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Jhessie L. Abella,RN,RM,MAN
Traditional Health Care Model
The primary goal is cure The object of analysis is the disease process Symptoms are treated primarily as clues to diagnosis Primary value is placed on measurable data Tends to devalue information that is subjective, immeasurable, or unverifiable Therapy is medically indicated if it eradicates or slows the progression of disease
Symptoms at the End of Life:
Pain Trouble breathing Nausea and vomiting Sleeplessness Confusion Depression Loss of appetite Constipation Bedsores Incontinence 84% 47% 51% 51% 33% 38% 71% 47% 28% 37% 67% 49% 27% 36% 38% 36% 38% 32% 14% 33%
Seale and Cartwright, 1994
. 1860).’ She went on to say:' The very elements of nursing are all but unknown’ (Nightingale.FLORENCE THE FIRST PALLIATIVE CARE NURSE Florence Nightingale herself stated: ‘I use the word nursing for want of a better.
far advanced disease for which the prognosis is limited and the focus of care is on quality of life World Health Organization: Active.Definitions of Palliative Care Study and management of persons with progressive. total care of persons whose disease is no longer responsive to curative treatment 3 .
Palliative Care Distinctions from Hospice: Focuses on end-stages of chronic illness Targets people earlier in disease process Is not linked to reimbursement or prognosis Has greater flexibility to accommodate individual and family wishes Is complementary to hospice care 4 .
through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems.‟ WHO .DEFINING PALLIATIVE CARE „Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness. physical. psychosocial and spiritual.
WHO Definition of Palliative Care
Provides relief from pain Affirms life and regards dying as a normal process Intends to neither hasten nor postpone death Integrates the psychological and spiritual aspects of patient care Offers supports system to help patient live as actively as possible until death Offers supports system to help the family Will enhance quality of life
PALLIATIVE CARE GOAL
Its goal is much more than comfort in dying; palliative care is about living, through meticulous attention to control of pain and other symptoms, supporting emotional, spiritual, and cultural needs, and maximizing functional status
PALLIATIVE CARE SETTINGS anywhere .
or to a peaceful death.’ . ‘Nursing is primarily assisting the individual in the performance of those activities contributing to health and its recovery.VIRGINIAS DEFINITION OF NURSING The most succinct and relevant to palliative care is Virginia's definition of nursing.
I have the right to participate in decisions concerning my care. I have the right to maintain a sense of hopefulness however changing its focus may be. however changing this might be. I have the right to be cared for by those who can maintain a sense of hopefulness. I have the right to express my feelings and emotions about my approaching death in my own way.Dying Person’s Bill of Rights I have the right to be treated as a living human being until I die. .
I have the right not to die alone. I have the right to have my question answered honestly. I have the right to be free from pain.Dying Person’s Bill of Rights I have the right to expect continuing medical and nursing attention even though “cure” goals must be changed to “comfort” goals. . I have the right not to be deceived.
whatever these may mean to others. . knowledgeable people who will attempt to understand my needs and will be able to gain some satisfaction in helping me face my death. I have the right to retain my individuality and not be judged for my decisions which may be contrary to beliefs of others. I have the right to discuss and enagage my religious and/or spiritual experiences. I have the right to expect that the sanctity of the human body will be respected after death. sensitive. I have the right to be cared for by caring.Dying Person’s Bill of Rights I have the right to have help from and for my family in accepting my death. I have the right to die in peace and dignity.
such as congestive heart failure HIV/AIDS Kidney failure Liver failure Lung disease. such as Alzheimer’s Disease Diabetes Heart disease. such as chronic obstructive pulmonary disease (COPD) or emphysema Multiple Sclerosis (MS) Stroke .Common Condition Amyotrophic Lateral Sclerosis Cancer Dementia.
such as leukemia.Most Common Condition in Children Birth defects Heart defects Certain cancers. brain and neurological cancers. bone cancers and lymphoma Cystic fibrosis Muscular dystrophy Cerebral palsy Sickle Cell Anemia Spina bifida Liver disease Kidney disease .
Domains of Palliative Care Advance care planning Physical and emotional comfort Social. and spiritual support 5 . bereavement.
death Religious or spiritual concerns Understand Legal Requirements Statutes and requirements vary by state 6 .Advance Care Planning Understand Values of the Person What makes life worth living Quality vs. family. suffering. prolongation of life Concerns over illness. alertness. control.
Advance Directives are a way for you to make decisions regarding health care in advance. . or unable to make sound decisions for themselves. This document allows people to plan their health care before they become incapacitated.
