MEDICAL SURGICAL NURSING V

COURSE CODE GNS 320

PALLIATIVE CARE

Introduction

Nurses and other health care clinicians can work in a variety of setting caring for many different
populations. Some of these setting provide inpatient care, such as hospital or nursing home
Nurses care for diverse population of patients both in age and position along the heath / illness
continuum, one of the main goal in nursing care is to promote heath and prevent illness The
human body is remarkable and can heal from many serious conditions including severe trauma,
infectious disease and many other alterations in health. Sometimes however, people developed
conditions that cannot be cured despite the many modern advances in medicine; the end result
of medicine that cannot reverse the process of illness eventually will be death

Sometimes death is unexpected as from accidents, while other time it can be anticipated as
when chemotherapy is no longer effective for a person diagnosed with and advance form of
cancer. The majority of these deathsoccur in a health care setting, where most nurses works
Nurses working in health care setting not only provide care to patients who are restoring their
health, but also to those who are dying, it is essential that nurses have the knowledge and skills
to cure for patients who are dying and their families who are dealing with impending loss.

PALLIATIVE CARE DEFINITION

Definition—the word palliative has it is origin in the latin word ‘’pallium’’ meaning to cloak or
cover. A more contemporary and simplest definition is to mitigate the suffering of the patients,
not to effect a cure [Macpherson 2002]

According to World Health Organization [W.H.O] [2009] –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 problem, physical,
psychosocial, and spiritual .

Palliative care is a specialized medical care for patients living with a serious illness. These types
of care are focused on providing relief from the symptoms and stress of the illness. The goal is
to improved quality of the life for both the patient and the family.

Palliative care is provided by a specially- trained team of nurses, doctors and other specialist
who work together with a patient toprovided an extra layer of support. Palliative care is based

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on the needs of the patient not on the patient’s prognosis, it is appropriate at any age and at
any stage in aa serious illness.

PALLIATIVE CARE TEAM

Palliative care tram – is a multi-professional team whose primary function is to support patients
at home or in hospital, they include the following members

1Nurses

2 Physician [specialist]

3 Physiotherapists

4 Pharmacists

5 Psychiatrists

6 Clinical psychologists / counselor

7 Social workers

8 Dieticians

9 Music or art therapists

10 Volunteers

11 imam / chaplain

PRINCIPLE OF PALLIATIVE CARE

The principle of palliative include the following

1 Provide relief from pain and other distressing symptoms

2 Affirms life and regards dying as a normal process

3 Intends to neither hasten nor postpone death

4 Integrate the psychological and spiritual aspect of patient care

5 Offers a support system to help patients live as actively as possible

6 Offers a support system to help the family cope during the patient’s illness and in their own
bereavement

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7 Use a team approach to address the need of patients and their families including
bereavement the case of illness

INDICATION FOR PALLIATIVE CARE

Palliative care is offered to the patient‘s who have a serious or life- threatening illness such as

1 Cancer

2 Congestive cardiac failure

3 Chronic obstructive pulmonary diseases [COPD]

4 Stroke

5 Diabetes mellitus

6 Pneumonia

7 Kidney failure

8 Parkinson’s disease

9 Accident [unintentional injuries]

10 Intentional self- harm [suicide]

TYPES OF PALLIATIVE CARE

Types of palliative care include the following

1 Physical palliative care – physical palliative care for physical side effect result from the
disease effect such as pain, fatigue nausea and vomiting, dyspnea and insomnia might include
physical therapy or help with nutrition, sleep specialist, or pain specialist to help with the
physical site effect.

2 Social palliative care- patients might find it hard to talk with their loved ones or caregivers
about how they feel or what they are going through, or they may need a support group. A social
worker can help with these situations. For example they can

I helpthe patient plan a family meeting

II Suggest ways to organized people who want to help

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A social worker can also provide palliative care for family members and caregivers For example;
if they feel overwhelmed the social worker can help them figure what kind of help they need
and find it.

3 Emotional palliative– having cancer can make the patient feel many different emotions, such
as sadness, anxiety or anger, it can also make the patient very stressful. A support group
counselor/ psychologist can help the patient understand and cope with these feelings or
emotions.

