Course Book : #103 - End of Life - Palliative Care

End of Life / Palliative Care

Meets Florida Requirement

2 contact hours

Course # 103

Author: Monica Oram, RN, BSN


This course is intended for the reader to be able to achieve the following objectives:

    Understand the difference between palliative care and curative treatment.

    Understand Advance directives, and living wills.

    Use of pain management and comfort techniques

    Emotional and psycho-social and spiritual needs of terminally ill patients and their families.

5. Understand what is involved for palliative care.

6. Appropriate use of medications in terminally ill

7. Methods of communication with families regarding anticipated grief and

Loss of loved one.


What is Palliative care?


Palliative care is when the focus of treatment shifts from cure to comfort. Patients who are terminally ill and their families may consider this choice when providing comfort would be of greatest benefit. Palliative care helps ensure this time can be lived as fully as possible, in peace- physically and emotionally. Searching and fighting for a cure becomes less of a benefit as compared to maintaining a quality of life through comfort measures. Due to some medical treatments taking too long and too much of a toll on terminally ill patients, it is becoming more of a choice to seek out palliative care. Often times curative treatments are far to aggressive for the terminally ill, and the side effects associated with curative treatment modalities are far more than the patient can tolerate. Therefore, palliative care is a decision often made while receiving hospital care for the terminally ill. Palliative care is a positive choice being made by both the patient and the families, as it is a choice for quality of life.

 

 

 

What is involved for palliative care?


Palliative care involves caring for the whole patient- not just the illness. This means that healthcare workers need to be more focused on the individual and be aware of pain management concerns, helping to ease symptoms of illness, and caring for conditions that cause discomfort.

 

The patients emotional and spiritual well being is just as important as the patient’s physical comfort. As the patient’s medical and physical condition begins to change, there is often more focus on palliative care.


Pain control is a big focus of palliative care. ( More on pain management to follow) Medical measures to help reduce pain can include the use of pain medications, radiation to shrink tumors, surgery to remove growths and masses, nerve blocks to deaden the pain.


Palliative care involves making a pain management plan. The patient has the right to adequate pain control. The patient should feel comfortable enough to be able to discuss needs and concerns with those who are involved in his/her care. Healthcare professionals have the obligation to make sure the patient is comfortable and not be judgmental by labeling the patient as a “complainer”.


Palliative care can and should also provide comfort in other areas than just pain management. For instance, the patient should be comfortable in regards to their breathing ability. They may require bronchodilators, nebulizer treatments, or the use of oxygen to facilitate better respiratory status. They may need to be assessed and monitored for the need of diuretics as well. Some may need the benefit of anti-anxiety medications. Increased anxiety will cause increase in difficulty breathing. In addition, the healthcare professional should be mindful to the need for anti-emetics/anti -nausea medications. The focus is on the comfort of the patient.


Palliative care can also focus on the need for antibiotics for infections, and IV therapy as appropriate. Remember, choosing comfort over cure does not mean less care. It means more care for conditions that affect the patient’s physical comfort.


Part of Palliative care is offering emotional support. Some suggestions would be to:

    Offer and arrange for counselors, volunteers, involvement with community support groups and community resources.

    Help make it possible for families to spend quality time with their loved one

    Find ways for the patient to share feelings, thoughts, and ideas

    Help make it possible for the patient to continue to enjoy activities and interactions as much as possible.


Healthcare professionals should be mindful to the patient’s concerns regarding worry and anxiety. The use of medications may be appropriate, but there are other methods that could be implemented.

Such as :

    allow the patient to discuss his fears and concerns

    Guide the patient through relaxation exercises to help calm him down

    Answer questions and concerns regarding treatment and comfort measures


Spiritual support should be an important focus in palliative care and treatment. Offer clergy or a religious advisor to spend time with the patient. This can be useful, valuable insight for the patient, as well as a good way to relief fear and anxiety.


Making Choices About Palliative Care


When it comes to patient choices in regards to palliative care, the patient essentially has two choices:

    The patient must decide if they believe in fighting the course of the illness, no matter what the cost- even if a cure is not likely.

    The patient must decide if they believe that quality of life is most important, right up to the final moments of life.

 

The patient who is in favor of choice one, wanting to fight for cure, even if a cure is not likely is probably not one who is ready to accept palliative care measures. They have more of a focus on medical treatment of the condition.

 

Those who are in favor of quality of life, and supportive care measures are more favorable for palliative care modalities.


Sometimes a patient may be mixed, with deciding between the two choices. In this case the patient will then need to decide how to best balance medical treatment and palliative care.


Some of the options available for palliative care include:

    Home Health Care

    Hospice

    Be as pain free as possible

    Be as alert as possible

    Maintain as much independence and cognition as possible

    Be free of artificial means of survival ( Tube feeding, Ventilators, Ect)

    May choose to be a Do Not Resuscitate


When a patient/family is faced with the choice of palliative care measures it is important to consider the following:

    Does pain threaten to make end of life less fulfilling?