Medical procedures you would want to receive Procedures you would like to avoid Life support Being kept alive versus comfort care only .
determine comfort level with discussion. determine competence and desire to name an agent Discuss preferences and wishes and explore any inconsistencies Document thoroughly and review frequently Update as needed Step 2: Structure Discussions Step 3: Document Preferences 7 .Process of Advance Care Planning Step 1: Introduce the Topic Define ACP process and philosophy.
diarrhea. constipation.Assessment & Management of Symptoms Physical symptoms may include pain. shortness of breath. and others Attend to self reports and behavioral cues Manage symptoms Assess frequently and communicate with appropriate professionals Develop an ongoing plan of care focused on maximizing comfort 8 . itching. lack of appetite. nausea/vomiting.
” . She says.Pain Pain defines it as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. a nurse and leader in the pain management field. has a more useful definition for nurses. “:Pain is whatever the person experiencing it says it is and exists whenever he says it does. McCaffery.
Autonomic Nervous System Responses to Pain Sympathetic Nervous System Responses ↑ Blood pressure ↑ Pulse rate ↑ Respiratory rate Dilated pupils Perspiration Pallor Parasympathetic Nervous System Responses Constipation Urinary retention .
short duration duration Sign of tissue injury No purpose No report of pain unless Reports pain. longer Limited.CHARACTERISTIC Time Purpose Verbal Behavioral Physiologic Interventions CHRONIC Lasts 3-6 months. pacing. blood pressure. minimal Restless. focuses on pain questioned Tired-looking. thrashing. and other facial expressions of attention on other pain things Normal heart rate. respiratory rate rate Less responsive to Responds to analgesics analgesics Higher doses needed for Standard doses effective pain relief Parenteral or oral route used Oral route preferred Additional drugs (adjuvant) Additional drugs often ACUTE . sleeps. rests. quiet. grimacing. respiratory pressure. body part. rubbing facial expression. blood Increased heart rate.
Acute pain is temporary. Neuropathic pain results from nerve damage resulting from a wide variety of anatomic and physiologic conditions and underlying diseases. it may last a lifetime. renal colic pain from kidney stones. . and pain in childbirth. and its cause is known and treatable. however. Chronic pain is usually defined as pain that persists or recurs for more than 3 to 6 months. Examples are postoperative pain from incisions. most chronic pain is called neuropathic pain because it follows an abnormal pathway for pain. Chronic pain may also be nociceptive.Acute and Chronic Pain Most pain experienced in the hospital is acute pain. Acute pain follows the normal pathway for pain from nociceptor activation to the brain and may be called nociceptive pain. It serves as a warning of tissue damage and subsides when healing takes place. bone fractures.
Requires skilled personnel. Music Imagery Educational Instruction . transcutaneous electrical reducing pain and improving physical function.INTERVENTION COMMENTS PHYSICAL Increase pain threshold. Effective for reduction of mild to moderate pain. Progressive muscle relaxation Simple imagery Use when patients express an interest in relaxation. nerve stimulation (TENS) Techniques require skilled personnel and special equipment. PSYCHOLOGICAL Relaxation Jaw relaxation Effective in reducing mild to moderate pain and as an adjunct to analgesic drugs for severe pain. Both patient-preferred and “easy listening” music are effective in reducing mild to moderate pain. reduce muscle spasm. cold. Requires 5-15 minutes of staff time. Should include sensory and procedural information and be aimed at reducing activity-related pain. Requires 3-5 minutes of staff time for instructions. Effective for reduction of pain. massage. Effective in Heat. May be useful as adjuncts to drug therapy. and decrease congestion in injured area.
If you do not know how to do abdominal breathing.” . say silently to yourself a word such as “peace” or “relax.Relation Techniques 1. say to yourself. “out.Each time you breathe out. Do steps 1 through 4 only once. 6. “I feel alert and relaxed.” b. You may imagine that you are doing this in a position and a place you have found very calming and relaxing. 7. 4. End with a slow. Now breathe in and out slowly and regularly at whatever rate is comfortable for you. two. or repeat steps 3 and 4 for up to 20 minutes. 2. To help you focus on your breathing and to breathe slowly and rhythmically. You may wish to try abdominal breathing. As you breathe out. deep breath. three.” 5. do the following: a.Breathe out as you say silently to yourself. 3. such as lying on a beach in the sun. “in. three. feel the tension leaving your body. ask your nurse for help. two.” c. feel yourself beginning to relax. Breathe in slowly and deeply. As you breathe out slowly.Breathe in as you say silently to yourself.
ankles. or lower legs .Serious Side Effects of Morphine slow. or irregular breathing blue or purple color to the skin fast or slow heartbeat seizures hallucinations (seeing things or hearing voices that do not exist) blurred vision fainting hives rash itching tightness in the throat difficulty swallowing swelling of the arms. shallow. hands. feet.