4 Mental palliative- cancer symptoms and other life- threatening illness can affect how the
mine is works. For example if the patient is not sleeping enough, he might feels stressed and
have a hard time thinking clearly, or might be very anxious about whether the treatment is
working. Palliative care for mental health include exercise, counseling, meditation and possibly
medication to help with anxiety, depression or insomnia

5 Spiritual palliative—having cancer or other life- threatening illness can bring up many
spiritual questions the patent might be struggle to understand why he/ she get cancer or other
life-threatening disease, if the patient belong to the faithful community a spiritual leader or a
community members might be able to help support the patient spiritually

6 Financial palliative—cancer and other life—threatening disease treatment can be expensive,

this might be cause of stress and anxiety for the patient and his family members the patient
should talk to the health care team about any financial consequences. A social worker or
financial counselor can provide palliative care for these concerns, for instance they may

I help the patient and family member to talk to the health care team about the cost of care

II Explain billing and insurance or find someone who can do this

II Find programs that provide free or low- cost medicines

ETHICS IN PALLIATIVE CARE

Introduction-- physicians and nurses encounter difficulties in their practice of palliative Care. They do
need a good understanding of ethical principles and precedents. There are a wide range of medical
issues and ethical dilemmas that arise in the provision of palliative care. It is now realized that a good
understanding of medical ethics will contribute to the health professional's decision-making and day-to-
day practice of medicine for a terminally ill patient.

SIX VALUES IN MEDICAL ETHICS

The medical ethics include the following

1 Autonomy - patient has the right to choose or refuse the treatment

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2 Beneficence - a physician or a nurse should act in the best interest of the patient

3 Non-maleficence - first, do no harm

4 Justice - it concerns the distribution of health resources equitably.

5 Dignity - the patient and the persons treating the patient have the right to dignity

6 Truthfulness and honesty - the concept of informed consent and truth telling

INTEGRATING MEDICAL ETHICS INTO PALLIATIVE CARE

1 Patient has a right to know

The team of palliative care should be knowledgeable to give proactive care, understand the patient's
preferences and forgive conflicts. The process of truth telling in advanced cancer or any other terminal
illness can be a difficult task. Whenever a patient is too moribund and not in a suitable mental stage, the
families are required to give informed consent. The doctor and nurse in the palliative care team have to
build the communication with a responsible family member so that confidentiality and dignity for
patient's last stage are maintained.

2 Palliative care is a legal choice

Legal aspects and human rights give the fundamental protections that allow equal participation and
individual justice in a society. It means ‘no one ought to harm another in his life, health, liberty or
possessions’. In the 20th century, the right to healthcare is well-established, encompassing not only the
delivery of basic clinical services but also an environment that allows good health to flourish. In this
context, a terminal stage patient may often seek to end his/her life. Euthanasia is defined as ‘a
deliberate intervention undertaken with the express intention of ending life to relieve intractable
suffering’. The practice of euthanasia is legalized in some countries (The Netherlands, Belgium, some
states of USA and Australia). However, euthanasia poses an ethical dilemma in palliative care. Simply
said, ‘a doctor or nurse is not trained to deliberately end a patient's life’. It is interesting to note that the
spread of palliative care, use of analgesics, have reduced the need for euthanasia. Hence, palliative care
should be considered a better legal choice for the medical fraternity and the society.

PAIN

Definition of pain- according to the International Association for the Study of Pain, pain is an unpleasant
sensory and emotional experience arising from actual or potential tissue damage. Clinically, pain is
whatever the person says he or she is experiencing whenever he or she says it occur.

TYPES OF PAIN

There are many different types and causes of pain, which include the following

1 Acute pain

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2 Chronic pain

3 Breakthrough pain

4 Neuropathic pain

5 Somatic pain

6 Visceralpain

7 Phantompain

8 Referred pain

1 Acute pain- this starts suddenly and only lasts for a short period (ie, minutes, hours, and a couple of
days, occasionally a month or two).It is usually caused by a specific event or injury, such as a broken
bone, a car crash, a faill or other type of accidents.

2 Chronic pain- chronic pain is pain that has persisted for longer than six months and is experienced
most days. It may have originally started as acute pain, but the pain has continued long after the original
injury or event has healed or resolved. Chronic pain can range from mild to severe and is associated with
conditions such as, arthritis, back pain cancer etc

3 Breakthrough pain - breakthrough pain is a sudden, short, sharp increase in pain that occurs in people
who are already taking medications to relieve chronic pain caused by conditions such as, arthritis, cancer
fibromyalgia.

4 Neuropathic pain- this type of pain can be described as burning, shooting, tingling, radiating, or
numbness. Sometimes patients say that their pain is like a fire or an electrical jolt. This type of pain can
be due to nerve disorders; nerve involvement by a tumor pressing on cervical, brachial, or lumbosacral
plexi;

5 Somatic pain, described as achy, throbbing, or dull, somatic pain is typically well localized. Somatic
pain accompanies arthritis, bone or spine metastases, low back pain, and orthopedic procedures.

