Palliative CarePalliative CareCHCPA301BCHCPA301B

INTRODUCTION:INTRODUCTION:Learning Outcomes:Learning Outcomes:• Understand a Palliative Approach and Understand a Palliative Approach and

support the incorporation and ongoing support the incorporation and ongoing management of ACD’s within the care plan.management of ACD’s within the care plan.

• Be able to support clients to identify their Be able to support clients to identify their preferences for quality of life choices.preferences for quality of life choices.

• Be able to take action to assess and alleviate Be able to take action to assess and alleviate pain and other end of life symptoms.pain and other end of life symptoms.

• Identify and manage own responses in self Identify and manage own responses in self and others.and others.

ASSESSMENTSASSESSMENTS

There are 3 parts to this assessment.. There are 3 parts to this assessment.. Students must pass each part.Students must pass each part.

PART A: Open book take home quiz.PART A: Open book take home quiz.

PART B: Case Study. Mr W.PART B: Case Study. Mr W.

Part 3: Role play, day 2 in class.Part 3: Role play, day 2 in class.

The assessments are due in 2 weeks.The assessments are due in 2 weeks.

What is palliative careWhat is palliative care..

What does it mean to you?What does it mean to you?

What is Palliative Care?What is Palliative Care?

A Palliative Care approach aims to improve A Palliative Care approach aims to improve the quality of life for a person who is dying the quality of life for a person who is dying and their family, whether as a result of and their family, whether as a result of disease, illness or the ageing process.disease, illness or the ageing process.

The word ‘palliate’ means to relieve; palliative The word ‘palliate’ means to relieve; palliative care therefore is care that relieves the care therefore is care that relieves the physical and mental distress of dying.physical and mental distress of dying.

What is palliative care? What is palliative care? continuedcontinued

Palliative care is a multi-disciplinary Palliative care is a multi-disciplinary approach that involves medical, approach that involves medical, psychological and spiritual responses to psychological and spiritual responses to the dying person, their family and friends.the dying person, their family and friends.

People are usually encouraged to live as People are usually encouraged to live as actively as possible until deathactively as possible until death

Palliative care affirms life and regards Palliative care affirms life and regards death as a normal part of life.death as a normal part of life.

Definition:Definition: World Health Organization 2002 World Health Organization 2002

Palliative care is an approach that improves the Palliative care is an approach that improves the quality of care of patients and their families quality of care of patients and their families facing the problems associated with life-facing the problems associated with life-threatening illness, through the prevention threatening illness, through the prevention and relief of suffering by means of early and relief of suffering by means of early identification and impeccable assessment identification and impeccable assessment and treatment of pain and other problems, and treatment of pain and other problems, physical, psychosocial and spiritual.physical, psychosocial and spiritual.

Dying in AustraliaDying in Australia

134,000 deaths in Australia each year134,000 deaths in Australia each year 64,000 are considered to be ‘expected 64,000 are considered to be ‘expected

deaths’ – when death is related to a deaths’ – when death is related to a diagnosed life limiting illnessdiagnosed life limiting illness

1/3 of patients whose death is expected 1/3 of patients whose death is expected are seen by palliative care services with are seen by palliative care services with the balance by primary care servicesthe balance by primary care services

Responsibility to Responsibility to allall Australians Australians

WHERE can a palliative WHERE can a palliative

approach be provided?approach be provided? A palliative approach can be used in any A palliative approach can be used in any

setting.setting. A palliative approach can be provided in the A palliative approach can be provided in the

resident’s resident’s familiar familiar surroundings surroundings if if adequate adequate skilled care is available, which reduces the skilled care is available, which reduces the need for transfer to an acute setting; need for transfer to an acute setting; thereby, avoiding potential distress to the thereby, avoiding potential distress to the resident and his/her family.resident and his/her family.

The reality of the above should be The reality of the above should be discussed discussed earlyearly in the care planning. in the care planning.

WHO can provide the care??WHO can provide the care??

A palliative approach is best provided by a A palliative approach is best provided by a multidisciplinary team. They may include:multidisciplinary team. They may include:

# Specialist Physicians and GP’s # Specialist Physicians and GP’s

# General nurses# General nurses # Specialist nurses# Specialist nurses

# Volunteers# Volunteers # Pharmacists# Pharmacists

# OT’s# OT’s # Physiotherapist# Physiotherapist

# Social workers # Social workers # Dieticians# Dieticians

# Carers # Carers #Diversional Therapist#Diversional Therapist

#Chaplains #Chaplains # Pain specialist# Pain specialist

WHO DECIDES??WHO DECIDES?? The decision to implement a palliative The decision to implement a palliative

approach should not be based on the approach should not be based on the individual’s clinical stage or diagnosis; individual’s clinical stage or diagnosis; rather, it should be offered according to rather, it should be offered according to the needs of the individual.the needs of the individual.

The decision to consider a palliative The decision to consider a palliative approach should be made in collaboration approach should be made in collaboration with the resident, the family and the team.with the resident, the family and the team.

Lack of openness with residents and their Lack of openness with residents and their families may lead to conflict and confusion families may lead to conflict and confusion about care goals. about care goals.

