NURS 5052-Palliative Care in Nursing Essay Paper

NURS 5052-Palliative Care in Nursing Essay Paper

NURS 5052-Palliative Care in Nursing Essay Paper

Attitudes and principles required for successful palliative care
A caring attitude
involves sensitivity, empathy and compassion, and demonstrates concern for the individual
there is concern for all aspects of a patient’s suffering, not just the medical, nursing or social work problems
there is a non-judgmental approach in which personality, intellect, ethnic origin, religious belief or any other individual factors do not prejudice the delivery of optimal care

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Consideration of individuality
the practice of categorizing patients by their underlying disease, based on the similarity of the medical problems encountered, fails to recognize the psychosocial features and problems that make every patient a unique individual
these unique characteristics can greatly influence suffering and need to be taken into account when planning the palliative care for individual patients
Cultural considerations
ethnic, racial, religious and other cultural factors may have a profound effect on a patient’s suffering
cultural differences are to be respected and treatment planned in a culturally sensitive manner
Consent  NURS 5052-Palliative Care in Nursing Essay Paper
the consent of a patient, or those to whom the responsibility is delegated, is necessary before any treatment is given or withdrawn
the majority of patients want shared decision making although physicians tend to underestimate this
having assessed what treatment is appropriate or inappropriate, this is discussed with the patient
in most instances, adequately informed patients will accept the recommendations made if they have been explained in non-medical jargon.
Choice of site of care
the patient and family need to be included in any discussion about the site of care
patients with a terminal illness should be managed at home whenever possible though in the developed world few do so, most dying in hospitals
good communication between all the health care professionals involved in a patient’s care is essential and is fundamental to many aspects of palliative care. There is strong evidence that such communications are less than optimal.
good communication with patients and families is also essential
Clinical context: Appropriate treatment
all palliative treatment should be appropriate to the stage of the patient’s disease and the prognosis
over-enthusiastic investigations, therapy that is inappropriate and patient neglect are equally deplorable
Palliative care has been accused of the medicalisation of death, and care must be taken to balance technical interventions with a humanistic orientation to dying patients. This is where a team approach is essential, each member of the team being able to see different aspects of the patient’s suffering, personality and needs.
the prescription of appropriate treatment is particularly important in palliative care because of the unnecessary additional suffering that may be caused by inappropriately active therapy or by lack of treatment

when palliative care includes active therapy for the underlying disease, limits should be observed, appropriate to the patient’s condition and prognosis and expressed wishes which may be different from those of the clinicians
treatment known to be futile, given because ‘you have to do something’, is unethical
where only symptomatic and supportive palliative measures are employed, all efforts are directed at the relief of suffering and the quality of life, and not necessarily at the prolongation of life
Comprehensive inter-professional care
the provision of total or comprehensive care for all aspects of a patient’s suffering requires an interdisciplinary team
Care excellence
palliative care should deliver the best possible medical, nursing and allied health care that is available and appropriate
Consistent medical care
consistent medical management requires that an overall plan of care be established, and regularly reviewed, for each patient
this will reduce the likelihood of sudden or unexpected alterations, which can be distressing for the patient and family. It may lessen the chance of crises or medical emergencies which can frighten the patient and relatives.
Coordinated care
involves the effective organization of the work of the members of the inter professional team, to provide maximal support and care to the patient and family
care planning meetings, to which all members of the team can contribute, and at which the views of the patient and the family are presented, are essential to develop a plan of care for each individual patient
Continuity of care  NURS 5052-Palliative Care in Nursing Essay Paper
the provision of continuous symptomatic and supportive care from the time the patient is first referred until death is basic to the aims of palliative care
problems most frequently arise when patients are moved from one place of care to another and ensuring continuity of all aspects of care is most important (A useful means of delivering this is the Liverpool Care Plan. See the Recommended Reading List)
Crisis prevention (see Consistent Medical Care)
good palliative care involves careful planning to prevent the physical and emotional crises that occur with progressive disease
many of the clinical problems can be anticipated and some can be prevented by appropriate management
patients and their families should be forewarned of likely problems, and contingency plans made to minimize physical and emotional distress
Caregiver support
the relatives of patients with advanced disease are subject to considerable emotional and physical distress, especially if the patient is being managed at home
particular attention must be paid to their needs as the success or failure of palliative care may depend on the caregivers’ ability to cope
Palliative care, whether at home or in a hospital, often succeeds or fails depending on the care and support provided for the caring relatives
Continued reassessment
is a necessity for all patients with advanced disease for whom increasing and new clinical problems are to be expected
this applies as much to psychosocial issues as it does to pain and other physical symptoms
Advance Care Planning
See Advance Care Planning