6 Visceral pain, pain described as squeezing, pressure, cramping, distention, dull, deep, and stretching is
visceral in origin. Visceral pain is manifested in patients after abdominal or thoracic surgery. It also
occurs secondary to liver metastases, bowel or venous obstructions.

7 Phantom pain- phantom pain is pain that is feels in a part of the body that is no longer there. It is
common in people who have had a limb amputated.

8 Referred pain- this is pain that feels in particular location, rather than the original location of the
events. For example, during a heart attack, pain is often felt in the neck, left shoulder, and down the
right arm, rather than the left site of the chest

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PAIN MEASUREMENT AND ASSESSMENT

1 Pain measurement -pain should be measured using an assessment tool that identifies the quantity
and/or quality of one or more of the dimensions of the patients’ experience of pain. This includes the:

 intensity of pain

 Intensity and associated anxiety and behavior.

Measuring pain enables the nurse to assess the amount of pain the patient is experiencing.

=Pain assessment tools- the range of pain measurement tools is vast, and includes both uni-dimensional
and multi-dimensional methods

IUni-dimensional pain assessment tools- these tools: measure one dimension of the pain experience,
for example, intensity, are accurate, simple, quick, easy to use and understand, and commonly used for
acute pain assessment. Have numerical rating scale and the verbal or facial descriptor scales, for
example, none, mild, moderate, severe

II Multi-dimensional pain assessment tools- these tools, provide information about the qualitative and
quantitative aspects of pain, may be useful if neuropathic pain is suspected, the tools include, McGill
pain questionnaire (short and long), Behavioral pain scales, Multidimensional pain inventory

2 Pain assessments - pain assessment should be ongoing (occurring at regular intervals), individualized,
and documented so that all involved in the patient's care understand the pain problem. Using the
WILDA approach ensures that the 5 key components to a pain assessment are incorporated into the
process.

I Words

A patient's statement, “I have pain,” is not descriptive enough to inform a health care professional about
pain type. Asking patients to describe their pain using words will guide clinicians to the appropriate
interventions for specific pain types. Patients may have more than 1 type of pain. The following
questions should be asked of patients:

 What does your pain feel like?

 Because various pain types are described using different words, what words would you use to
describe the pain you are having?

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II Intensity

The ability to quantify the intensity of pain is essential when caring for patient with acute and chronic
pain. Dalton and McNaull advocate a universal adoption of a 0 to 10 scale for clinical assessment of pain
intensity in adult patients. Using a pain scale with 0 being no pain and 10 being the worst pain
imaginable, a numerical value can be assigned to the patient's perceived intensity of pain. Asking
patients to rate their present pain, their pain after an intervention, and their pain over the past 24 hours
will enable health care providers to see if the pain is worsening or improving.

III Location

Most patients have 2 or more sites of pain. Thus, it is important to ask patients, “Where is your pain?” or
“Do you have pain in more than one area?” The pain that the patient may be referring to may be
different than the one the nurse or physician is talking about. Having the patient point to the painful
area can be more specific and help to determine interventions.

IV Duration

Breakthrough pain refers to a transitory exacerbation or flare of pain occurring in an individual who is on
a regimen of analgesics for continuous stable pain. Patients need to be asked, “Is your pain always there,
or does it come and go?” or “Do you have both chronic and breakthrough pain?” Pain descriptors,
intensity, and location are important to obtain not only on breakthrough pain but on stable (continuous)
pain as well.

V Aggravating/alleviating factors

Asking the patient to describe the factors that aggravate or alleviate the pain will help plan
interventions. A typical question might be, “What makes the pain better or worse?” Analgesics, non-
pharmacologic approaches (massage, relaxation, music or visualization therapy, heat or cold), and nerve
blocks are some interventions that may relieve the pain. Other factors (movement physical activity,
intravenous sticks or blood draws, depression, sadness, bad news) may intensify the pain.

PAIN MANAGEMENTS

Pain management strategies- pain managements strategies include- pharmacological and non-
pharmacological

Pharmacological [pain medicines]

Analgesic

 Acetaminophen – often recommended as the first medicine to relieve short-term pain.

 Aspirin – for short-term relief of fever and mild-to-moderate pain such as headache
 Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen – these medicines relieve
pain and reduce inflammation (redness and swelling).

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  Opioid medicines, such as codeine, morphine and oxycodone – these medicines are reserved for
severe or cancer pain.
 Local anesthetics (drops, sprays, creams or injections) – used when nerves can be easily
reached.