Open a window to provide a breeze and fresh air. If you are familiar with guided imagery and meditation. Try relaxation techniques – Play relaxing music. both techniques may help. Provide emotional support – Listening closely to what the patient has to say and providing reassurance can go a long way. Have the patient sit upright in bed and focus on deep breathing. Use a fan to blow air directly at the patient's face. .Dypsnea Cool the room and make sure patient has on light weight clothing. as long as it is tolerated well. use massage or other relaxing touch of the patient's choice.
NSAID’s. . Because treatment of nausea and vomiting can largely depend what's causing it. antibiotics. tastes. and chemotherapeutic agents can cause nausea as well. Noxious odors.Nausea and Vomiting There are several causes of nausea and vomiting. your health care provider will do a thorough assessment to try to determine the cause. Physical changes in the gastrointestinal tract such as constipation or a bowel obstruction are yet other examples of causes. or sights can sometimes trigger this response. Certain medications such as opioid analgesics (narcotic pain medications).
which can limit odors that can make a patient nauseated. Apply a cool compress to the patients forehead. Offer liquids at other times during the day but drinking too much liquid with food can cause vomiting. neck.Managing Nausea and Vomiting Provide fresh air and loosen the patients clothing. . Prompt treatment will help ensure that the patient gets comfortable as soon as possible. avoid cooking heavily odored food and don’t wear perfume or after-shave when you will be close to the patient. and wrists. be sure to contact your health care provider immediately. As with any symptom. Avoid odors that can trigger an episode. Serve food cold. Offer small meals and limit drinks served with each one.
Cancer patients may have the highest prevalence with as many as 70% to 100% of patients experiencing constipation at some point in their disease. differing for individuals based on normal pattern of bowel movements and symptoms of discomfort. Constipation impacts a patient‟s quality of life substantially. It can be caused by anything that slows down the motility of the gut or obstructs the intestines. social.” Constipation is subjective. which impacts their caregivers as well. and psychological distress for patients.Constipation Constipation is defined as “a decrease in the frequency of passage of formed stools and characterized by stools that are hard and small and difficult to expel. . It causes physical. Constipation occurs frequently in patients near the end of life.
therapist. and others Assess frequently Communicate with primary care provider(s) and. anxiety. or clergy Develop an ongoing plan of care focused on minimizing patient and family distress 9 . psychiatrist.Assessment & Management of Symptoms Emotional symptoms may include depression. if appropriate. agitation. irritability.
Bereavement.Social. and Spiritual Support Meeting the needs of the dying person Offering hope Providing comfort Assuring community Maintaining meaning Sustaining dignity Limiting fears of abandonment 10 .
provide comfort foods. liberalize diet. engage community services. assure wishes are congruent with advance directives and resolve any conflicts Arrange meals for family. dignity. encourage family involvement in care Coordinate family support. provide extra fluids for person 11 Social Services Dietary . and privacy.Social & Spiritual Support Nursing Assist with hygiene. maintain open communication with individual and family.
and visits from children as desired Assist in maintenance of independence and comfort. music therapy. local clergy. reminiscence. safety issues. aromatherapy. gardening.Social & Spiritual Support Activities Offer pet therapy. and volunteers 12 PT/OT Community . and pressure ulcer care Involve hospice. consult on positioning.
Moment of Death Develop approaches to ensure that death does not occur alone Maintain on call system-. and volunteers to spend time with those actively dying Support family members at time of death Assume care of and show reverence for the body 13 . staff.family.
referral to community services Memorial services Bedside services Flowers and cards in reception area Angel tree. or other remembrance area Follow-up call or letter to family 14 . memorial garden.Bereavement Support for Survivors Sympathy cards Pamphlets on grief and loss.
PALLIATIVE CARE COMPETENCIES Communication skills Physical care skills Psychosocial skills Teamwork skills Intrapersonal skills Life closure skills (BECKER 2009) .
perhaps deny patients to discuss the imminent death of a relative with families. to use therapeutic comforting touch with confidence. to challenge colleagues who may wish to information. and. . because that is the most appropriate response.COMMUNICATION SKILLS The ability to field and respond to sometimes profound or rhetorical questions about life and death to know when to say nothing.
