .Avoid communication barrier verbal memory and motor functioning (Nail 2006).Helps the client to make connections to their › co morbid disease management spiritual practice or cultural community.provide reassurance and respect ideation. clients remains a primary goal of palliative care 3.Ongoing clinical assessment. developing pain pharmacological. some what impaired in executive function. CARING FOR THE PATIENT MANAGE THE SYMPTOMS 1. both pharmacological and non and medication side effects. . management expertise and advocating for 5. contentment & preventing complication.Establish caring and trusting relationship syndrome.Invite the clients to reveal the emotions & receives systematic cancer treatment were consensus of greatest importance to them.stoma care .Provide information that help the client to understand their disease. Direct nursing care . Providing psychological reassurances nursing.

S › building up trust .VProvide education and information L .facilitating › recognises patient autonomy FACILITATE MOURNING .Supporting Colleagues HOPE COMFORT Physical Distress Physical Ease HOPE DIM HOPE SU 17 ATTACHMENT . .EInform family members are able to get way toE › usually as a result of the patient‘s death rest and relax .Help them to accept the lossEMPOWERING CONNECTING .Breaking the connection . Collaborates with the client own spiritual N Pleaders and community.IAnswer promptly.Allow to grieve INTEGRITY MEANING › facilitating healing . sharing MANAGEMENT EXPERT I SUPPORT THE GRIEVING FAMILY O secrets.Making a connection L CASE MANAGER PROTECT AGAINST ABANDONMENT AND ISOLATION E › establishing a rapport .Confronting own mortality .Acknowledging death › giving or reiterating bad news › talking about death and the time left PALLIATIVE CARE NURSING PRESERVING INTEGRITY . spending time.Team player › Acting as the patient’s advocate FINDING MEANING .Encourage establishment of new relationship . FACILITATOR R CONNECTING L S .encouraging . U . Provide psychological support EMPOWERING ASSIST WITH END OF LIFE DECISION MAKING VALUING ..giving information .mending PRESERVING FINDING .AInvolving the family members in clients care.Provide continuous support .Taking charge › Symptom control › Making arrangements .ADVOCATE if they have doubts.Burnout . sharing self.Support efforts to adjust › dealing with negative feelings FOR .defusing DOINGto the loss .Maintaining a connection ASSESSMENT AND T R › being available. DOING FOR… .ADemonstrate patience.Be alert for ineffective coping.Interpret normal behavior . . maintaining trust.Focusing on living › helping the patient to live as fully as possible .

Inadequate standards of care . in around 100 countries. › Assessment. future wishes. There are over 135 hospice and palliative care services in 16 states in India. .A 1999 listing of palliative care organizations with a global perspective(43) also includes: CARE OF THE FAMILY › British Aid for Hospices Abroad.Attachment force development and limited national › Be there. caring environment.Worth › Explore previous experience. Saitama. › WHO Collaborating Centre for Palliative . Lack of accountability in the care of dying patients. Oxford. . Encourage realistic goals & autonomy.Depressing/Sad availability of basic palliative care. services now exist. work . education. 2001) one to two persons shouldering the heavy daily . Inadequate training of health care personnel in symptom management & other End of life skills. . PALLIATIVE CARE DEVELOPMENTS AROUND THE enhance independence WORLD . The total number of hospice or BARRIERS IN AVAILING PALLIATIVE CARE palliative care initiatives is in excess of 8000 18 .Death also affects family members and with (ARANDA. .Glowing testimonial of 100 million people who would benefit by the . and decision making r/t patient care.Comfort include – poverty. . on every continent of the world. .Including patient & significant others in › Hospice Education Institute. CARE . Improve planning & coping.Niceness routine of care.Other groups include WHO experts and . . concentrated in large cities. this gives a conservative figure . Wisconsin.It is estimated that hospice or palliative care 4. geographic distances. population density. There are 19 states or Union territories in which HOPE NURTURING INTERVENTIONS IN PALLIATIVE no palliative care provision was identified. .Communicating with family facilitates to international collaborators and WHO 1.Attending to their grief. collaborating centers in Milan. communication . worries. THE TYRANNIES OF PALLIATIVE CARE . promote palliative care policy. or are under development. Maintain trust. opioid availability.The rise of hospice and palliative care in its distinctly modern guise (combining clinical care. preparing them Cancer Care. and 2. and research) is generally traced to the late 1950s and early 1960s. for the loss .The estimated number of persons needing palliative care is just over 33 million. 3. Lack of investment in research pertaining to palliative & end of life care. Barriers to the development of palliative care .Passive . Reduce uncertainty. psychosocial issues. Lack of appropriate information & resources . .

