FLORENCE THE FIRST PALLIATIVE

CARE NURSE
Florence Nightingale herself stated:
‘I use the word nursing for want of a better.’
She went on to say:
‘The very elements of nursing are all but
unknown’
(Nightingale, 1860).
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, though the prevention and relief of
suffering by means of early identification and
impeccable assessment and treatment of pain and
other problems, physical, physiological and
spiritual.’
WHO
 PALLIATIVE CARE
• Affirms life
• Promotes quality of life
• Treats the person
• Supports the family
EVOLVING MODEL OF PALLIATIVE CARE

“Active Treatment” Palliative Care Death

Cure/Life-
prolonging Intent
Death Bereavement
Palliative/
Comfort Intent
 PALLIATIVE CARE GOAL
Its goal is much more than comfort in
dying; palliative care is about living through
meticulous attention to control pain and other
symptoms, supporting emotional, spiritual,
and cultural needs, and maximizing functional
status
PALLIATIVE CARE SETTINGS

ANYWHERE!
any
VIRGINIAS DEFINITION OF NURSING
The most succinct and relevant to palliative care
is Virginia’s definition of nursing;

‘Nursing is primarily assisting the individual in

the performance of those activities
contributing to health and its recovery, or to
a peaceful death.’
 PALLIATIVE CARE COMPETENCIES
• Communication skills
• Physical skills
• Psychosocial skills
• Teamwork skills
• Intrapersonal skills
• Life closure skills
 COMMUNICATION SKILLS
The ability
• To field and respond to sometimes profound or
rhetorical questions about life and death
• To know when to say nothing, because that is the
most appropriate response;
• To use therapeutic comforting touch with confidence;
• To challenge colleagues who may wish to deny
patients information; and, perhaps
• To discuss the imminent death of a relative with
families
 TEAM WORK SKILLS
Pharmacist
Palliative
Care Nurse
Natural
Therapist
• The growth of the
Occupational
Dietician
Therapist nursing role within
Domiciliary these teams has
Care Paramedical
Meals on Aide been dramatic and
Wheels
General continues to
Practitioner
Funeral
Director Medical represent a much
Specialists
admired model of
Volunteers Social Bereavement
Support
working .
Worker
Spiritual Worker
Counsellor
 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
recognise 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.
 PSYCHOSOCIAL SKILLS
An ability
• work with families,
• Anticipating their needs,
• Putting them in touch with services and
• Supporting them when appropriate
 INTRAPERSONAL SKILLS
Nurses need to recognise and attempt to
understand personal reactions that occur as a
natural consequence of working with dying and
bereaved people and to be able to reflect on how
this affects care given in sensitive situations.
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.
 LIFE CLOSURE SKILLS
• This area is concerned with nursing behaviours
and skills that are crucial to patients’ and
families; dignity, as they perceive it, when life
is close to an end and thereafter.
• Such care has been described as a sacred
work, in which the nurse enters into the
patient’s intimate space and touches parts of
the body that are usually private
 FACILITATOR

PALLIATIVE MANAGEMENT
EXPERT
CASEMANAGER

NURSES
ROLE

ASSESSMENT ADVOCATE
 PALLIATIVE CARE PLAN
Palliative care plan includes:
• Care goals
• Symptom management
• Advance care planning
• Financial support
• Spiritual care
• Functional status support and rehabilitation
• Co morbid disease management
MULTIDIMENSIONALITY OF
SUFFERINGS

PHYSICAL

PSYCHOSOCIAL SUFFERING EMOTIONAL

SPIRITUAL
 COMMON SYMPTOMS
• Fatigue • Anorexia; cachexia
• Pain • Impaired mental
• Nausea status
• Vomiting • Dry mouth
• Insomnia • Constipation
• Dyspnoea • Diarrhoea
• Pyrexia • Fever
 MANAGING PAIN
• Asses the multi dimensions of pain and 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 above 90% with
supplemental oxygen
• Suctioning is generally not indicated
• Administer 5-10mg morphine q4h if the
patient is not on opioids
 HANLING ANXIETY
Types include situational anxiety, drug related anxiety. Organic anxiety and
psychological anxiety.
 Multidisciplinary assessment
 Treat the reversible causes
 Non pharmacological therapy
 Spiritual support
 Short term psychotherapy
 Short term psychotherapy
 Tranquilizers for severe anxiety
 NOURISHING AND HYDATING
• 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 Generally
Not Palliative
Support
•Emotional Variable CPR
•Spiritual Transfusions Ventilation
•Psychological
Infections Highly
Control of Hypercalcemia burdensome
•Pain Tube Feeding Interventions
•Dyspnea
•Nausea Dialysis
•Vomiting
 FUNTIONAL STATUS SUPPORT
• Assess ability to perform ADL & IADL
• Find and rule out underlying reversible causes
of functional impairment
• Refer to rehabilitation evaluation as
appropriate
• Optimize and maintain functional status with
physical, occupational and complementary
therapies
 PALLIATIVE SEDATION
Intermittent sedation for relief of the intractable
symptoms when they are not controlled even
with aggressive measures.
– It is different from assisted death as it is not
intended for death yet often foreseen
– Sedative dose is not killing does
 SPIRITAUL CARE
• Assess the desire for spiritual counselling 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, functioning, strengths and
weaknesses, knowledge deficits
• 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
 ETHICAL DECISION MAKING
Nurses can seek the help of the ethical
standards of decision making. Shared
decisions should be made after,
• Considering what is known of the patients
wishes and preferences given the current
condition
• Balancing the burdens and benefits of each
option in terms of quality of life and
• Achieving a consensus among decision makers
Education Public Awareness
•Core competencies •Raise awareness and
•Curriculum in expectations
undergrad and post- •Improve “death culture”
grad in all involved •Empower in decision
disciplines making
•Continuing education

Professional Practice
•Stds of practice for symptom
management, availability,
responsiveness,
communication
•Certain palliative
interventions held to higher
scrutiny and rigour – eg.
Palliative sedation
•Specialty area for nursing