    Will a change in treatment make it more possible for the patient to do things he/she enjoys?

    Will this allow quality time to spend the last days with family, and to get affairs in order?

    Will there be support of healthcare and family to manage pain issues, anxiety, or any other discomforts?

Insight On Advance Directives


One important issue in regards to palliative care and end of life issues involves the implementation of advance directives. Advance directives help ensure the patient’s wishes are followed when they become unable to speak, and/or make choices on their own.


Two specific types of advance directives include:

    Durable power of attorney

    Living will

 


A durable power of attorney gives a person who is designated by the patient, the right to make choices and healthcare decisions on behalf of the patient when they are unable to do so.

A living will is created while the patient is alive, and therefore this is why it is called a living will. Simply put, a living will outlines the kinds of care the patient wishes to receive, and what they do not want in certain situations.


State Laws allow patient’s to be able to make their own choices. Laws vary from state to state, but they still have the ability to make healthcare decisions and choices.


Focus on Pain Management


Pain management is a very important part of palliative care. Pain is defined as a complex subjective sensation reflecting real or potential tissue damage and the response to it. Pain can be described as acute or chronic, somatogenic or psychogenic. Recurrent acute pain, such as with sickle cell crisis, and continuous pain is an unending pain with out remission or relief.

Acute pain only lasts a short time. (less than a month) It is a protective mechanism that warns about potential bodily injury and problems.

Chronic pain is pain that lasts more than a month after occurrence of an acute tissue injury or physical medical condition. Pain is considered to be chronic if it persists more than three months, or is expected to continue to get worse or progress. Chronic pain serves no biological warning or protective purpose. Chronic pain is often accompanied by depression, lack of sleep, and limited mobility. Other complications can include constipation, decreased appetite, and loss of taste. ( to name just a few)

Somatogenic pain is organic in nature and is caused by organic patho-physiology, meaning it is pain originating from within the body.

Psychogenic pain occurs in the absence of any organic pathology that can not explain the presence or extent of the pain. It is said to be a result of a psycho-somatic etiology for cause of pain.


In contrast, Pain management is defined as the systematic study of clinical and basic science and its application for the reduction of pain and suffering. The blending of tools, techniques, and principles taken from the discreet healing art disciplines and reformulates pain to be viewed from a holistic approach for reduction of pain and suffering. Holistic approach to pain management is focused on the whole patient, mind, body and soul.


One of the primary goals of Healthcare professionals is to provide relief from needless suffering and pain that affects so many of our acute, chronic, and terminally ill patients, and diminishes their ability to enjoy optimal quality of life.


Assessing Pain Management


Methods to assess pain should begin with a base line assessment.

    This assessment should include an understanding of how the patient describes his pain. ( dull, ache, sharp, ect.)

    Also assess for other methods that the patient or family has sought out as a treatment modality to help with pain control.

    The healthcare professional would want to also assess the patient’s cognitive ability by determining mental status and orientation.

    Assess pain level by using the scale of 1- 10.( With one being minimal, to ten being the worse pain imaginable)

    It would be helpful to assess the patient/family beliefs and attitudes related to pain, and treatment modalities.

    Take in to consideration the history of past failures or successes and/or adverse side effects experienced with different pain management treatments, including analgesics.

    Determine any barriers that could lead to the patient not being able to report pain, such as fears, ethnical origin, culture, diminished cognition, or inability to speak.

    Assess for history of any chronic disorders that could contribute to or cause pain.

    Assess for anxiety and depression, and ways in which the individual has coped with pain in the past.

Part of doing an adequate pain assessment includes reassessment. As part of reassessment, the healthcare professional should assess and document the pain in terms of duration, characteristics, location, intensity, and frequency. Also note the time, pain rating on the pain scale of 1-10, and any use of pain medication followed by the effectiveness of the medication, if given.

Other pain interventions include monitoring and documenting vital signs, effectiveness of all interventions, and any side effects or adverse reactions.

Non- Invasive and Medication Options


With all of the focus on treating the “whole” Patient, we have discussed several methods for providing palliative care. Though the focus is on ways to make certain the patient is kept comfortable, and needs are met physically, emotionally, spiritually, and socially sometimes the need for medication has its place in comfort measures.


A number of non-pharmacological therapies are available as a form of mind diversion to take the focus off of pain. They include non-invasive techniques such as TENS units, massage therapy, physical therapy, chiropractic therapy, and acupressure. The application of heat and cold are also effective alternatives. Research has shown that a supportive environment is very effective in controlling pain. Participation in activities and plan of care gives the patient a sense of control over the pain. This will also show the patient that the healthcare team is sincerely striving to provide comfort and is willing to implement or modify the pain care plan based on the patient’s needs.