USA organized in the Yodogwa Christian Hospital in 1973. ----- 1998 Japan 102 127 295 482 5 . the Japanese Association for Clinical .Poznan Declaration leads to the foundation of the Eastern and Central European Palliative Malaysia 30 22 7 825 24 Task Force (1999) New 42 4 7 461 83 Zealand Singapor 1999 e 10 4 4 237 66 . . day care centers.First International Congress on the Care of the Research on Death and Dying was established. and the vast majority are incurable founded at diagnosis. 1976 . Washington. founded at St e care (millions) cancer palliative deaths (millions) care Christopher‘s Hospice. .Protocols for the introduction of the WHO three- step analgesic ladder were first introduced in INTERNATIONAL ASSOCIATIONS AND INITIATIVES IN China in 1991.In Japan. community-based teams.International Hospice Institute. the Ministry of Health and Welfare . UK services India 49 1000 ----. and other modes of delivery.Foundation for Hospices in Sub-Saharan Africa Taiwan 28 22 32 000 5 founded in USA . contains 2000 one-sixth of the world‘s population and is a .Asia Pacific Hospice Palliative Care Network each year. Terminally Ill. London. the first hospice ward inside a hospital was created. with one billion inhabitants. India. .Hospice Information Service.World Health Organization Cancer Pain and NETWORKS Palliative Care Estimate Organizations d Estimate 1990 providing Populatio d annual coverage Sectors hospice/palliativ n by .The country‘s first service for dying people was founded Issaquah.by 1993. hospital- based services. Canada . Around one million new cases of cancer occur . An Indian Association of Palliative Care was 2002 formed in 1994 with the support of WHO and by . 1973 accounting for about 295 000 deaths in 2000. leading to increased opioid use SUPPORT OF HOSPICE-PALLIATIVE CARE and greater interest in pain and palliative care.UK Forum for Hospice and Palliative Care Worldwide founded by Help the Hospices 19 . 1980 .International Association for the Study of Pain. with 231 beds in total (1995) and International Association for Hospice and Palliative Care (1999) PALLIATIVE CARE SERVICES IN THE 14 SECTORS OF 1982 THE ASIA PACIFIC HOSPICE PALLIATIVE CARE .Latin American Association of Palliative Care country of striking ethnic. and these include inpatient units. cancer is the principal cause of death. cultural. became had recognized palliative care units in 11 International Hospice Institute and College hospitals.in 1979. 2001 .in 1981. . and religious founded diversity. ASIA PACIFIC REGION . Montreal.

Phenytoin programs. and state) Epileptic seizures have begun to recognize the importance of pain . psychosis 131 countries around the world. .Opioid antagonist › Naloxene Nausea and Vomiting . so levels of morphine consumption for .Prednisole one million people experience cancer pain in India every year.Opioids (mild to moderate pain) .Non-opioids (mild pain) .Omeprazole FOR PALLIATIVE CARE Fluid Retention Analgesics . only ‘pump. federal. Some of these policies have had real impact.Haloperidol several cancer control and some HIV/AIDS . omitting .Hyoscine butylbromide pain relief were low. Diarrhea Often. failure results from the lack of a .Prednisone . they reached a low of just 18 kg and per capita consumption ranked 113th among Anxiety. Magnesium hydroxide initiatives across the country. There is evidence that governments at many levels (national. A detailed analysis of opioid availability Appetite problems in India shows that approximately .Prednisolone .Codene Opioids (moderate to severe pain) .Mineral oil FOR HANDLING ANY ESSENTIAL DRUG LIST . . provincial.Nystatin .Dexametasone .Chlorpromazine .Spironolactone › Acetylsalicylic acid › Paracetamol Oral Candidiasis › Ibuprofen .Holoperidol .Loperamide the community system. 2000 there were nearly 100 palliative care . . Gastric Protection EXAMPLE OF A SUGGESTED ESSENTIAL DRUG LIST . . depression. for example.Ketoconazole › Morphine Methadone .Lorazepam development of officially formulated policies.Prochlorperazine Laxatives .Senna . insomnia.Dimenhydrinate Corticosteroids . .Amitryptiline .Codeine phosphate comprehensive strategy. others have been ‘paper tigers’ with little effect.Lactulose 20 .Furosemide . There was no official source of Bowel obstruction (when surgery not indicated) morphine in India in the 1980s. By 1997.Haloperidol projects.Sodium valproate . Palliative care has also been incorporated into . .Cotrimoxazole .Sodium ducosate WHO HAS PRODUCED GUIDELINES .Diazepam relief and palliative care through the .Metoclopramide .Dimenhydrinate priming’ supplies for specific centers and .Metoclopramide .

