Transcript palliative care

Palliative Care
CHCPA301B
INTRODUCTION:
Learning Outcomes:
• Understand a Palliative Approach and
support the incorporation and ongoing
management of ACD’s within the care plan.
• Be able to support clients to identify their
preferences for quality of life choices.
• Be able to take action to assess and alleviate
pain and other end of life symptoms.
• Identify and manage own responses in self
and others.
ASSESSMENTS
There are 3 parts to this assessment..
Students must pass each part.
PART A: Open book take home quiz.
PART B: Case Study. Mr W.
Part 3: Role play, day 2 in class.
The assessments are due in 2 weeks.
What is palliative care.
What does it mean to you?
What is Palliative Care?
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A Palliative Care approach aims to
improve the quality of life for a person who
is dying and their family, whether as a
result of disease, illness or the ageing
process.
 The
word ‘palliate’ means to relieve;
palliative care therefore is care that
relieves the physical and mental distress
of dying.
What is palliative care? continued
 Palliative
care is a multi-disciplinary
approach that involves medical,
psychological and spiritual responses to
the dying person, their family and friends.
 People are usually encouraged to live as
actively as possible until death
 Palliative care affirms life and regards
death as a normal part of life.
Definition:
World Health Organization 2002
Palliative care is an approach that improves the
quality of care of patients and their families
facing the problems associated with lifethreatening 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.
Dying in Australia
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134,000 deaths in Australia each year
64,000 are considered to be ‘expected
deaths’ – when death is related to a
diagnosed life limiting illness
1/3 of patients whose death is expected
are seen by palliative care services with
the balance by primary care services
Responsibility to all Australians
WHERE can a palliative
approach be provided?
A palliative approach can be used in any
setting.
 A palliative approach can be provided in the
resident’s familiar surroundings if adequate
skilled care is available, which reduces the
need for transfer to an acute setting;
thereby, avoiding potential distress to the
resident and his/her family.
 The reality of the above should be
discussed early in the care planning.
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WHO can provide the care??
A palliative approach is best provided by a
multidisciplinary team. They may include:
# Specialist Physicians and GP’s
# General nurses # Specialist nurses
# Volunteers
# Pharmacists
# OT’s
# Physiotherapist
# Social workers
# Dieticians
# Carers
#Diversional Therapist
#Chaplains
# Pain specialist
WHO DECIDES??
 The
decision to implement a palliative
approach should not be based on the
individual’s clinical stage or diagnosis;
rather, it should be offered according to
the needs of the individual.
 The decision to consider a palliative
approach should be made in collaboration
with the resident, the family and the team.
 Lack of openness with residents and their
families may lead to conflict and confusion
about care goals.
ADVANCED CARE PLANNING
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Advanced care planning empowers the person to
state their wishes in writing, in accordance with how
they define quality of life.
 By doing so, the burden of responsibility is removed
from the surrogate and control is maintained by the
resident.
 As with preparing of a will, the plan cannot be
attended too early.
 When the time comes and the resident is no longer
able to validate decisions it will be of great comfort
to loved ones knowing the decisions they are
maintaining were those chosen.
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An ACD can be an individual process, and does
not have to involve family members. However,
evidence suggests that many people prefer them
to be involved.
 The process of advanced care planning may
provide opportunity for discussing dying wishes,
settling interpersonal differences, may prevent
later conflict over substitute decisions about
treatment, and improve communication amongst
the family members.
 Advanced care planning is a continuum of
treatment choices that may be reviewed as the
persons condition, and possibly preferences
change.
End of life strategies:
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Goals of treatment may need to be re-negotiated
several times.
Good open communication, regular team meetings,
continuity of care (nursing and medical),
a culture which values challenging and
constructive debate –
all these contribute to improving team functioning
which is an essential factor in managing the complex
interface between acute and palliative care.
Sensitive and careful management of the transitional
phases in disease is integral to successful palliation
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patients and their families quality of life will
be maximised where the goals of palliative care
are valued, and expert symptom management
is practised.
 An
understanding of the psychosocial stressors
involved in experiencing chronic illness will
assist in good communication, both within the
health care team and the patient/family.
 Respect
for the ability of the patient and family
to participate in their own care is fundamental to
the practise of palliation
Legal Issues in palliative care
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Nurses working in palliative care need to practise
within the legal controls of the jurisdiction in which
they practise and adhere to the procedural
guidelines.
Pain management is a fundamental part of palliative
care and one that has civil and criminal implications.
The importance of accurate documentation cannot
be overstated.