In reference to medication choices, depending on the nature, source and intensity of pain, pharmacological interventions may be necessary.


Non-opioid and opioid analgesics are commonly ordered.


Non- opioid medications include acetaminophen, and NSAID’s ( Non Steroidal Anti-inflammatory Drugs) such as ibuprofen and other common over the counter type analgesics. They are useful for mild to moderate pain relief.


Opioid medications are a synthetic or natural narcotic medication that produces an antagonist action by binding to the opiod receptors in the central nervous system. They are successful in the management of severe pain management. Although they create physical dependence in those who use them for a prolonged period of time, virtually all patients who take them for chronic pain management , addiction is actually rare according to research conducted by the Federal Drug Administration. Opioids should be used properly when chronic pain is a serious reality.


The most common opioids are morphine, Demerol, hydromorphine, codeine, and oxycodone. There are many types with the similar compound makeup.


Of these, Morphine is usually a better choice than Demerol for the elderly because it has a higher duration rate of action, and less total dose is generally required. A lower total dose decreases the risk for hemodynamic alterations and other associated adverse reactions and toxicity.

 


The Need For Improved Care


Back in the early 1900’s, healthcare professionals had little to offer the terminally ill, sick and dying. Most of what to be offered was focused on palliative care even back in the time period of the early 1900’s. Easing symptoms associated with disease and offering emotional support through the presence of family members caring for the dying was about the best one could hope for. Many died within days of onset of symptoms of illness.


As science and technology began to bring about changes, such as improvements in living and working conditions, sanitation, and an emphasis on disease prevention, the outcome of patient illness proved to be a benefit as people were then beginning to live longer, more productive lives.

Science and technology has come along way, bringing antibiotics, life saving techniques, CPR, and advanced medical treatments which has shifted the focus from easing suffering to curing disease. As we are living in a very evolved society, technology and medicine has continued to make miraculous

changes in our healthcare industry. Still, medical modalities are far from perfect. As long as we continue to have sickness and pain in our society, there will always be the question as to what treatment is best. With the ability to make choices and decisions we will see that palliative care will lead the healthcare industry as our focus shifts once again, from medical treatments to patient comfort and supportive care measures.


SUMMARY


End of life issues and palliative care is a changing way patient’s are choosing for their healthcare needs. As healthcare providers, we need to be aware of how to meet these needs. At the end of life, nursing care should shift from a focus of “wellness” to an understanding of “healing” in ways that will enhance the quality of the individual’s life. Not all deaths are peaceful. It may be difficult to control symptoms, or to resolve all issues that the patient or family wishes to address. Working with the dying is never easy. At the same time, the satisfaction of having helped a person with his or her fears of death generates a new understanding, a new level for personal self- awareness and a new capacity for giving.

 

References


Mosby Year Book, 2000 Mosby drug Reference


Springhouse Publishers Nursing Procedures and Assessment, Third edition

Springhouse, Pennsylvania


Brunner and Sudderath’s Medical and Surgical Nursing, JP Lippencott, 1998

Philadelphia, Pennsylvania


Mosby Year Book Mary M. Cannobis, Handbook of Patient Teaching, Mosby Year Book, St. Louis, Missouri, 1998


American Academy of Pain Management

www.aapainmanage.com

End of Life / Palliative Care

Meets Florida Requirement

2 contact hours

Course # 103

Author: Monica Oram, RN, BSN


This course is intended for the reader to be able to achieve the following objectives:

    Understand the difference between palliative care and curative treatment.

    Understand Advance directives, and living wills.

    Use of pain management and comfort techniques

    Emotional and psycho-social and spiritual needs of terminally ill patients and their families.

5. Understand what is involved for palliative care.

6. Appropriate use of medications in terminally ill

7. Methods of communication with families regarding anticipated grief and

Loss of loved one.


What is Palliative care?


Palliative care is when the focus of treatment shifts from cure to comfort. Patients who are terminally ill and their families may consider this choice when providing comfort would be of greatest benefit. Palliative care helps ensure this time can be lived as fully as possible, in peace- physically and emotionally. Searching and fighting for a cure becomes less of a benefit as compared to maintaining a quality of life through comfort measures. Due to some medical treatments taking too long and too much of a toll on terminally ill patients, it is becoming more of a choice to seek out palliative care. Often times curative treatments are far to aggressive for the terminally ill, and the side effects associated with curative treatment modalities are far more than the patient can tolerate. Therefore, palliative care is a decision often made while receiving hospital care for the terminally ill. Palliative care is a positive choice being made by both the patient and the families, as it is a choice for quality of life.

 

 

 

What is involved for palliative care?


Palliative care involves caring for the whole patient- not just the illness. This means that healthcare workers need to be more focused on the individual and be aware of pain management concerns, helping to ease symptoms of illness, and caring for conditions that cause discomfort.