Palliative care refers to the optimization of quality of life for both the patients with serious illness and their families using special measures to anticipate, treat, and prevent suffering. This care encompasses the continuum of illnesses including physical, psychosocial, emotional, and spiritual needs of seriously ill patients.[6] The Institute of Medicine notes a responsibility to ensure that end of life care is compassionate, affordable, sustainable, and of the best quality possible.[6] Failure to provide holistic care limits the effectiveness of palliative care and can contribute to physical, social, spiritual, and/or emotional suffering.[3,7,8]

availability of palliative care services.

Resources: Programs and Services

What is the nature and course of the illness?NURS 5052-Palliative Care in Nursing Essay Paper

The path of a progressive illness, such as an incurable cancer, can often be anticipated. It’s usually clear when it’s time to focus mainly on comfort. At this point a person’s condition appears to be declining steadily and the ability to function independently becomes a challenge. With a chronic condition, or when someone has several medical problems but no specific terminal diagnosis, it’s harder to recognize terminal stages. Setbacks or complications can happen throughout the illness and may be treatable and reversible. In early stages, palliative measures such as pain control may be only a small part of overall care. As the illness progresses, some previously reversible problems become irreversible, or the burden of treatment outweighs its benefits. Then the focus of care turns increasingly toward comfort. For example, someone with lung disease may have had pneumonia previously, and had treatment in hospital to overcome the infection itself. With a palliative approach, symptoms such as shortness of breath are treated, while treatment for the pneumonia itself may or may not be given. The change of focus can come from the patient, or it can be determined by the illness. In such situations, it’s best to integrate palliative care into overall health care, rather than to choose a specific starting point.

Increasingly, palliative care advocates promote a combined approach to care for patients with life-threatening illnesses. This means that palliative care provides comfort even while a disease is being treated. Advocates believe this approach helps people make more informed decisions about their care. The World Health Organization (WHO) defines palliative care as “applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life.”

A person doesn’t have to be involved in a formal program to receive palliative care. In some areas, people can get palliative care from their health care team, and become part of a formal palliative care program near the end of life. The criteria for palliative care services can vary. The point is that just because someone isn’t a patient in a designated palliative care unit or part of a palliative care program doesn’t mean that palliative care isn’t or can’t be provided.NURS 5052-Palliative Care in Nursing Essay Paper

Palliative care is treatment, care and support for people with a life-limiting illness, and their family and friends. It’s sometimes called ‘supportive care’.

The aim of palliative care is to help you to have a good quality of life – this includes being as well and active as possible in the time you have left. It can involve:

managing physical symptoms such as pain
emotional, spiritual and psychological support
social care, including help with things like washing, dressing or eating
support for your family and friends.
A life-limiting illness is an illness that can’t be cured and that you’re likely to die from. You might hear this type of illness called ‘life-threatening’ or ‘terminal’. People might also use the terms ‘progressive’ (gets worse over time) or ‘advanced’ (is at a serious stage) to describe these illnesses. Examples of life-limiting illnesses include advanced cancer, motor neuron disease (MND) and dementia.

You can receive palliative care at any stage in your illness. Having palliative care doesn’t necessarily mean that you’re likely to die soon – some people receive palliative care for years. You can also have palliative care alongside treatments, therapies and medicines aimed at controlling your illness, such as chemotherapy or radiotherapy.

However, palliative care does include caring for people who are nearing the end of life – this is sometimes called end of life care.

What is end of life care?
End of life care involves treatment, care and support for people who are nearing the end of their life. It’s an important part of palliative care.NURS 5052-Palliative Care in Nursing Essay Paper

It’s for people who are thought to be in the last year of life, but this timeframe can be difficult to predict. Some people might only receive end of life care in their last weeks or days.

End of life care aims to help you to live as comfortably as possible in the time you have left. It involves managing physical symptoms and getting emotional support for you and your family and friends. You might need more of this type of care towards the end of your life.