An advanced care directive that complies with the
requirements is legally binding in NSW.
Failure to comply with ACD may result in the health
professional incurring criminal or civil liability.
Patients Rights
The right to choose or refuse:
 While a patients consent cannot justify that
which the law forbids, for example the direct
taking of life, it can justify that which the law
allows, for example, the termination and
refusal of medical treatment.
 A person is completely at liberty to undergo
treatment, even if the result of doing so will
be that he dies
( Kennedy and Grubb, 1994: 163, 1270. )
Before life-sustaining treatment is
discontinued the patient must be:
 competent
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free from coercion or controlling influence
 fully aware of the implications of the proposed
course of action.
 Legislation allows a person to appoint someone to
make decisions about medical treatment on their
behalf if they become incapable of making decisions
for themselves.
 Such an appointment is made under the ‘enduring
power of attorney (medical treatment)’, also referred
to as a ‘living will’
Cultural Issues:
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Culture is a way of life that is shaped by values,
beliefs and practises that are learnt from experience of
being in the world and from experiences transmitted
through generations.
 All residents require careful assessment to ensure
assumptions are not made for cultural needs based on
a resident’s language ability alone.
 To provide cultural appropriate palliative care requires
first that a persons culture is understood and,
secondly, that health care staff respect that culture.
 Australia is a multi cultural country. It is also possible
that the family unit comes from more than one culture.
This may require unique handling.
 Approximately
120 residential services
provide care operated by ethnic community
organisations, with additional community
resources specifically allocated for
Aboriginal and Torres Strait Islander people
and those from a diverse range of cultural
and linguistic backgrounds.
A
specific program known as Partners in
cultural Appropriate care operates
throughout Australia. Contacts:
 Multicultural
Health Communication service
Website: www.mhcs.health.nsw.gov.au
 Transcultural Aged Care Services (NSW)
(02) 85855025
 Ethnic Communities Council of QLD
(07) 38461099
 Multicultural Aged Care (SA)
(08) 82324410
 Migrant Resource (TAS) (03) 62349411
 Anglican Aged Care (VIC) (03) 93982354
 Multicultural Aged Care (WA) (08) 93468240
Spiritual Care:
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Spiritual care involves assisting people to
articulate those things that are important to them
personally.
 Spiritual care involves sensitive listening, rather
than providing answers. It is not necessary for the
nurse to share the same spiritual beliefs as the
person in order to understand the persons
spiritual needs, nor is it the aim of spiritual care to
impose your own views onto that person.
 It is important that every effort is made by staff to
enable the person to have access to spiritual
supports and spiritually related items.
COMMUNICATION
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Redpath (1998) suggests that communication skills
of the health professional are central to successful
patient decision making, and negotiation of
optimum palliative care outcomes.
 It is also said that nurses are the most frequent
observers of patients’ psychological and emotional
responses to illness and treatment
(Fincannon,1995).
 Therefore it is important to acknowledge the
valuable role communication and negotiating skills
can play in palliative care.
Cultural context of communication
When learning English as a new language, people go
through 5 stages.
 Hearing what is said in english.
 Translating it into their own language.
 Constructing the response in english.
 Responding in English.
When broken down in this way, the room for error is
obvious.
Clear communication is an essential component of
palliative care so language barriers need strategies
put in place to overcome them.
Dealing with conflict & resolution
 CONFLICT
results from individuals or
groups wanting different things.
Differences can include:
 Differences in values, Different
interpretation of the facts, Different ideas.
 NEGOTIATION is a process of
collaboration. It employs the skill of:
 Listening, questioning, Speaking and Body
language.
Body language in communication
Nonverbal communication, known as “body
language” sends strong positive and negative
signals. This is how much it influences any
message:
Words
8%
Tone of voice
34%
Non verbal cues 58%
Body language speaks for itself and can be of
enormous comfort to the patient and carers
…… it can also create the opposite.
The power of listening
Sometimes in palliative care it is more
important to listen than to speak.
Sometimes patients and carers alike want to
discuss their fears but don’t want to burden
their loved ones and they will turn to you.
The philosopher Epictetus stressed the power
of listening in this quote:
“Nature gave us one tongue and two ears so
we could hear twice as much as we
speak”
NUTRITION AND HYDRATION:
 Consenting to or refusing food is an expression of a
persons autonomy.
 One of the most difficult ethical issues that families
and health care workers confront is uncertainty about
how to manage residents who refuse food and / or
fluids.