ADVANCED CARE PLANNINGADVANCED CARE PLANNING

Advanced care planning empowers the person to Advanced care planning empowers the person to state their wishes in writing, in accordance with how state their wishes in writing, in accordance with how they define quality of life.they define quality of life.

By doing so, the burden of responsibility is removed By doing so, the burden of responsibility is removed from the surrogate and control is maintained by the from the surrogate and control is maintained by the resident.resident.

As with preparing of a will, the plan cannot be As with preparing of a will, the plan cannot be attended too early.attended too early.

When the time comes and the resident is no longer When the time comes and the resident is no longer able to validate decisions it will be of great comfort able to validate decisions it will be of great comfort to loved ones knowing the decisions they are to loved ones knowing the decisions they are maintaining were those chosen.maintaining were those chosen.

An ACD can be an individual process, and does An ACD can be an individual process, and does not have to involve family members. However, not have to involve family members. However, evidence suggests that many people prefer them evidence suggests that many people prefer them to be involved.to be involved.

The process of advanced care planning may The process of advanced care planning may provide opportunity for discussing dying wishes, provide opportunity for discussing dying wishes, settling interpersonal differences, may prevent settling interpersonal differences, may prevent later conflict over substitute decisions about later conflict over substitute decisions about treatment, and improve communication amongst treatment, and improve communication amongst the family members.the family members.

Advanced care planning is a continuum of Advanced care planning is a continuum of treatment choices that may be reviewed as the treatment choices that may be reviewed as the persons condition, and possibly preferences persons condition, and possibly preferences change.change.

End of life strategies:End of life strategies:

Goals of treatment may need to be re-negotiated Goals of treatment may need to be re-negotiated several times. several times.

Good open communication, regular team meetings, Good open communication, regular team meetings, continuity of care (nursing and medical),continuity of care (nursing and medical),

a culture which values challenging and a culture which values challenging and constructive debate – constructive debate –

all these contribute to improving team functioning all these contribute to improving team functioning which is an essential factor in managing the complex which is an essential factor in managing the complex interface between acute and palliative care.interface between acute and palliative care.

Sensitive and careful management of the transitional Sensitive and careful management of the transitional phases in disease is integral to successful palliationphases in disease is integral to successful palliation

For patients and their families quality of life will For patients and their families quality of life will be maximised where the goals of palliative care be maximised where the goals of palliative care are valued, and expert symptom management are valued, and expert symptom management is practised. is practised.

An understanding of the psychosocial stressors An understanding of the psychosocial stressors involved in experiencing chronic illness will involved in experiencing chronic illness will assist in good communication, both within the assist in good communication, both within the health care team and the patient/family.health care team and the patient/family.

Respect for the ability of the patient and family Respect for the ability of the patient and family to participate in their own care is fundamental to participate in their own care is fundamental to the practise of palliationto the practise of palliation

Legal Issues in palliative careLegal Issues in palliative care

Nurses working in palliative care need to practise Nurses working in palliative care need to practise within the legal controls of the jurisdiction in which within the legal controls of the jurisdiction in which they practise and adhere to the procedural they practise and adhere to the procedural guidelines. guidelines.

Pain management is a fundamental part of palliative Pain management is a fundamental part of palliative care and one that has civil and criminal implications. care and one that has civil and criminal implications.

The importance of accurate documentation cannot The importance of accurate documentation cannot be overstated.be overstated.

An advanced care directive that complies with the An advanced care directive that complies with the requirements is legally binding in NSW.requirements is legally binding in NSW.

Failure to comply with ACD may result in the health Failure to comply with ACD may result in the health professional incurring criminal or civil liability.professional incurring criminal or civil liability.

Patients RightsPatients RightsThe right to choose or refuse:The right to choose or refuse: While a patients consent cannot justify that While a patients consent cannot justify that

which the law forbids, for example the direct which the law forbids, for example the direct taking of life, it can justify that which the law taking of life, it can justify that which the law allows, for example, the termination and allows, for example, the termination and refusal of medical treatment.refusal of medical treatment.

A person is completely at liberty to undergo A person is completely at liberty to undergo treatment, even if the result of doing so will treatment, even if the result of doing so will be that he diesbe that he dies

( Kennedy and Grubb, 1994: 163, 1270. )( Kennedy and Grubb, 1994: 163, 1270. )

Before life-sustaining treatment is Before life-sustaining treatment is discontinued the patient must be:discontinued the patient must be:

competentcompetent free from coercion or controlling influencefree from coercion or controlling influence fully aware of the implications of the proposed fully aware of the implications of the proposed

course of action.course of action. Legislation allows a person to appoint someone to Legislation allows a person to appoint someone to

make decisions about medical treatment on their make decisions about medical treatment on their behalf if they become incapable of making decisions behalf if they become incapable of making decisions for themselves.for themselves.

Such an appointment is made under the ‘enduring Such an appointment is made under the ‘enduring power of attorney (medical treatment)’, also referred power of attorney (medical treatment)’, also referred to as a ‘living will’ to as a ‘living will’

Cultural Issues:Cultural Issues: Culture is a way of life that is shaped by values, Culture is a way of life that is shaped by values,

beliefs and practises that are learnt from experience of beliefs and practises that are learnt from experience of being in the world and from experiences transmitted being in the world and from experiences transmitted through generations.through generations.