 

The patients emotional and spiritual well being is just as important as the patient’s physical comfort. As the patient’s medical and physical condition begins to change, there is often more focus on palliative care.


Pain control is a big focus of palliative care. ( More on pain management to follow) Medical measures to help reduce pain can include the use of pain medications, radiation to shrink tumors, surgery to remove growths and masses, nerve blocks to deaden the pain.


Palliative care involves making a pain management plan. The patient has the right to adequate pain control. The patient should feel comfortable enough to be able to discuss needs and concerns with those who are involved in his/her care. Healthcare professionals have the obligation to make sure the patient is comfortable and not be judgmental by labeling the patient as a “complainer”.


Palliative care can and should also provide comfort in other areas than just pain management. For instance, the patient should be comfortable in regards to their breathing ability. They may require bronchodilators, nebulizer treatments, or the use of oxygen to facilitate better respiratory status. They may need to be assessed and monitored for the need of diuretics as well. Some may need the benefit of anti-anxiety medications. Increased anxiety will cause increase in difficulty breathing. In addition, the healthcare professional should be mindful to the need for anti-emetics/anti -nausea medications. The focus is on the comfort of the patient.


Palliative care can also focus on the need for antibiotics for infections, and IV therapy as appropriate. Remember, choosing comfort over cure does not mean less care. It means more care for conditions that affect the patient’s physical comfort.


Part of Palliative care is offering emotional support. Some suggestions would be to:

    Offer and arrange for counselors, volunteers, involvement with community support groups and community resources.

    Help make it possible for families to spend quality time with their loved one

    Find ways for the patient to share feelings, thoughts, and ideas

    Help make it possible for the patient to continue to enjoy activities and interactions as much as possible.


Healthcare professionals should be mindful to the patient’s concerns regarding worry and anxiety. The use of medications may be appropriate, but there are other methods that could be implemented.

Such as :

    allow the patient to discuss his fears and concerns

    Guide the patient through relaxation exercises to help calm him down

    Answer questions and concerns regarding treatment and comfort measures


Spiritual support should be an important focus in palliative care and treatment. Offer clergy or a religious advisor to spend time with the patient. This can be useful, valuable insight for the patient, as well as a good way to relief fear and anxiety.


Making Choices About Palliative Care


When it comes to patient choices in regards to palliative care, the patient essentially has two choices:

    The patient must decide if they believe in fighting the course of the illness, no matter what the cost- even if a cure is not likely.

    The patient must decide if they believe that quality of life is most important, right up to the final moments of life.

 

The patient who is in favor of choice one, wanting to fight for cure, even if a cure is not likely is probably not one who is ready to accept palliative care measures. They have more of a focus on medical treatment of the condition.

 

Those who are in favor of quality of life, and supportive care measures are more favorable for palliative care modalities.


Sometimes a patient may be mixed, with deciding between the two choices. In this case the patient will then need to decide how to best balance medical treatment and palliative care.


Some of the options available for palliative care include:

    Home Health Care

    Hospice

    Be as pain free as possible

    Be as alert as possible

    Maintain as much independence and cognition as possible

    Be free of artificial means of survival ( Tube feeding, Ventilators, Ect)

    May choose to be a Do Not Resuscitate


When a patient/family is faced with the choice of palliative care measures it is important to consider the following:

    Does pain threaten to make end of life less fulfilling?

    Will a change in treatment make it more possible for the patient to do things he/she enjoys?

    Will this allow quality time to spend the last days with family, and to get affairs in order?

    Will there be support of healthcare and family to manage pain issues, anxiety, or any other discomforts?

Insight On Advance Directives


One important issue in regards to palliative care and end of life issues involves the implementation of advance directives. Advance directives help ensure the patient’s wishes are followed when they become unable to speak, and/or make choices on their own.


Two specific types of advance directives include:

    Durable power of attorney

    Living will

 


A durable power of attorney gives a person who is designated by the patient, the right to make choices and healthcare decisions on behalf of the patient when they are unable to do so.

A living will is created while the patient is alive, and therefore this is why it is called a living will. Simply put, a living will outlines the kinds of care the patient wishes to receive, and what they do not want in certain situations.


State Laws allow patient’s to be able to make their own choices. Laws vary from state to state, but they still have the ability to make healthcare decisions and choices.


Focus on Pain Management


Pain management is a very important part of palliative care. Pain is defined as a complex subjective sensation reflecting real or potential tissue damage and the response to it. Pain can be described as acute or chronic, somatogenic or psychogenic. Recurrent acute pain, such as with sickle cell crisis, and continuous pain is an unending pain with out remission or relief.

Acute pain only lasts a short time. (less than a month) It is a protective mechanism that warns about potential bodily injury and problems.