End of life care also involves talking to you and your family and friends about what to expect towards the end of your life. The people looking after you will talk to you about your needs and wishes, and make sure they consider what you want in the care they provide.

It can also involve support with practical things like making a Will or getting financial support.

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How do I get palliative or end of life care?
Speak to your GP or another healthcare professional about how palliative or end of life care might help you and how you can access it.

If you’re a family member or friend of the person who is ill, you may be able to access support for yourself. If the person who is ill is receiving care from a hospice or other local service, you may also be able to get support from them. Even if the person who’s ill doesn’t want to have palliative or end of life care, you can still get support. To find out what’s available, speak to your GP, the person’s GP, or another health or social care professional.

Who provides palliative care?
The professionals involved in your care will depend on what sort of care and support you need. Palliative care can be provided in different places including in your home, in hospital, in a care home or nursing home, and in a hospice.

General care professionals
General health and social care professionals give day-to-day palliative care to people as part of their roles. You might see these people regularly as part of your care:

your GP
district or community nurses
social workers
care workers
spiritual care professionals.
These professionals should be involved as early as possible after you’ve been diagnosed. They will assess your needs and wishes, and those of your family and friends. They might refer you to specialist care if you need it.NURS 5052-Palliative Care in Nursing Essay Paper

Specialist care professionals
Specialist palliative care professionals are experts in providing palliative care and will have training and experience in this area. They might be involved in managing more complex care problems. Specialists usually work in teams to provide joined-up care and you might see one or more specialists if you’re referred to them.

Specialist teams include:

palliative care doctors
nurse specialists
specialist health professionals, such as physiotherapists, occupational therapists, dieticians and social workers.
Specialist palliative care services may be provided by the NHS (Health and Social Care in Northern Ireland), local councils or voluntary organisations.

The palliative care or hospice nurse provides compassionate care, typically for the terminally ill and those who have little hope of meaningful recovery. This type of nurse has a special interest in creating an environment of pain relief and comfort, and works to promote these aspects of care through the cooperation of friends and/or family. The goals of care in these situations then become relieving suffering through a thorough assessment of the needs of the patient and family on a psychosocial, physical, and spiritual level. This nurse coordinates with other providers to meet the needs of the family and patient. Once death has occurred, the palliative care nurse offers bereavement support and assists in helping the family make final decisions. They also work to prepare patients and families for a peaceful and comfortable end of life transition.

Palliative care teams specialize in treating people suffering from the symptoms and stress of serious illnesses such as cancer, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), kidney disease, Alzheimer’s, Parkinson’s, Amyotrophic Lateral Sclerosis (ALS) and many more. This type of care treats pain, depression, shortness of breath, fatigue, constipation, nausea, loss of appetite, difficulty sleeping, anxiety and any other symptoms that may be causing distress.NURS 5052-Palliative Care in Nursing Essay Paper

The team will help you gain the strength to carry on with daily life. In short, palliative care will help improve your quality of life.

Close Communication
The palliative care team will also spend time talking to you and listening. They will make sure you understand all of your treatment options and choices. By deeply exploring your personal goals, the palliative care team will help you match those goals to your treatment options. They will also make sure that all of your doctors are coordinated and know and understand what you want. This gives you more control over your care and will improve your quality of life.

A Partnership of Palliative Care Team, Patient and Family
Palliative care teams are specialists who work together with you, your family and your other doctors. They provide an extra layer of support when you need it most. In addition to treating your symptoms and stress and supporting you and your family, the palliative care team coordinates and communicates with all of your doctors so that everyone is on the same page. They support you every step of the way.NURS 5052-Palliative Care in Nursing Essay Paper

Palliative care can be provided concurrently with curative measures.[6] Concurrent care is different than a traditional hospice model, where curative therapy, or life extending measures such as palliative chemotherapy, generally have ceased. The concurrent model of palliative care may be, particularly important in lower and lower middle-income countries where access to curative care is limited. Like geriatrics and hospice, palliative care generally will use a multidisciplinary team that may be made up of nursing, social work, spiritual care, and medicine to meet the multifaceted needs of patients with serious illness, or who are at the end of life.[4]

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Distinguishing Different Roles of Nurses
The evidence supports that nurses work in a variety of roles. These include as being members of a multidisciplinary consultation team, as individual practitioners in targeted pain and symptom management, or as case managers.[4,6,9,10]

Registered nurses
A registered nurses (RN) educates, give advice, and provides emotional support to patients and their family members. Other duties include physical assessments, health histories, health promotion, counseling, education, medication and treatment administration, wound care, and numerous other personalized interventions. RN’s consult and collaborate with a multidisciplinary team and contribute to the plan of care. RN can supervise care delivery by other medical personnel like nurse aides as well as conduct research in support of improved practice and patient outcomes.