All residents require careful assessment to ensure All residents require careful assessment to ensure assumptions are not made for cultural needs based on assumptions are not made for cultural needs based on a resident’s language ability alone.a resident’s language ability alone.

To provide cultural appropriate palliative care requires To provide cultural appropriate palliative care requires first that a persons culture is understood and, first that a persons culture is understood and, secondly, that health care staff respect that culture.secondly, that health care staff respect that culture.

Australia is a multi cultural country. It is also possible Australia is a multi cultural country. It is also possible that the family unit comes from more than one culture. that the family unit comes from more than one culture. This may require unique handling.This may require unique handling.

Approximately 120 residential services Approximately 120 residential services provide care operated by ethnic community provide care operated by ethnic community organisations, with additional community organisations, with additional community resources specifically allocated for resources specifically allocated for Aboriginal and Torres Strait Islander Aboriginal and Torres Strait Islander people and those from a diverse range of people and those from a diverse range of cultural and linguistic backgrounds.cultural and linguistic backgrounds.

A specific program known as Partners in A specific program known as Partners in cultural Appropriate care operates cultural Appropriate care operates throughout Australia. Contacts:throughout Australia. Contacts:

Multicultural Health Communication service Multicultural Health Communication service Website: Website: www.mhcs.health.nsw.gov.au

Transcultural Aged Care Services (NSW) Transcultural Aged Care Services (NSW)

(02) 85855025(02) 85855025 Ethnic Communities Council of QLD Ethnic Communities Council of QLD

(07) 38461099 (07) 38461099 Multicultural Aged Care (SA)Multicultural Aged Care (SA)

(08) 82324410(08) 82324410 Migrant Resource (TAS) (03) 62349411Migrant Resource (TAS) (03) 62349411 Anglican Aged Care (VIC) (03) 93982354Anglican Aged Care (VIC) (03) 93982354 Multicultural Aged Care (WA) (08) 93468240Multicultural Aged Care (WA) (08) 93468240

Spiritual Care:Spiritual Care: Spiritual care involves assisting people to Spiritual care involves assisting people to

articulate those things that are important to them articulate those things that are important to them personally. personally.

Spiritual care involves sensitive listening, rather Spiritual care involves sensitive listening, rather than providing answers. It is not necessary for the than providing answers. It is not necessary for the nurse to share the same spiritual beliefs as the nurse to share the same spiritual beliefs as the person in order to understand the persons person in order to understand the persons spiritual needs, nor is it the aim of spiritual care to spiritual needs, nor is it the aim of spiritual care to impose your own views onto that person.impose your own views onto that person.

It is important that every effort is made by staff to It is important that every effort is made by staff to enable the person to have access to spiritual enable the person to have access to spiritual supports and spiritually related items.supports and spiritually related items.

COMMUNICATIONCOMMUNICATION

Redpath (1998) suggests that communication skills Redpath (1998) suggests that communication skills of the health professional are central to successful of the health professional are central to successful patient decision making, and negotiation of patient decision making, and negotiation of optimum palliative care outcomes.optimum palliative care outcomes.

It is also said that nurses are the most frequent It is also said that nurses are the most frequent observers of patients’ psychological and emotional observers of patients’ psychological and emotional responses to illness and treatment responses to illness and treatment (Fincannon,1995).(Fincannon,1995).

Therefore it is important to acknowledge the Therefore it is important to acknowledge the valuable role communication and negotiating skills valuable role communication and negotiating skills can play in palliative care.can play in palliative care.

Cultural context of communicationCultural context of communicationWhen learning English as a new language, people go When learning English as a new language, people go

through 5 stages.through 5 stages. Hearing what is said in english.Hearing what is said in english. Translating it into their own language.Translating it into their own language. Constructing the response in english.Constructing the response in english. Responding in English.Responding in English.

When broken down in this way, the room for error is When broken down in this way, the room for error is obvious.obvious.

Clear communication is an essential component of Clear communication is an essential component of palliative care so language barriers need strategies palliative care so language barriers need strategies put in place to overcome them.put in place to overcome them.

Dealing with conflict & resolution Dealing with conflict & resolution

CONFLICTCONFLICT results from individuals or results from individuals or groups wanting different things. groups wanting different things. Differences can include: Differences can include:

Differences in values, Different Differences in values, Different interpretation of the facts, Different ideas.interpretation of the facts, Different ideas.

NEGOTIATION NEGOTIATION is a process of is a process of collaboration. It employs the skill of:collaboration. It employs the skill of:

Listening, questioning, Speaking and Body Listening, questioning, Speaking and Body language.language.

Body language in communicationBody language in communication

Nonverbal communication, known as “body Nonverbal communication, known as “body language” sends strong positive and negative language” sends strong positive and negative signals. This is how much it influences any signals. This is how much it influences any message:message:

WordsWords 8%8%Tone of voice Tone of voice 34%34%Non verbal cuesNon verbal cues 58%58%

Body language speaks for itself and can be of Body language speaks for itself and can be of enormous comfort to the patient and carers enormous comfort to the patient and carers …… it can also create the opposite.…… it can also create the opposite.

