Chapter 12

Palliative Care
Makayla Sims, Cole Davis, Katie Hansen, Lauren Battista,
Lexy Herman
What is palliative care?

● Coined by Dr Balfour Mount in 1974

● Comes from the Latin root word Pallium, which referred to an outer garment
that cloaked a person
● 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.
What is Hospice care?

● Hospice is the speciality of interprofessional team members who care for

the patient and family who are facing end of life.
● This care includes:
○ Aggressive pain and symptom control
○ Affirmation of life
○ Teaching the natural process of dying
○ Spiritual and psychological care
What is the difference between the two?

Both palliative care and hospice care provide comfort. But palliative care can
begin at diagnosis, and at the same time as treatment. Hospice care begins after
treatment of the disease is stopped and when it is clear that the person is not
going to survive the illness
HPNA

● Provides age-appropriate cultural, ethical , and spiritually sensitive care and

support.
● Maintains a safe environment.
● Coordinates care across settings and among caregivers.
● Manages information and protects confidentiality.
● Educates patients/family to identify appropriate settings and treatment
options.
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.

https://www.sharecare.com/health/caregiving/what-is-bereavement-care-offere
d-by-hospice
Prognostication
Prognostication cont.( Karnofsky scale )
● Compare patient scores and status at 12, 6, and 1 month, as well as their
current status
● Laboratory findings can also help validate the progression of a serious
illness
The Meeting

● After gathering all the objective and subjective data, a meeting with the
patient and family is very important
○ Hear the same thing
○ Less room for misinterpretation
○ Time for questions
○ “ usual course of Illness “
○ Educate
Two Roads to death

● Usual Road
○ Peaceful death
○ Begin sleeping more
○ Less responsive
○ Progress to a comprise state
○ Pass
● Difficult Road
○ Restless
○ Increased confusion
○ Hallucinations
Criteria

● Things that may trigger a palliative care consult:

○ “ would I be surprised if this patient died within 6 months to a year ?”
○ Patients with multifaceted care such as ventilator support, parenteral feeding, and
assistance with functional needs
○ A patient's place of residence is a long-term care facility ( Nursing Home )
○ The age of the patient
○ Cognitive impairments
○ Metastatic cancer
○ Current or past enrollment in Hospice care
○ A patient without an advanced care plan
 Key Elements of Palliative Care

Eight Elements of End-of-Life Nursing

Education Consortium

1.Nursing care at the

5.Cultural considerations
end of life
2.Pain management 6.Communications
3. Symptom 7.Loss/grief/bereavement
management 8. Final hours
4.Ethical/legal issues
 Eight Domains of National
Consensus Project

National Consensus Project (NCP)

In 2001 a task force of organizations was
created to improve palliative care. Some
organizations include: the Center to Advance
Palliative Care and, Hospice and Palliative
Care Nurses Association
Domain 1: Structure and Processes of Care
-Interprofessional teamwork
-Assess and plan care with patient and family
 Domain 2: Physical Aspects of Care

-Assessment and treatment of physical symptoms

 Domain 3: Psychological and Psychiatric
Aspects of Care

-Assess and treat psychiatric concerns

-Bereavement
 Domain 4: Social Aspects of Care

-Engages patient and family in the patient’s care

-Communication and support
 Domain 5: Spiritual, Religious, & Existential
Aspects of Care
-Usually involving a chaplain
-Spiritual and religious practices
 Domain 6: Cultural Aspects of Care

-Culturally knowledgeable
 Domain 7: Care of the Patient at the End of
Life
-Communication
-Physical signs and symptoms of the dying process
Domain 8: Ethical and Legal Aspects of Care

-Care planning
-Ethical and legal aspects
Benefits of palliative care

https://youtu.be/s40EvW9YI18
Benefits of palliative care

● Family caregiving
● Pain and symptom management
● To help manage patient suffering
● Comfort
● Support
● Can continue alongside curative care
Target area for palliative care

We are living in a time where unprecedented numbers of

older Americans are living with chronic illnesses. These
elderly people must be cared for. Through palliative care,
their suffering can be eased by also managing their pain and
paying close attention to their symptoms. All the while the
patient's family is their with them every step of the way.
Target area cont.

● Contrary to what many people think of palliative care, the

patient does not have to be old and dying to receive the
benefits of palliative care.
● For example: if a cancer patient were to receive a
therapeutic massage or counseling that would be
considered palliative care, these things can make a
person feel much better.
Family

● “54 percent of Americans die in acute care facilities surrounded by strangers

and suffer from prolonged chronic illnesses and, in many cases, receiving
futile treatment that may result in financial burden for the family.”
● Family plays such a huge role in palliative care, it helps the patient who is in
need of those close family and friends to relax. Having those you love
around you in that vulnerable state creates less stress and suffering.
Family cont.

● The family presence also allows for better

communication between the health care providers and
the patients.
● This allows for easier decision making on the care (or
aggressive care) for both the patient and the health care
provider.
Pain and Symptom Management

● This persistent pain can interfere with normal activities

of daily living such as eating, sleeping, thinking, and
interacting with others.
● If pain of someone who is very sick cannot be eased it
can cause heightened psychological distress.
Pain and Symptom Management cont.

