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