Chronic pain is pain that lasts more than a month after occurrence of an acute tissue injury or physical medical condition. Pain is considered to be chronic if it persists more than three months, or is expected to continue to get worse or progress. Chronic pain serves no biological warning or protective purpose. Chronic pain is often accompanied by depression, lack of sleep, and limited mobility. Other complications can include constipation, decreased appetite, and loss of taste. ( to name just a few)

Somatogenic pain is organic in nature and is caused by organic patho-physiology, meaning it is pain originating from within the body.

Psychogenic pain occurs in the absence of any organic pathology that can not explain the presence or extent of the pain. It is said to be a result of a psycho-somatic etiology for cause of pain.


In contrast, Pain management is defined as the systematic study of clinical and basic science and its application for the reduction of pain and suffering. The blending of tools, techniques, and principles taken from the discreet healing art disciplines and reformulates pain to be viewed from a holistic approach for reduction of pain and suffering. Holistic approach to pain management is focused on the whole patient, mind, body and soul.


One of the primary goals of Healthcare professionals is to provide relief from needless suffering and pain that affects so many of our acute, chronic, and terminally ill patients, and diminishes their ability to enjoy optimal quality of life.


Assessing Pain Management


Methods to assess pain should begin with a base line assessment.

    This assessment should include an understanding of how the patient describes his pain. ( dull, ache, sharp, ect.)

    Also assess for other methods that the patient or family has sought out as a treatment modality to help with pain control.

    The healthcare professional would want to also assess the patient’s cognitive ability by determining mental status and orientation.

    Assess pain level by using the scale of 1- 10.( With one being minimal, to ten being the worse pain imaginable)

    It would be helpful to assess the patient/family beliefs and attitudes related to pain, and treatment modalities.

    Take in to consideration the history of past failures or successes and/or adverse side effects experienced with different pain management treatments, including analgesics.

    Determine any barriers that could lead to the patient not being able to report pain, such as fears, ethnical origin, culture, diminished cognition, or inability to speak.

    Assess for history of any chronic disorders that could contribute to or cause pain.

    Assess for anxiety and depression, and ways in which the individual has coped with pain in the past.

Part of doing an adequate pain assessment includes reassessment. As part of reassessment, the healthcare professional should assess and document the pain in terms of duration, characteristics, location, intensity, and frequency. Also note the time, pain rating on the pain scale of 1-10, and any use of pain medication followed by the effectiveness of the medication, if given.

Other pain interventions include monitoring and documenting vital signs, effectiveness of all interventions, and any side effects or adverse reactions.

Non- Invasive and Medication Options


With all of the focus on treating the “whole” Patient, we have discussed several methods for providing palliative care. Though the focus is on ways to make certain the patient is kept comfortable, and needs are met physically, emotionally, spiritually, and socially sometimes the need for medication has its place in comfort measures.


A number of non-pharmacological therapies are available as a form of mind diversion to take the focus off of pain. They include non-invasive techniques such as TENS units, massage therapy, physical therapy, chiropractic therapy, and acupressure. The application of heat and cold are also effective alternatives. Research has shown that a supportive environment is very effective in controlling pain. Participation in activities and plan of care gives the patient a sense of control over the pain. This will also show the patient that the healthcare team is sincerely striving to provide comfort and is willing to implement or modify the pain care plan based on the patient’s needs.


In reference to medication choices, depending on the nature, source and intensity of pain, pharmacological interventions may be necessary.


Non-opioid and opioid analgesics are commonly ordered.


Non- opioid medications include acetaminophen, and NSAID’s ( Non Steroidal Anti-inflammatory Drugs) such as ibuprofen and other common over the counter type analgesics. They are useful for mild to moderate pain relief.


Opioid medications are a synthetic or natural narcotic medication that produces an antagonist action by binding to the opiod receptors in the central nervous system. They are successful in the management of severe pain management. Although they create physical dependence in those who use them for a prolonged period of time, virtually all patients who take them for chronic pain management , addiction is actually rare according to research conducted by the Federal Drug Administration. Opioids should be used properly when chronic pain is a serious reality.


The most common opioids are morphine, Demerol, hydromorphine, codeine, and oxycodone. There are many types with the similar compound makeup.


Of these, Morphine is usually a better choice than Demerol for the elderly because it has a higher duration rate of action, and less total dose is generally required. A lower total dose decreases the risk for hemodynamic alterations and other associated adverse reactions and toxicity.

 


The Need For Improved Care


Back in the early 1900’s, healthcare professionals had little to offer the terminally ill, sick and dying. Most of what to be offered was focused on palliative care even back in the time period of the early 1900’s. Easing symptoms associated with disease and offering emotional support through the presence of family members caring for the dying was about the best one could hope for. Many died within days of onset of symptoms of illness.


As science and technology began to bring about changes, such as improvements in living and working conditions, sanitation, and an emphasis on disease prevention, the outcome of patient illness proved to be a benefit as people were then beginning to live longer, more productive lives.