The power of listeningThe power of listening

Sometimes in palliative care it is more Sometimes in palliative care it is more important to listen than to speak.important to listen than to speak.

Sometimes patients and carers alike want to Sometimes patients and carers alike want to discuss their fears but don’t want to burden discuss their fears but don’t want to burden their loved ones and they will turn to you.their loved ones and they will turn to you.

The philosopher Epictetus stressed the power The philosopher Epictetus stressed the power of listening in this quote:of listening in this quote:

““Nature gave us one tongue and two ears so Nature gave us one tongue and two ears so we could hear twice as much as we we could hear twice as much as we speak”speak”

NUTRITION AND HYDRATION:NUTRITION AND HYDRATION: Consenting to or refusing food is an expression of a Consenting to or refusing food is an expression of a

persons autonomy.persons autonomy. One of the most difficult ethical issues that families One of the most difficult ethical issues that families

and health care workers confront is uncertainty about and health care workers confront is uncertainty about how to manage residents who refuse food and / or how to manage residents who refuse food and / or fluids.fluids.

‘‘There is little evidence that tube feeding substantially There is little evidence that tube feeding substantially prolongs life, and it carries additional risks that usually prolongs life, and it carries additional risks that usually will only add an additional burden of discomfort for will only add an additional burden of discomfort for dying patients’ ( Finucane,Christmas & Travis, 1999 )dying patients’ ( Finucane,Christmas & Travis, 1999 )

Factors affecting poor nutritionFactors affecting poor nutrition

Advanced dementiaAdvanced dementia Apathy / loss of interestApathy / loss of interest Fatigue / increased generalised weaknessFatigue / increased generalised weakness DepressionDepression Adverse medication side effectsAdverse medication side effects Shortness of breathShortness of breath NauseaNausea Anorexia assoc with deteriorating conditionAnorexia assoc with deteriorating condition

Potential reversible causesPotential reversible causes

Metabolic disorders such as thyroidismMetabolic disorders such as thyroidism Chronic infectionsChronic infections Alcoholism (nutritional malabsorption)Alcoholism (nutritional malabsorption) Oral health factorsOral health factors DepressionDepression Vitamin deficienciesVitamin deficiencies Nausea and vomitingNausea and vomiting Cultural food issuesCultural food issues Adverse medication side-effectsAdverse medication side-effects

DehydrationDehydration

Dehydration in the end-of-life stage has not Dehydration in the end-of-life stage has not been found to produce distressing symptoms been found to produce distressing symptoms or shorten lifespan and may in fact be or shorten lifespan and may in fact be beneficial.beneficial.

Benefits include:Benefits include: The production of a natural analgesia-The production of a natural analgesia-

endorphins and dynorphinsendorphins and dynorphins Ketoacidosis takes away the feeling of Ketoacidosis takes away the feeling of

hunger and results in further analgesiahunger and results in further analgesia Decrease in urinary output and diminished Decrease in urinary output and diminished

respiratory secretionsrespiratory secretions

Nutrition at End-of-lifeNutrition at End-of-life The desire to feed stems from the belief that The desire to feed stems from the belief that

dehydration in a person close to death is distressingdehydration in a person close to death is distressing Artificial feeding will not necessarily increase comfort Artificial feeding will not necessarily increase comfort

or quality of life during end stageor quality of life during end stage Dehydration should not be confused with thirstDehydration should not be confused with thirst Thirst is best treated by small amounts of fluid and Thirst is best treated by small amounts of fluid and

ice chips offered frequently and good mouth careice chips offered frequently and good mouth care The wishes of the resident and their family are The wishes of the resident and their family are

paramountparamount Resident’s best interest and preferences should Resident’s best interest and preferences should

guide decision makingguide decision making

Artificial HydrationArtificial Hydration

Artificial hydration should be considered in Artificial hydration should be considered in the palliative approach when dehydration the palliative approach when dehydration results from potentially correctable causes;results from potentially correctable causes;

Over treatment of diuretics and sedationOver treatment of diuretics and sedation Recurrent vomitingRecurrent vomiting DiarrhoeaDiarrhoea hypocalcaemiahypocalcaemia

Adverse effects of fluid accumulation caused Adverse effects of fluid accumulation caused by artificial hydration at end-of-life:by artificial hydration at end-of-life:

Increased urinary outputIncreased urinary output Increased fluid in GI tract – vomitingIncreased fluid in GI tract – vomiting Pulmonary oedema, pneumoniaPulmonary oedema, pneumonia Increase in respiratory tract secretionsIncrease in respiratory tract secretions AscitesAscites

All of the above potentially causing more All of the above potentially causing more discomfort for the palliative patient.discomfort for the palliative patient.

Nausea and vomitingNausea and vomiting

Nausea is sometimes prolonged and can be Nausea is sometimes prolonged and can be less easily controlled than vomiting. less easily controlled than vomiting.

