role of a nurse in palliative care
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ROLE OF A NURSE IN
PALLIATIVE CARE
FLORENCE THE FIRST PALLIATIVE CARE NURSE
Florence Nightingale herself stated:‘I use the word nursing for want of a better.’
She went on to say:‘The very elements of nursing are all but unknown’
(Nightingale, 1860).
DEFINING PALLIATIVE CARE
‘Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, though the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, physiological and spiritual.’
WHO
PALLIATIVE CARE
• Affirms life• Promotes quality of life• Treats the person• Supports the family
EVOLVING MODEL OF PALLIATIVE CARE
“Active Treatment” Palliative Care Death
Cure/Life-prolonging Intent
Palliative/Comfort Intent
Death Bereavement
PALLIATIVE CARE GOAL
Its goal is much more than comfort in dying; palliative care is about living through meticulous attention to control pain and other symptoms, supporting emotional, spiritual, and cultural needs, and maximizing functional status
PALLIATIVE CARE SETTINGS
anyANYWHERE!
VIRGINIAS DEFINITION OF NURSING
The most succinct and relevant to palliative care is Virginia’s definition of nursing;
‘Nursing is primarily assisting the individual in the performance of those activities
contributing to health and its recovery, or to a peaceful death.’
PALLIATIVE CARE COMPETENCIES
• Communication skills• Physical skills• Psychosocial skills• Teamwork skills• Intrapersonal skills• Life closure skills
COMMUNICATION SKILLS
The ability• To field and respond to sometimes profound or
rhetorical questions about life and death• To know when to say nothing, because that is the
most appropriate response;• To use therapeutic comforting touch with confidence;• To challenge colleagues who may wish to deny
patients information; and, perhaps• To discuss the imminent death of a relative with
families
TEAM WORK SKILLS
• The growth of the nursing role within these teams has been dramatic and continues to represent a much admired model of working .
Pharmacist Natural
Therapist OccupationalTherapist
ParamedicalAide
General Practitioner
Medical Specialists
Bereavement Support Worker
Social WorkerSpiritual
Counsellor
Volunteers
Funeral Director
Domiciliary Care
Meals on Wheels
Palliative Care NurseDietician
PHYSICAL CARE SKILLS
• The knowledge and skills necessary to deliver active, hands-on care in whatever setting throughout a long period of illness.
• Observational skills and the intuitive ability to recognise signs
• Advising doctors of the appropriate prescription and dosage to manage pain
• The advocacy role nurses have towards patients at a time of extreme vulnerability.
PSYCHOSOCIAL SKILLS
An ability• work with families,• Anticipating their needs,• Putting them in touch with services and• Supporting them when appropriate
INTRAPERSONAL SKILLS
Nurses need to recognise and attempt to understand personal reactions that occur as a natural consequence of working with dying and bereaved people and to be able to reflect on how this affects care given in sensitive situations.
It is the most challenging of all competency areas and plays a significant part in the professional growth of those who choose to work in this field.
LIFE CLOSURE SKILLS
• This area is concerned with nursing behaviours and skills that are crucial to patients’ and families; dignity, as they perceive it, when life is close to an end and thereafter.
• Such care has been described as a sacred work, in which the nurse enters into the patient’s intimate space and touches parts of the body that are usually private
PALLIATIVE NURSES
ROLE
FACILITATOR
CASEMANAGER
ADVOCATEASSESSMENT
MANAGEMENT EXPERT
PALLIATIVE CARE PLAN
Palliative care plan includes:• Care goals• Symptom management• Advance care planning• Financial support• Spiritual care• Functional status support and rehabilitation• Co morbid disease management
MULTIDIMENSIONALITY OF SUFFERINGS
SUFFERING
PHYSICAL
EMOTIONAL
SPIRITUAL
PSYCHOSOCIAL
COMMON SYMPTOMS
• Fatigue• Pain• Nausea• Vomiting• Insomnia• Dyspnoea• Pyrexia
• Anorexia; cachexia• Impaired mental
status• Dry mouth• Constipation• Diarrhoea• Fever
MANAGING PAIN
• Asses the multi dimensions of pain and determine the type of pain
• Employ a assessment scale• Use WHO ladder• Administer around the clock doses and break
through doses• Seek the help of appropriate alternative therapies• Continue evaluating pain control and pain status
DYSPNEA
• Address the anxiety with assurance and relaxation techniques
• Maintain saturation above 90% with supplemental oxygen
• Suctioning is generally not indicated• Administer 5-10mg morphine q4h if the
patient is not on opioids
HANLING ANXIETYTypes include situational anxiety, drug related anxiety. Organic anxiety and psychological anxiety. Multidisciplinary assessment Treat the reversible causes Non pharmacological therapy Spiritual support Short term psychotherapy Short term psychotherapy Tranquilizers for severe anxiety
NOURISHING AND HYDATING
• Suggest small meals and liquid supplements• Treat the symptom that may cause decreased
appetite• Administer appetite stimulants • Employ infusions and hypodermoclysis
Potential Palliative Care Interventions
Support•Emotional•Spiritual•Psychological
Control of•Pain•Dyspnea•Nausea•Vomiting
Variable CPRTransfusions Ventilation
Infections Highly Hypercalcemia burdensomeTube Feeding Interventions
Dialysis
Palliative GenerallyNot Palliative
FUNTIONAL STATUS SUPPORT
• Assess ability to perform ADL & IADL• Find and rule out underlying reversible causes
of functional impairment• Refer to rehabilitation evaluation as
appropriate• Optimize and maintain functional status with
physical, occupational and complementary therapies
PALLIATIVE SEDATION
Intermittent sedation for relief of the intractable symptoms when they are not controlled even with aggressive measures.– It is different from assisted death as it is not
intended for death yet often foreseen– Sedative dose is not killing does
SPIRITAUL CARE
• Assess the desire for spiritual counselling and support
• Obtain information regarding significant religious rituals, beliefs and practices
• Encourage their practice to the extent possible • Foster the insights
Spiritual coping strategies enhance self empowerment
SUPPORTING FAMILY
• Assess family structure, functioning, strengths and weaknesses, knowledge deficits
• Encourage communication among family members• Respect their privacy and accept the coping styles• Conduct meetings to review the goals and decisions • Teach care giving skills to the primary caregiver• Assist throughout grieving process and in bereavement
ADVANCED CARE PLANNING
• Living wills• Health power of attorney• A completed patient values history
ETHICAL DECISION MAKING
Nurses can seek the help of the ethical standards of decision making. Shared decisions should be made after,
• Considering what is known of the patients wishes and preferences given the current condition
• Balancing the burdens and benefits of each option in terms of quality of life and
• Achieving a consensus among decision makers
IMPROVING PALLIATIVE CARE•Stds of practice for symptom management, availability, responsiveness, communication•Certain palliative interventions held to higher scrutiny and rigour – eg. Palliative sedation•Specialty area for nursing
•Raise awareness and expectations•Improve “death culture”•Empower in decision making
Professional Practice
Education Public Awareness•Core competencies•Curriculum in undergrad and post-grad in all involved disciplines•Continuing education
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