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‘There is little evidence that tube feeding substantially
prolongs life, and it carries additional risks that usually
will only add an additional burden of discomfort for
dying patients’ ( Finucane,Christmas & Travis, 1999 )
Factors affecting poor nutrition
 Advanced
dementia
 Apathy / loss of interest
 Fatigue / increased generalised weakness
 Depression
 Adverse medication side effects
 Shortness of breath
 Nausea
 Anorexia assoc with deteriorating condition
Potential reversible causes
 Metabolic
disorders such as thyroidism
 Chronic infections
 Alcoholism (nutritional malabsorption)
 Oral health factors
 Depression
 Vitamin deficiencies
 Nausea and vomiting
 Cultural food issues
 Adverse medication side-effects
Dehydration
Dehydration in the end-of-life stage has not
been found to produce distressing symptoms
or shorten lifespan and may in fact be
beneficial.
Benefits include:
 The production of a natural analgesiaendorphins and dynorphins
 Ketoacidosis takes away the feeling of
hunger and results in further analgesia
 Decrease in urinary output and diminished
respiratory secretions
Nutrition at End-of-life
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The desire to feed stems from the belief that
dehydration in a person close to death is distressing
Artificial feeding will not necessarily increase comfort
or quality of life during end stage
Dehydration should not be confused with thirst
Thirst is best treated by small amounts of fluid and
ice chips offered frequently and good mouth care
The wishes of the resident and their family are
paramount
Resident’s best interest and preferences should
guide decision making
Artificial Hydration
Artificial hydration should be considered in
the palliative approach when dehydration
results from potentially correctable causes;
 Over
treatment of diuretics and sedation
 Recurrent vomiting
 Diarrhoea
 hypocalcaemia
Adverse effects of fluid accumulation caused
by artificial hydration at end-of-life:
 Increased
urinary output
 Increased fluid in GI tract – vomiting
 Pulmonary oedema, pneumonia
 Increase in respiratory tract secretions
 Ascites
All of the above potentially causing more
discomfort for the palliative patient.
Nausea and vomiting
Nausea is sometimes prolonged and can be
less easily controlled than vomiting.
Nausea can occur without vomiting ( the
reverse is also true )
It is important to try to identify the cause of
nausea or vomiting in order to manage the
symptoms.
Causes of nausea and vomiting
 Latrogenic
- medications, chemotherapy,
radiotherapy
 Metabolic – hypercalcaemia, UTI, altered
taste
 Organic – constipation, bowel obstruction
 Psychological – anxiety, anticipatory
 Other – odour from food or wounds
 Cause is often unknown at end-of-life
Non – pharmacological therapy
 Correct
reversible causes
 Environmental factors – fresh air, absence
of offensive smells
 Offer non-odourous foods, eat slowly &
small amounts frequently
 Avoid lying flat before and after meals
 Diversional therapies – relaxation
 Maintain good mouth care
Pharmacological management
General guidelines include:
 Determine the most likely cause
 Identify contributing factors
 Select an appropriate anti-emetic
 Select appropriate route for drug administration
 Consider possible toxicity
 Possible benefit versus potential burden
 Ensure patient compliance
 Evaluate regularly
 Give prophylactically
Bowel care in palliation
Bowel symptoms such as constipation or faecal
incontinence can have a negative effect on a
resident’s quality of life.
Bowel care is a key component of a palliative
approach as residents may be taking opioids,
which are a major cause of constipation.
Constipation may occur with:
 Limitation to fluid intake in faecal waste
 Limitation to movement of faeces through colon
 Limitation to muscle contraction
Bowel management
 Initial
assessment to identify normal bowel
habits
 Daily documentation of bowel habits
 Prophylaxis – essential part of management
 Early identification of abnormal bowel habits
 Identify cause – diet or drug induced
 Prompt and individually tailored treatments
 Minimization of interventions that can cause
loss of dignity
 Comfort for the resident
Types of Constipation
PRIMARY:
 Inadequate dietary fibre / dehydration
 Reduced mobility / reduced muscle tone
 Withholding faecal evacuation
SECONDARY:
 Partial bowel obstruction
 Spinal cord compression
 conditions such as hypercalcaemia
LATROGENIC:
Introduced by administration of drug therapies
Symptoms of constipation
 Nausea
and vomiting
 Straining during defecation
 Infrequent bowel movements
 Feelings of incomplete emptying after bowel
movements
 Frequent small amounts of diarrhoea
 Rectal pain on defecation
 Stomach pain, distension or discomfort
 Faecal incontinence
Pain management
To cure sometimes
To relieve often
To comfort always
Defining Pain:
ACUTE PAIN: Is usually due to a definable
acute injury or illness. It has a definite onset
and it’s duration is limited and predictable. It
is accompanied by anxiety and clinical signs
of sympathetic overactivity: tachycardia,
tachypnoea, hypertension, sweating,
pupillary dilatation and pallor. Acute pain may
also occur in a patient with chronic pain.