Nausea can occur without vomiting ( the Nausea can occur without vomiting ( the reverse is also true )reverse is also true )

It is important to try to identify the cause of It is important to try to identify the cause of nausea or vomiting in order to manage the nausea or vomiting in order to manage the symptoms.symptoms.

Causes of nausea and vomitingCauses of nausea and vomiting

Latrogenic - medications, chemotherapy, Latrogenic - medications, chemotherapy, radiotherapyradiotherapy

Metabolic – hypercalcaemia, UTI, altered Metabolic – hypercalcaemia, UTI, altered tastetaste

Organic – constipation, bowel obstructionOrganic – constipation, bowel obstruction Psychological – anxiety, anticipatoryPsychological – anxiety, anticipatory Other – odour from food or woundsOther – odour from food or wounds Cause is often unknown at end-of-lifeCause is often unknown at end-of-life

Non – pharmacological therapyNon – pharmacological therapy

Correct reversible causesCorrect reversible causes Environmental factors – fresh air, absence Environmental factors – fresh air, absence

of offensive smellsof offensive smells Offer non-odourous foods, eat slowly & Offer non-odourous foods, eat slowly &

small amounts frequentlysmall amounts frequently Avoid lying flat before and after mealsAvoid lying flat before and after meals Diversional therapies – relaxationDiversional therapies – relaxation Maintain good mouth careMaintain good mouth care

Pharmacological managementPharmacological management

General guidelines include:General guidelines include: Determine the most likely causeDetermine the most likely cause Identify contributing factorsIdentify contributing factors Select an appropriate anti-emeticSelect an appropriate anti-emetic Select appropriate route for drug administrationSelect appropriate route for drug administration Consider possible toxicityConsider possible toxicity Possible benefit versus potential burdenPossible benefit versus potential burden Ensure patient complianceEnsure patient compliance Evaluate regularlyEvaluate regularly Give prophylacticallyGive prophylactically

Bowel care in palliationBowel care in palliation

Bowel symptoms such as constipation or faecal Bowel symptoms such as constipation or faecal incontinence can have a negative effect on a incontinence can have a negative effect on a resident’s quality of life.resident’s quality of life.

Bowel care is a key component of a palliative Bowel care is a key component of a palliative approach as residents may be taking opioids, approach as residents may be taking opioids, which are a major cause of constipation.which are a major cause of constipation.

Constipation may occur with: Constipation may occur with: Limitation to fluid intake in faecal wasteLimitation to fluid intake in faecal waste Limitation to movement of faeces through colonLimitation to movement of faeces through colon Limitation to muscle contractionLimitation to muscle contraction

Bowel managementBowel management

Initial assessment to identify normal bowel Initial assessment to identify normal bowel habitshabits

Daily documentation of bowel habitsDaily documentation of bowel habits Prophylaxis – essential part of managementProphylaxis – essential part of management Early identification of abnormal bowel habitsEarly identification of abnormal bowel habits Identify cause – diet or drug inducedIdentify cause – diet or drug induced Prompt and individually tailored treatmentsPrompt and individually tailored treatments Minimization of interventions that can cause Minimization of interventions that can cause

loss of dignityloss of dignity Comfort for the residentComfort for the resident

Types of ConstipationTypes of Constipation

PRIMARY:PRIMARY: Inadequate dietary fibre / dehydrationInadequate dietary fibre / dehydration Reduced mobility / reduced muscle toneReduced mobility / reduced muscle tone Withholding faecal evacuationWithholding faecal evacuation

SECONDARY:SECONDARY: Partial bowel obstructionPartial bowel obstruction Spinal cord compression Spinal cord compression conditions such as hypercalcaemiaconditions such as hypercalcaemia

LATROGENIC:LATROGENIC:

Introduced by administration of drug therapiesIntroduced by administration of drug therapies

Symptoms of constipationSymptoms of constipation

Nausea and vomitingNausea and vomiting Straining during defecationStraining during defecation Infrequent bowel movementsInfrequent bowel movements Feelings of incomplete emptying after bowel Feelings of incomplete emptying after bowel

movementsmovements Frequent small amounts of diarrhoeaFrequent small amounts of diarrhoea Rectal pain on defecationRectal pain on defecation Stomach pain, distension or discomfortStomach pain, distension or discomfort Faecal incontinenceFaecal incontinence

Pain management Pain management

To cure sometimesTo cure sometimes

To relieve oftenTo relieve often

To comfort alwaysTo comfort always

Defining Pain:Defining Pain: ACUTE PAIN: Is usually due to a definable ACUTE PAIN: Is usually due to a definable

acute injury or illness. It has a definite onset acute injury or illness. It has a definite onset and it’s duration is limited and predictable. It and it’s duration is limited and predictable. It is accompanied by anxiety and clinical signs is accompanied by anxiety and clinical signs of sympathetic overactivity: tachycardia, of sympathetic overactivity: tachycardia, tachypnoea, hypertension, sweating, tachypnoea, hypertension, sweating, pupillary dilatation and pallor. Acute pain may pupillary dilatation and pallor. Acute pain may also occur in a patient with chronic pain.also occur in a patient with chronic pain.