Non pharmacological

Some non-medicine options include:

 Physical therapies – such as walking, stretching, or aerobic exercises may help reduce pain

 Heat or cold application – use ice packs immediately after an injury to reduce swelling. Heat
packs are better for relieving chronic muscle or joint injuries.

 Massage – this is another physical therapy; it is better suited to soft tissue injuries and should be
avoided if the pain is in the joints. There is some evidence that suggests massage may help
manage pain, but it is not recommended as a long-term therapy.

 Relaxation and stress management techniques – including meditation and yoga

 Cognitive behavioural therapy (CBT) – this form of psychological therapy can help a person learn
to change how they think and, in turn, how people feel and behave about pain. This is a valuable
strategy for learning to self-manage chronic pain.

 Acupuncture – a component of traditional Chinese medicine. Acupuncture involves inserting

thin needles into specific points on the skin. It aims to restore balance within the body and
encourage it to heal by releasing natural pain-relieving compounds (endorphins). Some people
find that acupuncture reduces the severity of their pain and enables them to maintain function.

 Transcutaneous electrical nerve stimulation (TENS) therapy – low voltage electrical currents pass
through the skin via electrodes, prompting a pain-relieving response from the body

GRIEF LOSS AND BEREAVEMENT

Definition

Grief –grief is a powerful emotional and physical reaction to the loss of someone or something. Grief is
the normal process of reacting to the loss. Grief reactions may be felt in response to physical losses (for
example, a death) or in response to symbolic or social losses (for example, divorce or loss of a job). Grief
may be experienced as a mental, physical, social, or emotional reaction. Mental reactions can include
anger, guilt, anxiety, sadness, and despair. Physical reactions can include insomnia, anorexia, physical
problems, or illness. Social reactions can include feelings about taking care of others in the family, failure
or delayed to return work

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Loss—is losing someone or something we value, like someone’s death, losing a job, a relationship
divorce etc. Each type of loss means the person has had something taken away. As a family goes through
a cancer illness, many losses are experienced, and each triggers its own grief reaction.

Bereavement-- is the period after a loss during which grief is experienced and mourning occurs. The
time spent in a period of bereavement depends on how attached the person was to the person who
died, and how much time was spent anticipating the loss.

Mourning-- is the process by which people adapt to a loss. Mourning is also influenced by cultural
customs, rituals, and society's rules for coping with loss.

GRIEF AND THE PHASES OF A LIFE-THREATENING ILLNESS

Understanding how other people cope with a life-threatening illness may help the patient and his or her
family prepares to cope with their own illness. A life-threatening illness may be described as having the
following 4 phases:

1 Pre diagnosis phase

2 The acute phase

3 The chronic phase

4 Recovery or death

1 Pre diagnosis phase- the phase before the diagnosis of a life-threatening illness is the period of time
just before the diagnosis when a person realizes that he or she may develop a life-threatening illness
This phase is not usually a single moment, but extends throughout the period when the person has a
physical examination, including various tests, and ends when the person is told of the diagnosis.

2 The acute phase- the acute phase occurs at the time of the diagnosis when a person is forced to
understand the diagnosis and make decisions about his or her medical care.

3 The chronic phase- the chronic phase is the period of time between the diagnosis and the result of
treatment. It is the period when a patient tries to cope with the demands of life while also undergoing
treatment and coping with the side effects of treatment. In the past, the period between a cancer
diagnosis and death usually lasted only a few months, and this time was usually spent in the hospital.
Today, people can live for years after being diagnosed with cancer.

4 The recovery or death phase- In the recovery phase people cope with the mental, social, physical,
religious, and financial effects of cancer.

In the final (terminal) phase of a life-threatening illness occurs when death is likely. The focus changes
from curing the illness or prolonging life, to providing comfort and relief from pain. Religious concerns
are often the focus during this time.

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PHASES OF GRIEF

The process of bereavement may be described as having 4 phases:

1 Shock and numbness: Family members find it difficult to believe the death; they feel stunned and
numb.

2 Yearning and searching: Survivors experience separation anxiety and cannot accept the reality of the
loss. They try to find and bring back the lost person and feel ongoing frustration and disappointment
when this is not possible.

3 Disorganization and despair: Family members feel depressed and find it difficult to plan for the future.
They are easily distracted and have difficulty concentrating and focusing.

4 Reorganization- is a phase were the family member of the deceased person are re-organized
themselves in to daily activities

TREATMENT FOR GRIEF

Most of the support that people receive after a loss comes from friends and family. Nurses and Doctors
may also be a source of support, for people who experience difficulty in coping with their loss, grief
counseling or grief therapy may be necessary.