Advanced practice registered nurses
Advanced Practice RN (APRN’s) can provide excellent service to those suffering from serious life-limiting illnesses. The educational preparation of APRNs allows a “greater depth and breadth of knowledge and ability to synthesize complex data to develop, implement, and coordinate comprehensive, holistic patient-centered plans of care with goals of maximizing health, quality of life, and functional capacity.”[11] Depending on state licensure, APRN’s may have the ability to practice, furnish medications, and bill independently.NURS 5052-Palliative Care in Nursing Essay Paper

Palliative Care Nursing
Palliative care nursing involves the assessment, diagnosis, and treatment of human responses to actual or potentially life-limiting illness and necessitates a dynamic, caring relationship with the patient and family to reduce suffering. Therefore, palliative nursing is a subspecialty of nursing practice that continues to evolve as the art and science of nursing, and palliative care evolves.[12]

Palliative care nurses work in varied settings including patients’ homes, residential hospices, clinics, long-term and skilled care facilities, and acute in-patient facilities.[6] Palliative care should adapt accordingly to meet the physical, emotional, social, and spiritual needs of the patient and their families.[11] Palliative care nurses may be hospice nurses, an advanced practice nurse (APN) with a master’s degree or higher, or an acute care RN with additional training. Currently, no standard education for a “palliative care” nurse exists, commitment to caring for a patient with a serious illness is a must. A palliative care nurse could have a wide variety of education, training, and clinical experience.NURS 5052-Palliative Care in Nursing Essay Paper

Special skills of palliative nursing
Palliative care nurses have adjusted their frame of mind from one which revolves around specific tasks such as vital signs, treatments, and interventions, to one of comfort, symptom management, and support.[13] Many nurses involved in palliative care face the challenge of combining the art of caring and the science of medicine into a cohesive model that reflects compassionate, individualized care regardless of the environment.[7] Palliative care nursing demands intense critical thinking, heightened levels of mental functioning, and the ability to utilize complex palliative nursing skills.[14] Palliative care nurses are repeatedly confronted with patients and families who encounter serious end-of-life illness and death.[14,15] These situations are further complicated by complex social situations, difficult diagnoses, challenging symptom management, and challenging communication concerning patient death and grief.[12,13,14,15,16]

The ability to effectively communicate with patients and families is an important skill for any palliative care nurse. Palliative care nurses must have the ability to explain complex information, as patients are often seeking clarity on disease progression, medications, and plan of care. Palliative care nurses must be able to communicate this information to both the patient and family. It is within the nursing scope of practice to thoroughly explain and educate patients and families on symptoms and treatments through the end of life, including medication regimens.

Merriam-Webster[17] defines compassion as “sympathetic consciousness of others’ distress together with a desire to alleviate it.” Compassion for self can help to prevent burnout, while compassion for patients and families helps to establish a supportive, trusting relationship as symptoms change or worsen or as death approaches.NURS 5052-Palliative Care in Nursing Essay Paper

Human vulnerability
Although the time of on-going disease progression and at the end of life can be distressful, it can also be a time of togetherness for patients and their loved ones. The palliative care nurse has a window into some of the most intimate moments in a person’s life. Patients and families tend to remember the nursing response to their needs, which, through communication, presence, symptom management, and other work within their multidisciplinary team, allows nurses to leave a legacy through care.

Building on Current Roles of Nurses
Primary or generalist palliative care
The generalist nurse has the necessary skills and knowledge to care for dying patients, as well as those with chronic, serious illness; this includes a basic ability to provide relief from pain in addition to symptom assessment and management.