INCIDENT PAIN: Occurs only in certain INCIDENT PAIN: Occurs only in certain circumstances eg: movement / procedurescircumstances eg: movement / procedures

CHRONIC PAIN: Results from a chronic CHRONIC PAIN: Results from a chronic pathological process. It has a gradual or ill-pathological process. It has a gradual or ill-defined onset, continues unabated and may defined onset, continues unabated and may become progressively more severe. The become progressively more severe. The patient appears depressed and withdrawn patient appears depressed and withdrawn and, as there are no signs of sympathetic and, as there are no signs of sympathetic overactivity, they are frequently labelled as overactivity, they are frequently labelled as “not looking like someone in pain’. Patients “not looking like someone in pain’. Patients with chronic pain may exhibit depression, with chronic pain may exhibit depression, lethargy, apathy, anorexia and insomnia.lethargy, apathy, anorexia and insomnia.

Chronic pain requires REGULAR use of Chronic pain requires REGULAR use of analgesics to control pain with breakthrough analgesics to control pain with breakthrough analgesia for additional acute episodes. analgesia for additional acute episodes.

As noted by Lord Devlin in As noted by Lord Devlin in R v Adams (Bodkin) R v Adams (Bodkin) (1957) even though direct killing is unlawful: (1957) even though direct killing is unlawful: ….. There is still much for a doctor to do that ….. There is still much for a doctor to do that he is entitled to do all that is proper and he is entitled to do all that is proper and necessary to relieve pain and suffering, even necessary to relieve pain and suffering, even if the measures he takes may incidentally if the measures he takes may incidentally shorten life.shorten life.

Criminal law requires intent. The intent to Criminal law requires intent. The intent to relieve pain is different from the intent to kill, relieve pain is different from the intent to kill, which does and should lead to criminal which does and should lead to criminal charges.charges.

Pain management requires a systemic and holistic Pain management requires a systemic and holistic approach to treatment that is tailored to the approach to treatment that is tailored to the individual’s physical, psychological and spiritual individual’s physical, psychological and spiritual needs. needs.

As Dickinson stated, As Dickinson stated,

“ “ Pain is a subjective sensation and therefore pain Pain is a subjective sensation and therefore pain is what the individual says it is and NOT what is what the individual says it is and NOT what others think it should be”.others think it should be”.

Recognition of an emotional and psychological Recognition of an emotional and psychological component to pain points to the need for a component to pain points to the need for a multidimensional assessment for effective pain multidimensional assessment for effective pain management.management.

Principle of pain managementPrinciple of pain management

RRegular around the clockegular around the clock

OOral medication if possibleral medication if possible

AAdjuvants for side effectsdjuvants for side effects

Barriers to effective pain Barriers to effective pain management:management:

Some include:Some include: Lack of knowledge of pain assessment Lack of knowledge of pain assessment

among some nurses and doctors.among some nurses and doctors. Overcoming cultural beliefs. Eg: a recent Overcoming cultural beliefs. Eg: a recent

study found some indigenous Australian study found some indigenous Australian communities feared morphine was given at communities feared morphine was given at the end of life to ‘get rid of me” (them).the end of life to ‘get rid of me” (them).

A belief that pain relief should only be given if A belief that pain relief should only be given if pain was currently present.pain was currently present.

Poor communication.Poor communication.

Pain assessment tools:Pain assessment tools:

Pain assessment tools have been developed to Pain assessment tools have been developed to attempt to overcome the incongruence attempt to overcome the incongruence between nurses perception of pain and the between nurses perception of pain and the patient’s.patient’s.

Some assessment tools used are:Some assessment tools used are: The ABBEY pain Scale.The ABBEY pain Scale. The FUNCTIONAL Pain scale. (FPS)The FUNCTIONAL Pain scale. (FPS) The NUMERICAL Rating Scale. (NRS)The NUMERICAL Rating Scale. (NRS) The McGILL Pain Questionnaire (MPQ)The McGILL Pain Questionnaire (MPQ) The BRIEF Pain Inventory (BPI).The BRIEF Pain Inventory (BPI).

Complementary therapies Complementary therapies

In 1995 RNSH (Sydney) analysed 319 patient In 1995 RNSH (Sydney) analysed 319 patient questionnaires where the question was asked questionnaires where the question was asked “Why do you use alternative treatments” Reasons “Why do you use alternative treatments” Reasons given include:given include:

New source of hope.New source of hope. Preference of natural therapies.Preference of natural therapies. Impression of non-toxic therapy.Impression of non-toxic therapy. Supportive alternative practitioner.Supportive alternative practitioner. Greater personal involvement.Greater personal involvement.

It is important therefore to endorse the patient’s It is important therefore to endorse the patient’s desire and choice of empowerment.desire and choice of empowerment.