 INCIDENT PAIN: Occurs only in certain
circumstances eg: movement / procedures
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 CHRONIC
PAIN: Results from a chronic
pathological process. It has a gradual or illdefined onset, continues unabated and may
become progressively more severe. The
patient appears depressed and withdrawn
and, as there are no signs of sympathetic
overactivity, they are frequently labelled as
“not looking like someone in pain’. Patients
with chronic pain may exhibit depression,
lethargy, apathy, anorexia and insomnia.
 Chronic pain requires REGULAR use of
analgesics to control pain with breakthrough
analgesia for additional acute episodes.
As noted by Lord Devlin in R v Adams (Bodkin)
(1957) even though direct killing is unlawful:
….. There is still much for a doctor to do that
he is entitled to do all that is proper and
necessary to relieve pain and suffering, even
if the measures he takes may incidentally
shorten life.
Criminal law requires intent. The intent to
relieve pain is different from the intent to kill,
which does and should lead to criminal
charges.
Pain management requires a systemic and holistic
approach to treatment that is tailored to the
individual’s physical, psychological and spiritual
needs.
As Dickinson stated,
“ Pain is a subjective sensation and therefore pain
is what the individual says it is and NOT what
others think it should be”.
Recognition of an emotional and psychological
component to pain points to the need for a
multidimensional assessment for effective pain
management.
Principle of pain management
Regular around the clock
Oral medication if possible
Adjuvants for side effects
Barriers to effective pain
management:
Some include:
 Lack of knowledge of pain assessment
among some nurses and doctors.
 Overcoming cultural beliefs. Eg: a recent
study found some indigenous Australian
communities feared morphine was given at
the end of life to ‘get rid of me” (them).
 A belief that pain relief should only be given if
pain was currently present.
 Poor communication.
Pain assessment tools:
Pain assessment tools have been developed to
attempt to overcome the incongruence
between nurses perception of pain and the
patient’s.
Some assessment tools used are:
 The ABBEY pain Scale.
 The FUNCTIONAL Pain scale. (FPS)
 The NUMERICAL Rating Scale. (NRS)
 The McGILL Pain Questionnaire (MPQ)
 The BRIEF Pain Inventory (BPI).
Complementary therapies
In 1995 RNSH (Sydney) analysed 319 patient
questionnaires where the question was asked
“Why do you use alternative treatments” Reasons
given include:
 New source of hope.
 Preference of natural therapies.
 Impression of non-toxic therapy.
 Supportive alternative practitioner.
 Greater personal involvement.
It is important therefore to endorse the patient’s
desire and choice of empowerment.
Some complementary therapies include:
 Counselling
 Massage /relaxation techniques
 Aromatherapy
 Naturopathy
 Therapeutic touch /Reiki /Reflexology
 Herbal / traditional Chinese medicines
 Creative visualisation
 Music therapy
 Meditation /hypnotherapy
 Acupressure / acupuncture
It is necessary to recognise the importance of
offering patients the choice of a range of
therapies BUT
If nurses are to incorporate complementary
therapies into nursing practise, certain issues
need to be addressed including:
 Training
 Staffing levels
 Time
 Informed consent
 Documentation
Given the above it is important that management
supports the use of complementary therapies.
Physiological changes
In the final stage when life-sustaining systems begin
to shut down, physical, mental, emotional and
spiritual changes may occur over weeks, days or
hours. These can include:
Increased weakness, fatigue. Loss of interest in
everyday things. Decreased appetite and fluid
intake. Difficulty swallowing. Neurological
dysfunction, confusion. Pain. Incontinence.
Restlessness. Increased sleepiness. Changes in
body temperature and colour. Loss of ability to close
eyes. Breathing difficulties.
Nursing care
As the dying persons physical changes occur so will
their nursing care needs.
These needs include:
 Hygiene
 Incontinence care
 Pressure area care
 Oral and eye care
 Bowel care
 Pain / comfort management
 Care of respiratory difficulty
 Psychological and spiritual care
Unexpected Alertness and Energy
Often a day or two or even a few hours before death,
the person may have a surge of energy, wake up,
become alert, can sometimes eat or drink or talk and
spend some quality time with loved ones.