2004).TEAM WORK SKILLS The growth of the nursing role within these teams has been dramatic and continues to represent a muchadmired model of working (Cox and James. .
PHYSICAL CARE SKILLS the knowledge and skills necessary to deliver active. hands-on care in whatever setting throughout a long period of illness. observational skills and the intuitive ability to recognize signs advising doctors of the appropriate prescription and dosage to manage pain the advocacy role nurses have towards patients at a time of extreme vulnerability. .
anticipating their needs.PSYCHOSOCIAL SKILLS An ability to work with families. putting them in touch with services and supporting them when appropriate .
and to be able to reflect on how this affects care given in sensitive situations.INTRAPERSONAL SKILLS Nurses need to recognize and attempt to understand personal reactions that occur as a natural consequence of working with dying and bereaved people. It is the most challenging of all competency areas and plays a significant part in the professional growth of those who choose to work in this field (Becker and Gamlin ) .
when life is close to an end and thereafter. as they perceive it. Such care has been described as sacred work. in which the nurse enters into the patient‟s intimate space and touches parts of the body that are usually private .LIFE CLOSURE SKILLS This area is concerned with nursing behaviours and skills that are crucial to patients‟ and families‟ dignity.
P A L L I A T I V E FACILITATOR CASEMANAGER ADVOCATE ASSESSMENT AND MANAGEMENT EXPERT N U R S E S R O L E .
PALLIATIVE CARE PLAN Palliative care plan includes -care goals -symptom management -advance care planning -financial planning -family support -spiritual care -functional status support and rehabilitation -co morbid disease management .
MULTIDIMENSIONALITYOF SUFFERINGS PHYSICAL SUFFERING PSYCHOSOCIAL EMOTIONAL SPIRITUAL .
cachexia Impaired mental status Dry mouth Constipation Diarrhoea Fever .COMMON SYMPTOMS Fatigue Pain Nausea Vomiting Insomnia Dyspnea pyrexia Anorexia.
MANAGING PAIN Assess the multi dimensions of pain & determine the type of pain Employ a assessment scale Use WHO ladder Administer around the clock doses and break through doses Seek the help of appropriate alternative therapies Continue evaluating pain control and pain status .
DYSPNEA Address the anxiety with assurance and relaxation techniques Maintain saturation supplemental oxygen above 90% with Suctioning is generally not indicated Administer 5-10mg of morphine q4h if the patient is not on opioids .
drug related anxiety. organic anxiety and psychological anxiety -multidisciplinary assessment -treat the reversible causes -non pharmacological therapy -spiritual support -short term psychotherapy -tranquilizers for severe anxiety .HANDLING ANXIETY Types include situational anxiety.
NOURISHING AND HYDRATING Suggest small meals and liquid supplements Treat the symptom that may cause decreased appetite Administer appetite stimulants Employ infusions and hypodermoclysis .
Potential Palliative Care Interventions Palliative Support • Emotional • Spiritual • Psychosocial Control of • • • • Pain Dyspnea Nausea Vomiting Generally Not Palliative Variable Transfusions Infections Hypercalcemia Tube Feeding Dialysis CPR Ventilation Highly burdensome Interventions .
occupational and complementary therapies .FUNCTIONAL STATUS SUPPORT Assess ability to perform ADL & IADL Find and rule out underlying reversible causes of functional impairment Refer to rehabilitation evaluation and conditioning exercises as appropriate Optimize and maintain functional status with physical.
it is different from assisted death as it is not intended for death yet often foreseen . .sedative dose is not a killing dose .PALLIATIVE SEDATION Intermittent sedation for relief of intractable symptoms when they are not controlled even with aggressive measures.
SPIRITUAL CARE Assess the desire for spiritual counseling and support Obtain information regarding significant religious rituals. beliefs and practices Encourage their practice to the extent possible Foster the insights Spiritual coping strategies enhance self empowerment .
SUPPORTING FAMILY Assess family structure. knowledge deficits. strengths and weaknesses. functioning. Encourage communication among family members Respect their privacy and accept the coping styles Conduct meetings to review the goals and decisions Teach care giving skills to the primary caregiver Assist throughout grieving process and in bereavement .
ADVANCED CARE PLANNING Living wills Health power of attorney A completed patient values history .
Considering what is known of the patient‟s wishes and preferences given the current condition Balancing the burdens and benefits of each option in terms of quality of life and Achieving makers a consensus among decision . Shared decisions should be made after.ETHICAL DECISION MAKING Nurses can seek the help of the ethical standards of decision making.
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