Some complementary therapies include:Some complementary therapies include: CounsellingCounselling Massage /relaxation techniquesMassage /relaxation techniques AromatherapyAromatherapy NaturopathyNaturopathy Therapeutic touch /Reiki /ReflexologyTherapeutic touch /Reiki /Reflexology Herbal / traditional Chinese medicinesHerbal / traditional Chinese medicines Creative visualisationCreative visualisation Music therapy Music therapy Meditation /hypnotherapyMeditation /hypnotherapy Acupressure / acupunctureAcupressure / acupuncture

It is necessary to recognise the importance of It is necessary to recognise the importance of offering patients the choice of a range of offering patients the choice of a range of therapies BUTtherapies BUT

If nurses are to incorporate complementary If nurses are to incorporate complementary therapies into nursing practise, certain issues therapies into nursing practise, certain issues need to be addressed including:need to be addressed including:

TrainingTraining Staffing levelsStaffing levels TimeTime Informed consentInformed consent DocumentationDocumentationGiven the above it is important that management Given the above it is important that management

supports the use of complementary therapies.supports the use of complementary therapies.

Physiological changes Physiological changes

In the final stage when life-sustaining systems begin In the final stage when life-sustaining systems begin to shut down, physical, mental, emotional and to shut down, physical, mental, emotional and spiritual changes may occur over weeks, days or spiritual changes may occur over weeks, days or hours. These can include:hours. These can include:

Increased weakness, fatigue. Loss of interest in Increased weakness, fatigue. Loss of interest in everyday things. Decreased appetite and fluid everyday things. Decreased appetite and fluid intake. Difficulty swallowing. Neurological intake. Difficulty swallowing. Neurological dysfunction, confusion. Pain. Incontinence. dysfunction, confusion. Pain. Incontinence. Restlessness. Increased sleepiness. Changes in Restlessness. Increased sleepiness. Changes in body temperature and colour. Loss of ability to close body temperature and colour. Loss of ability to close eyes. Breathing difficulties.eyes. Breathing difficulties.

Nursing care Nursing care

As the dying persons physical changes occur so will As the dying persons physical changes occur so will their nursing care needs. their nursing care needs.

These needs include:These needs include: HygieneHygiene Incontinence careIncontinence care Pressure area carePressure area care Oral and eye careOral and eye care Bowel careBowel care Pain / comfort managementPain / comfort management Care of respiratory difficultyCare of respiratory difficulty Psychological and spiritual carePsychological and spiritual care

Unexpected Alertness and Energy Unexpected Alertness and Energy

Often a day or two or even a few hours before death, Often a day or two or even a few hours before death, the person may have a surge of energy, wake up, the person may have a surge of energy, wake up, become alert, can sometimes eat or drink or talk and become alert, can sometimes eat or drink or talk and spend some quality time with loved ones.spend some quality time with loved ones.

This can be a very precious time that doesn’t often last This can be a very precious time that doesn’t often last long.long.

Nurses will often refer to it as “ the calm before the Nurses will often refer to it as “ the calm before the storm”storm”

Reliving this time is common following the passing of Reliving this time is common following the passing of the person by those left behind and can be very the person by those left behind and can be very comforting. comforting.

Signs of Impending DeathSigns of Impending Death Increased anxiety, restlessness, confusionIncreased anxiety, restlessness, confusion Loss of interest in daily activitiesLoss of interest in daily activities Loss of interest in eating and drinkingLoss of interest in eating and drinking LethargyLethargy Gradual cooling of skin, becomes pale, grey or bluish in Gradual cooling of skin, becomes pale, grey or bluish in

colourcolour The person becomes less responsive and eventually The person becomes less responsive and eventually

unresponsiveunresponsive Abnormal breathing pattern, known as Cheyne-stokesAbnormal breathing pattern, known as Cheyne-stokes Fast weak pulseFast weak pulse Shutdown of circulation to the extremities, with the Shutdown of circulation to the extremities, with the

development of cyanosisdevelopment of cyanosis

Signs of Clinical DeathSigns of Clinical Death

These include:These include: Absent heartbeat and respirationsAbsent heartbeat and respirations Pupils fixedPupils fixed Colour turns to waxen pallor as blood settlesColour turns to waxen pallor as blood settles Body temperature dropsBody temperature drops Muscles (sphincter) relax, often causing Muscles (sphincter) relax, often causing

incontinenceincontinence Eyes may remain openEyes may remain open Jaw falls openJaw falls openThe focus of care then shifts to those grieving.The focus of care then shifts to those grieving.

Care after DeathCare after Death A Medical Officer or RN will confirm deathA Medical Officer or RN will confirm death Respect the person in death as in lifeRespect the person in death as in life The person’s after death wishes are followedThe person’s after death wishes are followed Personal hygiene is completed with the same Personal hygiene is completed with the same

care and attention as if the person was still alive, care and attention as if the person was still alive, using standard precautions and safe manual using standard precautions and safe manual handlinghandling

If a Coroner’s case is suspected then the body is If a Coroner’s case is suspected then the body is not to be washed, dressings, cannulae and not to be washed, dressings, cannulae and catheters are not to removed.catheters are not to removed.

Give support to the family and friendsGive support to the family and friends

Loss and GriefLoss and Grief

During the palliative phase and following the During the palliative phase and following the death of a person those involved will death of a person those involved will experience various degrees of loss and grief.experience various degrees of loss and grief.

The people involved will include the dying The people involved will include the dying person , their loved ones and the staff. The person , their loved ones and the staff. The staff effected can be varied.staff effected can be varied.