Specialist palliative care
The palliative care RN and APRN specialist has expert knowledge in palliative care, including the pathophysiology of diseases, advanced pain and symptom assessment and management, counseling and communication skills, and advanced care planning. They also have advanced knowledge about caring for individuals with serious, life-threatening illness, as well as those who are imminently dying.[18]

Palliative Oncology Nursing
Although palliative care is useful for a variety of conditions, and much of the high-quality research completed is not unique to medical conditions, the evidence base is strongest for cancer.[4] Early palliative care is particularly beneficial with two recent randomized controlled trials showing that palliative care improves the quality of life of patients with lung cancer and also when they are receiving bone marrow transplant.[8,19,20] Oncology nurses in palliative care will bridge the gap of continuity as they deliver physical and psychosocial care throughout treatment and beyond. Oncology nurses are in a unique position to advocate and address many ethical and legal aspects of care as well as ensure the patient receives palliative care as the patient progresses through illness from curative to palliative treatments.NURS 5052-Palliative Care in Nursing Essay Paper

Methods to Upskill the Current Nursing Workforce
In March of 2017 the American Nurses Association and Hospice and Palliative Nurses Association (HPNA) presented a call to action for nurses to lead and transform palliative care. One of the nursing recommendations included the adoption of End of Life Nursing Education Consortium (ELNEC) curricula (Core, Geriatric, Critical Care, Pediatric, APRN and Online for Undergraduate Nursing Students) as the standard for primary palliative nursing education. ELNEC has also provided education in 90 countries including Japan, Korea, China, Eastern Europe, as well as Kenya. ELNEC has been translated into Spanish, Japanese, Korean, Chinese, Russian, Romanian, Albanian, and German.[8]

There are many educational offerings available for palliative care nurses to improve their knowledge base in palliative and end of life care. Other offerings range from 1 day, simple classes to long, and certifications programs. Certification in Palliative care is offered by the HPNA for Nurse Aides, licensed practical nurse/licensed vocational nurse, RN and APN levels. Colleges offer online and classroom options for certificate programs in palliative nursing. Alternative education including fellowship programs, leadership programs, conferences, and ELNEC courses are also offered.

Of note, for international providers, Stanford offers an online resource, Palliative Care Always (, which is offered annually and has been used by thousands of participants to gain a fundamental knowledge base about the practice of palliative care.NURS 5052-Palliative Care in Nursing Essay Paper

Sole Practitioners
The highest quality evidence for nurses as independent practitioners has been described in the Education Nurture Advise before Life Ends (ENABLE) studies. The ENABLE intervention included a series of 4 weekly sessions followed by at least monthly follow-up with patients and caregivers until death. Sessions focused broadly on the quality of life relevant issues, communication, and involved pro-active assessment and prevention. ENABLE II showed benefits in quality of life and depression in patients, and the intervention did not directly benefit caregivers. ENABLE III evaluated early versus later nurse intervention; earlier intervention was associated with improved mortality with 63% of patients getting early compared to 48% of patients receiving late palliative care surviving to 1 year.[5,9,10]

Transitions in Health Care
The APRN provides on-going assessment and intervention so he/she can educate and guide the patient and family on a realistic understanding of the disease processes. Not only does this build a trusting relationship with the patient and family but also promotes safe transitions and autonomy, as it allows the patient and family to be an active part of developing a plan of care.[3,7,11]

Conventionally, medical care has focused on cure-oriented care in an acute care setting based on episodic illnesses. However, people have begun to live longer with increasingly complex chronic illness making this type of care insufficient. The service areas should communicate, coordinate, and work together to care for the person as they promote the goals and wishes of the person.

Care transitions are not only from the hospital to home. Transitions also exist in the type of care which is being delivered to the patient. Points of transition in care include a mix of palliative, cure-oriented or life-prolonging care, a transition to palliative care only, or change to the end of life care.NURS 5052-Palliative Care in Nursing Essay Paper

For patients with longstanding serious chronic illness prognostic uncertainty makes the transition to alternate levels of care difficult. With these multiple transitions nurses must be able to work amidst the transitions and in a multitude of settings.

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Nurses Supporting Community Practice Models
People facing serious and end of life illness prefer to be in their own home and community. Palliative care in the community setting (defined here as care outside of the hospital) therefore focuses on providing palliative care through established delivery systems, such as home care and hospice, as well as collaborative partnerships with service agencies and individual clinicians. The point is to maintain a person’s life at home or place of residence by maximizing the quality of life, optimizing function and providing care that supports their goals and preferences. In community models, nurses may play a crucial role in coordinating, delivering, and overseeing care in the home and community by working indirectly with lay community health workers.