● Through thorough assessment and management of patient and family,

palliative is able to improve quality of life in many ways:

● Relief of suffering, optimization of function, promotion of healing and

comfort, genuine coordination of care at times of transition between health
care providers, and if anticipated patient and family are given assistance in
preparing for hospice.
Relief of patient suffering

● Relieving a patient’s and family’s suffering is central to

the work of palliative care.
● Pain and symptom management become the foundation
of relief due to the fact that active symptomatology can
dominate a patient’s life.
Relief of pain and suffering cont.

● Once physical problems are taken care of, emotional and

psychological problems can occur:
● For example: loss of hope, meaning, value, and
relationships.
● Once these are discovered counselling can be set up the
help resolve these kinds of issues.
 Barriers
● Lack of Understanding

● Lack of Awareness

○ Minorities

● Lack of Referrals

○ Doctors don’t want to give them

 Barriers
● Limited Trained Professionals

● Payment

● Communication
 Common Challenges
● Patient Safety
● Patient Independence
● Treating for Family
● Food and Water
○ Withdrawing
 Legal Concerns
● Right to Refuse Treatment
○ For adults with appropriate capacity
○ Passed in 1991
■ Patient Self-Determination Act
Professional Issues in Palliative Care
The Hospice and Palliative Nurse Association’s (HPNA) Scope and Standards of
Practice identifies the following areas for hospice and palliative care:

1. Clinical Judgement
2. Advocacy and Ethics
3. Professionalism
4. Collaboration
5. Systems thinking
6. Cultural competence
7. Facilitators of learning
8. Communication
Certification

3 Levels of certification for a Palliative Care Nurse.

1. CHPN- Certified Hospice Palliative Nurse

2. CHPA- Certified Hospice Palliative Administrator
3. ACHPN- Advanced Certified Hospice Palliative Nurse

‘The Joint Commission’ provides Palliative care programs that achieves

recognition for high-quality palliative care, at the institutional level.
Quality Assessment and Improvement

The National Hospice and Palliative Care Organization (NHPCO) is a hospice and
palliative care national organization committed to social change and
improvement of multiple areas of quality including:

- Patient-centered pleasures related to management of pain within 48 hrs.

- Avoiding unwanted hospitalizations.
- Avoiding unwanted CPR
- Patient safety.
Improvement cont.

The Center to Advanced Palliative Care (CAPC) is the nation’s leading resource
for palliative care, providing multiple learning opportunities to assist healthcare
institutions to build new hospital programs around the world.

CAPC helps increase the availability of quality palliative care service for people
facing serious, complex illness.
Research and Ethical Concerns

Palliative Care lacks research, funding, number of staff, and trained researchers.

Poor understanding is a barrier in Palliative care by patients/families as well as

healthcare providers.

When the ethically appropriate course of action or range of choices is unclear

then ethical challenges arise.
Advance Care Planning

Patient Self Determination Act(PSDA):

As of December 1991, every healthcare provider was mandated to provide for

new patients with written information describing their right under state law to
make decisions about medical care including their right of execute a living will or
durable power of attorney for health care.

However, ethical dilemmas can arise.

Double Effect

Nurses often face issues of stress requested to give patients opioid therapy in an
actively dying patient.

Nash and Nelson have explained the rule of the double effect and how it has two
effects----one good and one bad.

Good effect- has to be intended and not morally wrong.

Bad effect- not intended but can be foreseen, also cannot be the means to the
good effect.
Palliative Sedation
Patients receiving hospice care can present intolerable symptoms that cannot be
controlled by standard methods of pain management. To appropriately manage
these symptoms, palliative sedation can be considered. Informed consent is
given to the patient or the patients decision maker before therapy.

Palliative Sedation- is the use of sedation medication to relieve refractory or

intolerable symptoms when other pharmacological measures have failed.
Medically Futile Care

Treatment option that offers no possibility of physiologic benefit related to

diagnosis, prognosis, and the current medical condition.

Once the patient’s decision is established and understood, the physician clarifies
with the best treatment options in the case of futile treatments. The team will
clarify all questions and misconceptions to patient/family, then the medical plan
of action is stated clear for everyone present to hear.
Citations

Benefits of Palliative Care for Patients | VITAS Healthcare. (n.d.). Retrieved September 19, 2018, from

https://www.vitas.com/hospice-care-services/palliative-care/palliative-care-for-patients

Cherry, B., & Jacob, S. R. (2016). Contemporary Nursing: Issues, Trends, and Management. Philadelphia: Elsevier

Defining the benefits of palliative care. (2013, October 09). Retrieved September 19, 2018, from

https://youtu.be/s40EvW9YI18

Hawley, P. (2017, February 20). Barriers to Access to Palliative Care. Retrieved September 20, 2018, from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5398324/
Citations

Woo, J. A., Maytal, G., & Stern, T. A. (2006). Clinical Challenges to the Delivery
of End-of-Life Care. Primary Care Companion to The Journal of Clinical
Psychiatry, 8(6), 367–372.