To understand how we may assist them and To understand how we may assist them and ourselves we must first understand the ourselves we must first understand the effects that loss and grief have on the human effects that loss and grief have on the human body. body.

LOSS: LOSS: Loss can be actual, or perceived or Loss can be actual, or perceived or permanent, and it occurs when someone or permanent, and it occurs when someone or something can no longer be seen, heard, known, something can no longer be seen, heard, known, felt or experienced.felt or experienced.

GRIEF:GRIEF: Grief is the natural response to loss. It Grief is the natural response to loss. It includes a range of responses: physical, mental, includes a range of responses: physical, mental, emotional and spiritual. These are usually emotional and spiritual. These are usually associated with unhappiness, anger, guilt, pain and associated with unhappiness, anger, guilt, pain and longing for the lost person or thing.longing for the lost person or thing.

Each person will grieve and recover in their own way.Each person will grieve and recover in their own way.

NORMAL GRIEF REACTIONS:NORMAL GRIEF REACTIONS:

EMOTIONALEMOTIONAL MENTALMENTALAnxiety DisbeliefAnxiety DisbeliefFear ConfusionFear ConfusionSadness PreoccupationSadness PreoccupationAnger Sense of presenceAnger Sense of presenceGuilt HallucinationsGuilt HallucinationsInadequacyInadequacyReliefReliefLonelinessLoneliness

PHYSICAL REACTIONS TO GRIEF:PHYSICAL REACTIONS TO GRIEF:

Hollowness in the stomach.Hollowness in the stomach. Tightness in the chest and throat.Tightness in the chest and throat. Over sensitive to noise.Over sensitive to noise. A sense of depersonalisation.A sense of depersonalisation. Breathlessness.Breathlessness. Muscle weakness.Muscle weakness. Lack of energy.Lack of energy. Dry mouth.Dry mouth.

STAGES OF GRIEVING:STAGES OF GRIEVING:

Denial and isolation. Denial and isolation. Anger and resentment.Anger and resentment. Bargaining Depression.Bargaining Depression. Acceptance.Acceptance.Factors that can influence the reaction to Factors that can influence the reaction to

grief are:grief are: Stage of growth and development.Stage of growth and development. Cultural and spiritual beliefs.Cultural and spiritual beliefs. Socioeconomical status.Socioeconomical status. Relationships with significant others.Relationships with significant others.

Strategies for assisting a person to Strategies for assisting a person to deal with loss and grief.deal with loss and grief.

Reflective listening.Reflective listening. Provide appropriate environment.Provide appropriate environment. Accommodate the individuals needs eg: Accommodate the individuals needs eg:

Pets, music, Exercise, Reminiscence.Pets, music, Exercise, Reminiscence. Use of experts; clergy, grief counsellors.Use of experts; clergy, grief counsellors. Accommodate cultural and religious Accommodate cultural and religious

customs.customs. Support and encourage loved ones Support and encourage loved ones

participation in patient care if requested. participation in patient care if requested.

Characteristics a nurse requiresCharacteristics a nurse requires Caring and understandingCaring and understanding To be able to accept others beliefs and To be able to accept others beliefs and

customs (even when not your own)customs (even when not your own) Empathic approachEmpathic approach To take a risk and get involves (not afraid To take a risk and get involves (not afraid

of intense feelings)of intense feelings) To be able to acknowledge lossTo be able to acknowledge loss To support as a person moves through the To support as a person moves through the

stages of grievingstages of grieving To work with and support colleaguesTo work with and support colleagues

How to cope ?How to cope ?

Working within a team that ensures the well Working within a team that ensures the well being of it’s members is a vital component to being of it’s members is a vital component to providing holistic palliative care.providing holistic palliative care.

Past personal and professional experiences Past personal and professional experiences of staff will greatly influence how they cope of staff will greatly influence how they cope in different situations.in different situations.

Staff need to be encouraged to use Staff need to be encouraged to use resources available to them when needed.resources available to them when needed.

Communicate and ‘look out’ for your Communicate and ‘look out’ for your colleagues and together you can make a colleagues and together you can make a difference.difference.

When a patient dies, you are entitled to grieve.When a patient dies, you are entitled to grieve. How you reconcile your personal feelings of loss How you reconcile your personal feelings of loss

with your sense of professionalism is important as with your sense of professionalism is important as unresolved grief will wear you down.unresolved grief will wear you down.

It is only human to hurt, to grieve when a person It is only human to hurt, to grieve when a person who has influenced you in some way has died.who has influenced you in some way has died.

Supporting a patient and their loved ones in the final Supporting a patient and their loved ones in the final moments of life is a privilege and comes with moments of life is a privilege and comes with personal rewards.personal rewards.

‘‘No one ever complained that someone cried; but they No one ever complained that someone cried; but they have that no one cared’ – workcover NSW.have that no one cared’ – workcover NSW.

ReferencesReferences

www.who.com/palliativecare TAFE NSW.2006, TAFE NSW.2006, Aged Care in Australia Aged Care in Australia

a guide for aged care workers. Southwood a guide for aged care workers. Southwood PressPress

www.palliativecareaustralia.org.au