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. Palliative care:

provides relief from pain and other distressing symptoms;
affirms life and regards dying as a normal process;
intends neither to hasten or postpone death;
integrates the psychological and spiritual aspects of patient care;
offers a support system to help patients live as actively as possible until death;
offers a support system to help the family cope during the patients illness and in their own bereavement;
uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated;
will enhance quality of life, and may also positively influence the course of illness;
is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications.
WHO Definition of Palliative Care for Children NURS 5052-Palliative Care in Nursing Essay Paper

Palliative care for children represents a special, albeit closely related field to adult palliative care. WHO’s definition of palliative care appropriate for children and their families is as follows; the principles apply to other paediatric chronic disorders (WHO; 1998a):

Palliative care for children is the active total care of the child’s body, mind and spirit, and also involves giving support to the family.
It begins when illness is diagnosed, and continues regardless of whether or not a child receives treatment directed at the disease.
Health providers must evaluate and alleviate a child’s physical, psychological, and social distress.
Effective palliative care requires a broad multidisciplinary approach that includes the family and makes use of available community resources; it can be successfully implemented even if resources are limited.
It can be provided in tertiary care facilities, in community health centres and even in children’s homes.

Communication with Patients
Important and potentially difficult discussions are frequently necessary with palliative care patients who have active, progressive, far-advanced disease, regarding

breaking bad news
further treatment directed at the underlying disease
communicating prognoses
admission to a palliative care program
artificial nutrition
artificial hydration
medications such as antibiotics
do-not-resuscitate orders
Decisions must be individualised for each patient and should be made in discussion with the patient and family. The following guide is to help you plan for and hold such discussions.Before the Discussion
Ask yourself these questions:
Would you be surprised if this patient died of their disease within 6 months?
Bear in mind that even doctors with long experience tend to over-estimate prognosis.
This may provide a better guide for decision-making, as attempting to prognosticate may be difficult and inaccurate. Alternatively, assess how much the patient’s condition has deteriorated in the last month or six weeks, using observations by the team and objective measures such as x-rays and biochemistry. Observations by close relatives often help.
What specific therapies are available to treat the underlying disease?NURS 5052-Palliative Care in Nursing Essay Paper

What are the percentage chances of significant clinical improvement? __%
Does that take into account the patient’s age and any other diseases/co-morbidities?
How long would the improvement last? Days, weeks or months?
What are the percentage chances of serious adverse effects? __%
Does that take into account the patient’s age and any other diseases/co-morbidities?
On balance, do the potential benefits outweigh the potential burdens?
About the Patient and Family

What is their understanding of the state of the disease and the prognosis?
Do they understand the goal of any treatments to be discussed (i.e. palliative, not curative)?
Do they understand the potential benefits and burdens of the treatment options?
What are their expectations? What are they hoping for?
What do you think their preferences are?
The Discussion
Appropriate setting

Discussions should be held in person and not by telephone, except when face-to-face meetings are not possible for geographic reasons
Privacy, prevent interruptions (leave your pager/mobile with someone else)
Sitting down where the patient / relative can see your face (not standing over the patient’s bed)
Allow enough time
The patient has at least one family member or friend for support
Introduce the discussion

e.g. We need to talk about your current problems and our goals for your care
Find out what they understand

e.g. “Tell me in your own words what you understand about your illness at the moment. Don’t worry if you cannot remember medical terms.”
Find out what they expect

e.g. “Tell me what you see happening with this illness in the future”
e.g. “Tell me what things are important for you, perhaps things you’ve not mentioned before “
e.g. “Tell me what you don’t like about what we’ve done or said – we won’t be upset or angry, I promise you.”
Provide medical information, if necessary

in a caring and sympathetic way, not abruptly or bluntly
in a way they can understand
keep asking them to explain back to you what you have just tried to explain to them
clearly (avoid euphemisms and medical jargon)
what treatments can be offered
the possible benefits and adverse effects of any treatments
as much or as little information as they want (if unsure, ask them how much they want. “ Am I telling you too much at one time to take in? Would you like me to go over any of that again but explaining it differently?)
use trained interpreters. (Strictly what you need is a translator, not someone who interprets what is being said and as a consequence gets it wrong)
Discuss realistic possibilities in the context of their view of the present and future