This can be a very precious time that doesn’t often last
long.
Nurses will often refer to it as “ the calm before the
storm”
Reliving this time is common following the passing of
the person by those left behind and can be very
comforting.
Signs of Impending Death
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Increased anxiety, restlessness, confusion
Loss of interest in daily activities
Loss of interest in eating and drinking
Lethargy
Gradual cooling of skin, becomes pale, grey or bluish in
colour
The person becomes less responsive and eventually
unresponsive
Abnormal breathing pattern, known as Cheyne-stokes
Fast weak pulse
Shutdown of circulation to the extremities, with the
development of cyanosis
Signs of Clinical Death
These include:
 Absent heartbeat and respirations
 Pupils fixed
 Colour turns to waxen pallor as blood settles
 Body temperature drops
 Muscles (sphincter) relax, often causing
incontinence
 Eyes may remain open
 Jaw falls open
The focus of care then shifts to those grieving.
Care after Death
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A Medical Officer or RN will confirm death
Respect the person in death as in life
The person’s after death wishes are followed
Personal hygiene is completed with the same
care and attention as if the person was still alive,
using standard precautions and safe manual
handling
If a Coroner’s case is suspected then the body is
not to be washed, dressings, cannulae and
catheters are not to removed.
Give support to the family and friends
Loss and Grief
During the palliative phase and following the
death of a person those involved will
experience various degrees of loss and grief.
The people involved will include the dying
person , their loved ones and the staff. The
staff effected can be varied.
To understand how we may assist them and
ourselves we must first understand the
effects that loss and grief have on the human
body.
LOSS: Loss can be actual, or perceived or
permanent, and it occurs when someone or
something can no longer be seen, heard, known,
felt or experienced.
GRIEF: Grief is the natural response to loss. It
includes a range of responses: physical, mental,
emotional and spiritual. These are usually
associated with unhappiness, anger, guilt, pain and
longing for the lost person or thing.
Each person will grieve and recover in their own way.
NORMAL GRIEF REACTIONS:
EMOTIONAL
Anxiety
Fear
Sadness
Anger
Guilt
Inadequacy
Relief
Loneliness
MENTAL
Disbelief
Confusion
Preoccupation
Sense of presence
Hallucinations
PHYSICAL REACTIONS TO GRIEF:
 Hollowness
in the stomach.
 Tightness in the chest and throat.
 Over sensitive to noise.
 A sense of depersonalisation.
 Breathlessness.
 Muscle weakness.
 Lack of energy.
 Dry mouth.
STAGES OF GRIEVING:
 Denial
and isolation.
 Anger and resentment.
 Bargaining Depression.
 Acceptance.
Factors that can influence the reaction to
grief are:
 Stage of growth and development.
 Cultural and spiritual beliefs.
 Socioeconomical status.
 Relationships with significant others.
Strategies for assisting a person to
deal with loss and grief.
 Reflective
listening.
 Provide appropriate environment.
 Accommodate the individuals needs eg:
Pets, music, Exercise, Reminiscence.
 Use of experts; clergy, grief counsellors.
 Accommodate cultural and religious
customs.
 Support and encourage loved ones
participation in patient care if requested.
Characteristics a nurse requires
 Caring
and understanding
 To be able to accept others beliefs and
customs (even when not your own)
 Empathic approach
 To take a risk and get involves (not afraid
of intense feelings)
 To be able to acknowledge loss
 To support as a person moves through the
stages of grieving
 To work with and support colleagues
How to cope ?
 Working
within a team that ensures the well
being of it’s members is a vital component to
providing holistic palliative care.
 Past personal and professional experiences
of staff will greatly influence how they cope
in different situations.
 Staff need to be encouraged to use
resources available to them when needed.
 Communicate and ‘look out’ for your
colleagues and together you can make a
difference.
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When a patient dies, you are entitled to grieve.
 How you reconcile your personal feelings of loss
with your sense of professionalism is important as
unresolved grief will wear you down.
 It is only human to hurt, to grieve when a person
who has influenced you in some way has died.
 Supporting a patient and their loved ones in the final
moments of life is a privilege and comes with
personal rewards.
‘No one ever complained that someone cried; but they
have that no one cared’ – workcover NSW.
References
 www.who.com/palliativecare
 TAFE
NSW.2006, Aged Care in Australia
a guide for aged care workers. Southwood
Press
 www.palliativecareaustralia.org.au