Science and technology has come along way, bringing antibiotics, life saving techniques, CPR, and advanced medical treatments which has shifted the focus from easing suffering to curing disease. As we are living in a very evolved society, technology and medicine has continued to make miraculous

changes in our healthcare industry. Still, medical modalities are far from perfect. As long as we continue to have sickness and pain in our society, there will always be the question as to what treatment is best. With the ability to make choices and decisions we will see that palliative care will lead the healthcare industry as our focus shifts once again, from medical treatments to patient comfort and supportive care measures.


SUMMARY


End of life issues and palliative care is a changing way patient’s are choosing for their healthcare needs. As healthcare providers, we need to be aware of how to meet these needs. At the end of life, nursing care should shift from a focus of “wellness” to an understanding of “healing” in ways that will enhance the quality of the individual’s life. Not all deaths are peaceful. It may be difficult to control symptoms, or to resolve all issues that the patient or family wishes to address. Working with the dying is never easy. At the same time, the satisfaction of having helped a person with his or her fears of death generates a new understanding, a new level for personal self- awareness and a new capacity for giving.

 

References


Mosby Year Book, 2000 Mosby drug Reference


Springhouse Publishers Nursing Procedures and Assessment, Third edition

Springhouse, Pennsylvania


Brunner and Sudderath’s Medical and Surgical Nursing, JP Lippencott, 1998

Philadelphia, Pennsylvania


Mosby Year Book Mary M. Cannobis, Handbook of Patient Teaching, Mosby Year Book, St. Louis, Missouri, 1998


American Academy of Pain Management

www.aapainmanage.com

End of Life / Palliative Care

Meets Florida Requirement

2 contact hours

Course # 103

Author: Monica Oram, RN, BSN


This course is intended for the reader to be able to achieve the following objectives:

    Understand the difference between palliative care and curative treatment.

    Understand Advance directives, and living wills.

    Use of pain management and comfort techniques

    Emotional and psycho-social and spiritual needs of terminally ill patients and their families.

5. Understand what is involved for palliative care.

6. Appropriate use of medications in terminally ill

7. Methods of communication with families regarding anticipated grief and

Loss of loved one.


What is Palliative care?


Palliative care is when the focus of treatment shifts from cure to comfort. Patients who are terminally ill and their families may consider this choice when providing comfort would be of greatest benefit. Palliative care helps ensure this time can be lived as fully as possible, in peace- physically and emotionally. Searching and fighting for a cure becomes less of a benefit as compared to maintaining a quality of life through comfort measures. Due to some medical treatments taking too long and too much of a toll on terminally ill patients, it is becoming more of a choice to seek out palliative care. Often times curative treatments are far to aggressive for the terminally ill, and the side effects associated with curative treatment modalities are far more than the patient can tolerate. Therefore, palliative care is a decision often made while receiving hospital care for the terminally ill. Palliative care is a positive choice being made by both the patient and the families, as it is a choice for quality of life.

 

 

 

What is involved for palliative care?


Palliative care involves caring for the whole patient- not just the illness. This means that healthcare workers need to be more focused on the individual and be aware of pain management concerns, helping to ease symptoms of illness, and caring for conditions that cause discomfort.

 

The patients emotional and spiritual well being is just as important as the patient’s physical comfort. As the patient’s medical and physical condition begins to change, there is often more focus on palliative care.


Pain control is a big focus of palliative care. ( More on pain management to follow) Medical measures to help reduce pain can include the use of pain medications, radiation to shrink tumors, surgery to remove growths and masses, nerve blocks to deaden the pain.


Palliative care involves making a pain management plan. The patient has the right to adequate pain control. The patient should feel comfortable enough to be able to discuss needs and concerns with those who are involved in his/her care. Healthcare professionals have the obligation to make sure the patient is comfortable and not be judgmental by labeling the patient as a “complainer”.


Palliative care can and should also provide comfort in other areas than just pain management. For instance, the patient should be comfortable in regards to their breathing ability. They may require bronchodilators, nebulizer treatments, or the use of oxygen to facilitate better respiratory status. They may need to be assessed and monitored for the need of diuretics as well. Some may need the benefit of anti-anxiety medications. Increased anxiety will cause increase in difficulty breathing. In addition, the healthcare professional should be mindful to the need for anti-emetics/anti -nausea medications. The focus is on the comfort of the patient.


Palliative care can also focus on the need for antibiotics for infections, and IV therapy as appropriate. Remember, choosing comfort over cure does not mean less care. It means more care for conditions that affect the patient’s physical comfort.


Part of Palliative care is offering emotional support. Some suggestions would be to:

    Offer and arrange for counselors, volunteers, involvement with community support groups and community resources.

    Help make it possible for families to spend quality time with their loved one

    Find ways for the patient to share feelings, thoughts, and ideas

    Help make it possible for the patient to continue to enjoy activities and interactions as much as possible.