Discussing further active treatment for the underlying disease NURS 5052-Palliative Care in Nursing Essay Paper

truthful discussion of what therapy is or is not available
the benefits and burdens of any therapies
Never say ‘there is nothing more that can be done’
patients interpret this to mean no treatment for anything
it is never true
patients and families will feel abandoned
patients may be told there is no further therapy for the underlying disease, but the provision of continuing care and symptom control should be stressed
if further active therapy for the underlying disease is not appropriate, emphasise the positive aspects of symptomatic and supportive palliative care. Stress to the patient that he or she matters and is not a burden.
Discussing prognoses

Explain the uncertainty in estimating an individual patient’s prognosis
Avoid precise prognostication
Give a realistic time range
Provide realistic hope—helping them to achieve what is important for them
Recommend that family relationships and worldly affairs be attended to
Be prepared to answer questions about the process of dying. Remember that most people are more afraid of dying that of death itself.
Provide on-going support and counselling
Reassure about continuity of care
Discussing admission to palliative care units / services

discuss palliative care in the context of how it can help them achieve their goals
e.g. You have told me you would like to…………..Palliative care may be able to help you achieve what you want
emphasize the positive aspects of palliative care
e.g. living as well as possible, for as long as possible; not ‘giving up’
Discussing appropriate medical care

Issues related to the appropriateness of artificial hydration and nutrition, antibiotics and other medications are dealt with in the section on Ethical Issues
Explain the possible benefits and burdens (or futility) of any intervention. Patients appreciate such honesty
If agreement is not reached, the intervention can be tried for a specified time
Discussing ‘Do-not-resuscitate’ orders (DNR)NURS 5052-Palliative Care in Nursing Essay Paper

Introduce the discussion
e.g. We need to discuss something we discuss with all patients admitted to the hospital
Find out what the patient understands
e.g. What do you understand about your current medical problems?
Find out what the patient expects, what their goals are
e.g. What do you see happening in the future?
Discuss a DNR order in the context of the patient’s view of their future
e.g. You have told me you would like……so CPR would not seem appropriate if you died
If necessary, discuss:
futility of CPR (chances of surviving to discharge)
indignity of CPR
being on a respirator in ICU and unable to communicate
Respond sympathetically to emotional reactions
Reassure patient that all other medical care will continue. Being left to suffer is what moist patients dread, not death itself.
If a patient clearly understands that they are dying and that the only care that they will receive is directed to their comfort, it may not be necessary to discuss DNR orders. If this is the case, it must be recorded in case-notes.
Respond sympathetically to emotional reactions
Agree on a plan, with provision that it can be modified if circumstances change

Offer to document the plan, including appointing an agent and regarding resuscitation
Remember, death is the natural end to life and is not a failure of medicine or any clinicians,

Advance Care Planning
Advance care planning is a means for patients to record their end-of-life values and preferences, including their wishes regarding future treatments (or avoidance of them).
Advance care planning involves a number of processes:NURS 5052-Palliative Care in Nursing Essay Paper

informing the patient
eliciting preferences
identifying a surrogate decision maker to act if the patient is no longer able to make decisions about their own care
it involves discussions with family members, or at least with the person who is to be the surrogate decision maker
The principle of advance care planning is not new

it is common for patients aware of approaching death to discuss with their carers how they wish to be treated
however, these wishes have not always been respected, especially
if the patient is urgently taken to hospital
if there is disagreement amongst family members about what is appropriate treatment.
The “Respecting Choices” program developed in Wisconsin is an example of advance care planning:

employs trained personnel to facilitate the discussions and record the outcomes, which are in writing and signed, and kept in the front of the patient’s file
the surrogate decision maker is involved in the discussions so that they have explicit knowledge of the patient’s wishes; otherwise they may feel burdened by the responsibility
there is less conflict between patients and their families if advance care planning has been discussed.
Models of Care
there is no one right or wrong model for the provision of palliative care
the best model is determined by local needs and resources, in consultation with the local health care providers and authorities NURS 5052-Palliative Care in Nursing Essay Paper


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