loneliness administer opioids to patients in accordance .A: › anxiety.Opioids must be dispensed for medical use PAIN ASSESSMENT only. headache. depression.Radiation or Related Symptoms › Admire stoics or encourage sharing of pain .Spiritual Angst or Despair › Meaning of pain and suffering PAIN MANAGEMENT AND PALLIATIVE CARE › Retribution › Punishment › Spiritual cleansing COMPREHENSIVE PAIN ASSESSMENT .Meaning of the pain to patient and family › the doctor‘s name and business address .I: › interpersonal issues – family with their needs. and hopelessness. 1968) › Sexual relationship issues › Pain is a symptom.Onset .“Pain is whatever the experiencing person says › Family roles it is. anger.Severity – intensity and effect on function issues? . and pharmacists should be . as well LEGAL ISSUES as cancer pain . › Negative physician or nurse perceptions › Adjustments in leisure activities . tensions. empowered legally to prescribe.Opioids should be available in locations that › Depression or anxiety will be accessible to as many patients as › Hopelessness possible.Use of appropriate lab and radiologic studies › patient‘s name .Doctors. not a diagnosis › Burden on family › Believe the patient .FOR PALLIATIVE CARE THAT WILL INCLUDE OPIOID . nurses. .N: › non acceptance of approaching ACCOUNTABILITY death.Numerical or visual analog scales PRESCRIPTION . constipation. bladder spasms.Know your own attitudes and beliefs . thrush. P: › physical symptoms or conditions DRUGS › Arthritis.” › Physical appearance changes (McCaffery.Thorough assessment interview › date of prescription › drug name. strength and form. dosage.Psychological symptoms with pain ACCESSIBILITY › Fear of disease worsening .Social and Relational Issues .Patient’s description of pain and experience of .A prescription for opioids should contain at pain least the following information: . existing whenever he/she says it does.Quality . dispense. quantity prescribed PSYCHOSOCIAL-SPIRITUAL ASSESSMENT › instructions for use .Previous experiences with pain and coping › the doctor‘s signature mechanisms . financial issues .Temporal Pattern › What are your thoughts or beliefs about pain meds? › What are your thoughts about those who TOTAL PAIN COMPONENTS abuse pain meds? 21 . with responsibility in law. spiritual or existential pain .History and physical .Provocative or Palliative Features CULTURAL ISSUES .

Adjuvant Analgesics or decreasing blood levels (underdose or Step 2 Mild to Moderate Pain Weak Opioids miss doses).Adjuvant Analgesics › Need to safely taper drug • No more than 50% of dose/day Mild Pain Step 1 Non-Opioids (1-3 on a 10 Point Scale) +/.Faces Scale › Opioid doses remain stable if disease remains stable › Increased opioid requirement → worsening disease progression DEPENDENCE . patient requires higher doses to PAIN SCALE maintain same benefit . psychosocial and Paracetamol Codeine Morphine Cocodamol Tramadol Diamorphine environmental factors 8/500 Buprenorphine Oxycodone › Exhibit following behaviors: NSAID DF118 Hydromorphone • Impaired control over drug use Fentanyl Alfentanil • Compulsive use of drug Methadone • Continued use despite harm • Crave drug As with all opioids “start low and go slow” › Risk of iatrogenic addiction is rare in Remember ABC: patients with no past history of substance Antiemetic for the first week abuse Breakthrough medication Laxatives for Constipation .Non-opioids +/. Pseudoaddiction › Behaviors are driven by inadequate . Understanding Pain: touch – healing – active treatment of pain listening – mind shift – presence of near and › Behaviors disappear when pain is dear ones adequately treated . Respecting ones will .Non-opioids Scale) administration of an antagonist (naloxone). Analgesic tolerance is very rare . +/. PSEUDOADDICTION .Tolerance . Assess patient’s cultural beliefs and practices › State of adaptation in which exposure to regarding illness and treatment of pain drug induces changes that result in decrease in the drug’s effects over time › So. (7-10 on a 10 Point +/. abrupt cessation.Adjuvant Analgesics ADDICTION VS.Simple descriptive pain intensity scale › Therapeutic range of opioids is very wide .Opioid Addiction WHO ANALGESIC LADDER › Primary. Build trust with patient and family .0-10 scale .. Develop relationship with patient and family TOLERANCE . Not letting the sufferer feel underprivileged 22 . neurobiologic disease. Avoiding unnecessary interventions .Physical dependence ≠ addiction › Dependence is an expected result of LT opioid use › Adaptation manifested by development of a withdrawal syndrome following rapid Severe Pain Step 3 Strong Opioids dose reduction. chronic. Step 1 Step 2 Step 3 with genetic.Visual Analog Scale . (4-6 on a 10 Point Scale) +/.

. Treating and caring more through the heart than through the mind. 23 .