Healthcare professionals should be mindful to the patient’s concerns regarding worry and anxiety. The use of medications may be appropriate, but there are other methods that could be implemented.

Such as :

    allow the patient to discuss his fears and concerns

    Guide the patient through relaxation exercises to help calm him down

    Answer questions and concerns regarding treatment and comfort measures


Spiritual support should be an important focus in palliative care and treatment. Offer clergy or a religious advisor to spend time with the patient. This can be useful, valuable insight for the patient, as well as a good way to relief fear and anxiety.


Making Choices About Palliative Care


When it comes to patient choices in regards to palliative care, the patient essentially has two choices:

    The patient must decide if they believe in fighting the course of the illness, no matter what the cost- even if a cure is not likely.

    The patient must decide if they believe that quality of life is most important, right up to the final moments of life.

 

The patient who is in favor of choice one, wanting to fight for cure, even if a cure is not likely is probably not one who is ready to accept palliative care measures. They have more of a focus on medical treatment of the condition.

 

Those who are in favor of quality of life, and supportive care measures are more favorable for palliative care modalities.


Sometimes a patient may be mixed, with deciding between the two choices. In this case the patient will then need to decide how to best balance medical treatment and palliative care.


Some of the options available for palliative care include:

    Home Health Care

    Hospice

    Be as pain free as possible

    Be as alert as possible

    Maintain as much independence and cognition as possible

    Be free of artificial means of survival ( Tube feeding, Ventilators, Ect)

    May choose to be a Do Not Resuscitate


When a patient/family is faced with the choice of palliative care measures it is important to consider the following:

    Does pain threaten to make end of life less fulfilling?

    Will a change in treatment make it more possible for the patient to do things he/she enjoys?

    Will this allow quality time to spend the last days with family, and to get affairs in order?

    Will there be support of healthcare and family to manage pain issues, anxiety, or any other discomforts?

Insight On Advance Directives


One important issue in regards to palliative care and end of life issues involves the implementation of advance directives. Advance directives help ensure the patient’s wishes are followed when they become unable to speak, and/or make choices on their own.


Two specific types of advance directives include:

    Durable power of attorney

    Living will

 


A durable power of attorney gives a person who is designated by the patient, the right to make choices and healthcare decisions on behalf of the patient when they are unable to do so.

A living will is created while the patient is alive, and therefore this is why it is called a living will. Simply put, a living will outlines the kinds of care the patient wishes to receive, and what they do not want in certain situations.


State Laws allow patient’s to be able to make their own choices. Laws vary from state to state, but they still have the ability to make healthcare decisions and choices.


Focus on Pain Management


Pain management is a very important part of palliative care. Pain is defined as a complex subjective sensation reflecting real or potential tissue damage and the response to it. Pain can be described as acute or chronic, somatogenic or psychogenic. Recurrent acute pain, such as with sickle cell crisis, and continuous pain is an unending pain with out remission or relief.

Acute pain only lasts a short time. (less than a month) It is a protective mechanism that warns about potential bodily injury and problems.

Chronic pain is pain that lasts more than a month after occurrence of an acute tissue injury or physical medical condition. Pain is considered to be chronic if it persists more than three months, or is expected to continue to get worse or progress. Chronic pain serves no biological warning or protective purpose. Chronic pain is often accompanied by depression, lack of sleep, and limited mobility. Other complications can include constipation, decreased appetite, and loss of taste. ( to name just a few)

Somatogenic pain is organic in nature and is caused by organic patho-physiology, meaning it is pain originating from within the body.

Psychogenic pain occurs in the absence of any organic pathology that can not explain the presence or extent of the pain. It is said to be a result of a psycho-somatic etiology for cause of pain.


In contrast, Pain management is defined as the systematic study of clinical and basic science and its application for the reduction of pain and suffering. The blending of tools, techniques, and principles taken from the discreet healing art disciplines and reformulates pain to be viewed from a holistic approach for reduction of pain and suffering. Holistic approach to pain management is focused on the whole patient, mind, body and soul.


One of the primary goals of Healthcare professionals is to provide relief from needless suffering and pain that affects so many of our acute, chronic, and terminally ill patients, and diminishes their ability to enjoy optimal quality of life.


Assessing Pain Management


Methods to assess pain should begin with a base line assessment.

    This assessment should include an understanding of how the patient describes his pain. ( dull, ache, sharp, ect.)

    Also assess for other methods that the patient or family has sought out as a treatment modality to help with pain control.

    The healthcare professional would want to also assess the patient’s cognitive ability by determining mental status and orientation.

    Assess pain level by using the scale of 1- 10.( With one being minimal, to ten being the worse pain imaginable)

    It would be helpful to assess the patient/family beliefs and attitudes related to pain, and treatment modalities.