¿Grief counseling- helps mourners with normal grief reactions, work through the tasks of grieving. Grief
counseling can be provided by professionally trained people or in self-help groups where bereaved
people help other bereaved people. All of these services may be available in individual or group settings.

The goals of grief counseling include:

1 Helping the bereaved to accept the loss by helping him or her to talk about the loss

2 Helping the bereaved to identify and express feelings related to the loss (for example, anger, guilt,
anxiety, helplessness, and sadness).

3 Helping the bereaved to live without the person who died and to make decisions alone

4 Helping the bereaved to separate emotionally from the person who died and to begin new
relationships

5 Providing support and time to focus on grieving at important times such as birthdays and anniversaries

6 Describing normal grieving and the differences in grieving among individuals

7 Helping the bereaved to understand his or her methods of coping

8 Identifying coping problems the bereaved may have and making recommendations for professional
grief therapy.

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9 Providing continuous support

¿Grief therapy- is used with people who have more serious grief reactions. The goal of grief therapy is
to identify and solve problems the mourner may have in separating from the person who died. When
separation difficulties occur, they may appear as physical or behavioral problems.

Grief therapy may be available as individual or group therapy, in grief therapy, the mourner are allow to
talks about the deceased and tries to recognize whether he or she is experiencing an expected amount
of emotion about the death. Grief therapy may allow the mourner to see that anger, guilt, or other
negative or uncomfortable feelings can exist at the same time as more positive feelings about the
person who died.

In grief therapy, 6 tasks may be used to help a mourner work through grief:

1 Develop the ability to experience, express, and adjust to painful grief-related changes.

2 Find effective ways to cope with painful changes.

3 Establish a continuing relationship with the person who died.

4 Stay healthy and keep functioning.

5 Develop a healthy image of oneself and the world.

COMPLICATED GRIEF

Complicated grief reactions require more complex therapies than uncomplicated grief reactions.
Adjustment disorders (especially depression and anxious mood or disturbed emotions and behavior),
major depression, substance abuse, and even post-traumatic stress disorder are some of the common
problems of complicated bereavement. Complicated grief is identified by the extended length of time of
the symptoms, the interference caused by the symptoms, or by the intensity of the symptoms (for
example, intense suicidal thoughts or acts).

Factors that contribute to the chance that one may experience complicated grief include the
suddenness of the death, the gender of the person in mourning, and the relationship to the deceased
(for example, an intense, extremely close, or very relationship). Grief reactions that turn into major
depression should be treated with both drug and psychological therapy. One who is constantly thinks or
dreams about the person who died, and who gets scared and panics easily at any reminders of the
person who died may be suffering from post-traumatic stress disorder. Substance abuse may occur, and
can also be treated with drugs and psychological therapy.

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NURSES ROLE IN PALLIATIVE CARE

The nurse’s role in palliative care encompasses many interconnected dimension, these
dimension include the following

1 Valuing—means that the nurse has a basic belief in the inherent worth of all human beings
regardless of any particular characteristics of any one individual. Valuing allows the nurse to be
able to continue to respect and provide care to the patients even under adverse conditions.

2 Finding—means that the nurse is able to assist patients to find meaning in their situations.
This include helping patients to focus on living until death, helping them to make the best of
their situations, offering hope on their life and acknowledging death by talking death openly
about death when patients and families want them to do so.

3 Empowering—empowering involves facilitating, encouraging, defusing and giving

information. Facilitating builds individual and family strength. The nurse facilitates by involving
the patients and family in planning strategies offering suggestion, explaining options and
provides information. The nurse also recognizes limitation and helps them to works toward
more positive outcomes. Giving information pertains to the nurse‘s teaching and explaining
about medication challenge and pain and other symptoms, this strengthens the patient’s and
family‘s capacity to manage for themselves.

4 Counseling—refers to the nurse making contact with the patients and established a
therapeutic relationship. This involved introduction, explaining role, collecting baseline
information, and explaining how to contact the nurse

5 Doing for – doing for is focused on the physical care of the patients, it involved controlling
pain and symptoms making arrangement such as discharge planning and helping families to
access equipment. Team collaboration is also a component of doing for. Team collaboration
involved negotiation the system on behalf of the patient and family consoling with other team
members, sharing information, serving as liaison between various institution and programs

6 The nurse should advocate for and supporting patients in their experience of living and dying

7 The nurse should provide comprehensive, coordinated, compassionate and holistic care in the
patients and their families

8 The nurse should also offers a support to the patients in psychosocial grief and bereavement
to maximize a patient’s quality of life and death

9 The nurse should provide a compassionate and therapeutic presence to the patients and
families including support for grief and bereavement throughout the dying process

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