ROLE OF A NURSE IN PALLIATIVE CARE

LOW TECH AND HIGH TOUCH

Nse.Punithavathi Inbanathan
Thanthai Roever college of nursing perambalur

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 lifethreatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. WHO

PALLIATIVE CARE

EVOLVING MODEL OF PALLIATIVE CARE

D E A T H

Active Treatment

Palliative Care

Cure/Life-prolonging Intent Palliative/ Comfort Intent

D E A T H

nt me ve rea Be

PALLIATIVE CARE GOAL

Its goal is much more than comfort in dying; palliative care is about living, through meticulous attention to control of pain and other symptoms, supporting emotional, spiritual, and cultural needs, and maximizing functional status

PALLIATIVE CARE SETTINGS

anywhere

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 care skills Psychosocial skills Teamwork skills Intrapersonal skills Life closure skills (BECKER 2009)

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 information; and, perhaps deny patients

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 muchadmired model of working (Cox and James, 2004).

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 recognize 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 to work with families, anticipating their needs, putting them in touch with services and supporting them when appropriate

INTRAPERSONAL SKILLS
Nurses need to recognize 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 (Becker and Gamlin )

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 sacred work, in which the nurse enters into the patients intimate space and touches parts of the body that are usually private

P A L L I A T I V E

FACILITATOR
CASEMANAGER ADVOCATE

ASSESSMENT AND MANAGEMENT EXPERT

N U R S E S
R O L E

PALLIATIVE CARE PLAN

Palliative care plan includes
-care goals -symptom management -advance care planning -financial planning -family support -spiritual care -functional status support and rehabilitation -co morbid disease management

MULTIDIMENSIONALITYOF SUFFERINGS
PHYSICAL

SUFFERING PSYCHOSOCIAL EMOTIONAL

SPIRITUAL

COMMON SYMPTOMS
Fatigue Pain Nausea Vomiting Insomnia Dyspnea pyrexia Anorexia; cachexia Impaired mental status Dry mouth Constipation Diarrhoea Fever

MANAGING PAIN
Assess the multi dimensions of pain & 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 supplemental oxygen above 90% with

Suctioning is generally not indicated Administer 5-10mg of morphine q4h if the patient is not on opioids

HANDLING ANXIETY
Types 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 -tranquilizers for severe anxiety

NOURISHING AND HYDRATING

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

Palliative
Support Emotional Spiritual Psychosocial Control of Pain Dyspnea Nausea Vomiting

Generally Not Palliative Variable

Transfusions Infections Hypercalcemia Tube Feeding Dialysis CPR Ventilation Highly burdensome Interventions

FUNCTIONAL STATUS SUPPORT

Assess ability to perform ADL & IADL
Find and rule out underlying reversible causes of functional impairment Refer to rehabilitation evaluation and conditioning exercises as appropriate Optimize and maintain functional status with physical, occupational and complementary therapies

PALLIATIVE SEDATION
Intermittent sedation for relief of 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 a killing dose

SPIRITUAL CARE
Assess the desire for spiritual counseling 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 makers a consensus among decision

PALLIATIVE CARE IN INDIA

Described as freedom struggle another

Strong and bounding in kerala; feeble or not felt in other parts of country Nil special certification for nurses

13 registered centers in TN
IAPC conference at Trichy by 2010

 Core competencies Curriculum in undergrad and postgrad in all involved disciplines Continuing education

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 Professional Practice

Education

Improving Palliative Care

Public Awareness Service Availability Core requirements for facility and program accreditation (CCHSA) Risk management people need to see poor palliative care as a risk Re-frame good palliative care as prevention/promotion

Raise awareness and expectations Improve death culture Empower in decision-making