    Take in to consideration the history of past failures or successes and/or adverse side effects experienced with different pain management treatments, including analgesics.

    Determine any barriers that could lead to the patient not being able to report pain, such as fears, ethnical origin, culture, diminished cognition, or inability to speak.

    Assess for history of any chronic disorders that could contribute to or cause pain.

    Assess for anxiety and depression, and ways in which the individual has coped with pain in the past.

Part of doing an adequate pain assessment includes reassessment. As part of reassessment, the healthcare professional should assess and document the pain in terms of duration, characteristics, location, intensity, and frequency. Also note the time, pain rating on the pain scale of 1-10, and any use of pain medication followed by the effectiveness of the medication, if given.

Other pain interventions include monitoring and documenting vital signs, effectiveness of all interventions, and any side effects or adverse reactions.

Non- Invasive and Medication Options


With all of the focus on treating the “whole” Patient, we have discussed several methods for providing palliative care. Though the focus is on ways to make certain the patient is kept comfortable, and needs are met physically, emotionally, spiritually, and socially sometimes the need for medication has its place in comfort measures.


A number of non-pharmacological therapies are available as a form of mind diversion to take the focus off of pain. They include non-invasive techniques such as TENS units, massage therapy, physical therapy, chiropractic therapy, and acupressure. The application of heat and cold are also effective alternatives. Research has shown that a supportive environment is very effective in controlling pain. Participation in activities and plan of care gives the patient a sense of control over the pain. This will also show the patient that the healthcare team is sincerely striving to provide comfort and is willing to implement or modify the pain care plan based on the patient’s needs.


In reference to medication choices, depending on the nature, source and intensity of pain, pharmacological interventions may be necessary.


Non-opioid and opioid analgesics are commonly ordered.


Non- opioid medications include acetaminophen, and NSAID’s ( Non Steroidal Anti-inflammatory Drugs) such as ibuprofen and other common over the counter type analgesics. They are useful for mild to moderate pain relief.


Opioid medications are a synthetic or natural narcotic medication that produces an antagonist action by binding to the opiod receptors in the central nervous system. They are successful in the management of severe pain management. Although they create physical dependence in those who use them for a prolonged period of time, virtually all patients who take them for chronic pain management , addiction is actually rare according to research conducted by the Federal Drug Administration. Opioids should be used properly when chronic pain is a serious reality.


The most common opioids are morphine, Demerol, hydromorphine, codeine, and oxycodone. There are many types with the similar compound makeup.


Of these, Morphine is usually a better choice than Demerol for the elderly because it has a higher duration rate of action, and less total dose is generally required. A lower total dose decreases the risk for hemodynamic alterations and other associated adverse reactions and toxicity.

 


The Need For Improved Care


Back in the early 1900’s, healthcare professionals had little to offer the terminally ill, sick and dying. Most of what to be offered was focused on palliative care even back in the time period of the early 1900’s. Easing symptoms associated with disease and offering emotional support through the presence of family members caring for the dying was about the best one could hope for. Many died within days of onset of symptoms of illness.


As science and technology began to bring about changes, such as improvements in living and working conditions, sanitation, and an emphasis on disease prevention, the outcome of patient illness proved to be a benefit as people were then beginning to live longer, more productive lives.

Science and technology has come along way, bringing antibiotics, life saving techniques, CPR, and advanced medical treatments which has shifted the focus from easing suffering to curing disease. As we are living in a very evolved society, technology and medicine has continued to make miraculous

changes in our healthcare industry. Still, medical modalities are far from perfect. As long as we continue to have sickness and pain in our society, there will always be the question as to what treatment is best. With the ability to make choices and decisions we will see that palliative care will lead the healthcare industry as our focus shifts once again, from medical treatments to patient comfort and supportive care measures.


SUMMARY


End of life issues and palliative care is a changing way patient’s are choosing for their healthcare needs. As healthcare providers, we need to be aware of how to meet these needs. At the end of life, nursing care should shift from a focus of “wellness” to an understanding of “healing” in ways that will enhance the quality of the individual’s life. Not all deaths are peaceful. It may be difficult to control symptoms, or to resolve all issues that the patient or family wishes to address. Working with the dying is never easy. At the same time, the satisfaction of having helped a person with his or her fears of death generates a new understanding, a new level for personal self- awareness and a new capacity for giving.

 

References


Mosby Year Book, 2000 Mosby drug Reference


Springhouse Publishers Nursing Procedures and Assessment, Third edition

Springhouse, Pennsylvania


Brunner and Sudderath’s Medical and Surgical Nursing, JP Lippencott, 1998

Philadelphia, Pennsylvania


Mosby Year Book Mary M. Cannobis, Handbook of Patient Teaching, Mosby Year Book, St. Louis, Missouri, 1998


American Academy of Pain Management

www.aapainmanage.com