Prepared by: AUBREY C.

ROQUE RN, MAN

 It

is designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life rather than cure.

GOAL: To enable patients to be comfortable and free of pain, so that they live each day as fully as possible. PHILOSOPHY: To provide support for the patient's emotional, social, and spiritual needs as well as medical symptoms as part of treating the whole person.

 Palliative

care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through:

the prevention and relief of suffering by means of :

Identification of pain Impeccable assessment and treatment of pain Identification, assessment and treatment of physiological, psychosocial and spiritual problems

Palliative care for children is the active total care of the child's body, mind and spirit, and also involves giving support to the family. It begins when illness is diagnosed, and continues regardless of whether or not a child receives treatment directed at the disease. Health providers must evaluate and alleviate a child's physical, psychological, and social distress. Effective palliative care requires a broad multidisciplinary approach that includes the family and makes use of available community resources; it can be successfully implemented even if resources are limited.

 It

can be provided in tertiary care facilities, in community health centers and even in children's homes.
CARE- is designed to give support and comfort rather than cure of the illness or problem.

PALLIATIVE

 Current

licensure in the state of practice Minimum of one year of clinical practice in nursing.

Oncology Psychiatry Home care experience are prepared

Knowledge

of pathophysiology and disease

progression Understanding of pain and symptom management

 Excellent

assessment communication skills Ability to work within and contribute to an interdisciplinary team Ability to assist the patient and family in coping with emotional stress Understanding of an aptitude for organization and communication with patient, family and team members

 Capacity

to manage physical , psychological, social and spiritual problems of dying patients and their families Ability to coordinate the extended and expanded component1s of hospice service Acquisition of counseling, managing, instructing, caring and communicating skills and knowledge. Ability to balance the nurses self-care needs with the complexities and intensities of repeated encounter with death.

 Affirms

process Neither hasten nor postpones death Provides relief from pain and other distressing symptoms Integrates the psychological, ethical, legal and spiritual aspects of care Offers a support system to help patients live as actively as possible until death Offers a support system to help patients families to cope during the patients illness and in their own bereavement.

life and regards dying as a normal

1.) Effective Communication

COMMUNICATION- is the essential process by which individual share something of them, whether it is thoughts, feelings, opinions, ideas, values, or goals.

1. Principles of human communication

Its multidimensional

The content of the message sent (true or false, sensible or non-sense or undecipherable) Emotional content / feelings that modify the message (grief, anger, joy, confidence, peace, boredom, etc..) Relationship aspect- refers to how the message is received given the perceived social positions of the communicants.

Perception is selective

Only a part of the information sent is perceived. The idea that what is perceived is not precisely what actually is.

It is an interactive and continuous process

The sender is also a receiver of information The receiver is also a sender of information, during the communication process

Its inevitable

It is impossible not to communicate, (it is essential for health providers to be aware that even when words are not used or spoken, communication is occurring.

Culture influences communication pattern

It is critical for health provider to recognize their own cultural conditioning in order to explore the impact it has in their communication with those of another cultural background. Culture involves customs, beliefs, values, and relationship patterns, prescribed behaviors (dress, food preferences and time consciousness).

2. Importance of good communication at the end of life

Honest communication increases the likelihood that the dying experience will be one through which all the participants can grow emotionally and spiritually Families are better prepared for the final death event and have better bereavement experiences.

3. Barriers to good communication

patients and families

death is considered a taboo subject Common reactions are withdrawal from the patient or situation, denial of the reality of a terminal diagnosis, or avoidance of behavior, such as telling jokes or changing the subject.

health care provider

using the dying person's name throughout the conversation making eye contact holding the person's hand placing one's hand on a shoulder or arm smiling gesturing leaning forward caring in what the person is saying (or not saying) and feeling. Asking specific questions such as, "Can you help me understand?" as well as open-ended questions such as, "What is it that you need to do now?" are very important, as is being comfortable with silence.

Depth of the physicianpatient relationship: Health Care Providers (HCPs) may develop strong bonds with patient and family, whether they have known them for years or just a short time. These bonds may make breaking bad news or discussing issues around end-of-life care difficult since they may find it difficult to contemplate losing a patient they care for deeply.
Personal experiences of illness and death: May affect their ability to care for a person who is at the end of life. Physical, emotional and psychological stress and depletion: May affect ability to communicate caring, empathy and compassion.

Fears of confronting own mortality and fears of death: Caring for someone who is dying leads to physicians confronting their own mortality and fears of death. Lack of training and poor role models: A lack of training and role models results in poor communication skills and either a lack of awareness of patients feelings and reactions or inability or fear of discussing these emotions. Fears of emotional outbursts: HCPs are often not taught how to show empathy and caring and may fear emotional outbursts.

Fears of appearing weak or unprofessional for displaying emotions: Many HCPs have been taught that displaying emotion is a sign of weakness or unprofessional. These HCPs may have difficulty in discussing end-of-life issues for fear of feeling or displaying emotion.

Guilt and self-blame due to iatrogenic complications resulting in poor quality of life, increased severity of illness and/or death: When illness is due to or has been exacerbated by iatrogenic complications, HCPs may be consumed with self-blame and guilt which may affect their ability to consider the patients situation.
Communication Problems: Inconsistent approach to the issues, differences in language can lead to confusion (the perception of mixed messages) and misunderstandings with patients and families.

health care system

fast pace modern health care system, inadequate time to discuss important matters such as death Unclear who is responsible for initiating and providing follow-up-end-of life conversations?

Practical aspects of communicating at the end of life

Understand oneself and speak honestly (self-awareness) But remember that the key to talking to dying persons is to focus on their needs, rather than ones own. Consider the timing of communication ( ask is this a good time to talk) Provide a setting for open communication arrange the environment and how to adapt their own behavior to facilitate conversation avoid sense of arrogance maintain eye contact

Practical aspects of communicating at the end of life

Allow the patient to guide the communication process; patients personal autonomy and control should be preserved.

Use open ended questions (e.g. what is it that you need to know?)

Practical aspects of communicating at the end of life

Make

no assumptions about what the patient knows; a patient who has not told of their diagnosis might be aware that they are dying. ask and listen, listen and ask, the most important general rule in the end-of life setting is to listen more and to talk less

yes or no questions are helpful initially to broach a difficult subject, (e.g. have you experienced the death of a loved one before.. followed by do you feel like talking about it
attentive listening means no interruption, but listening patiently until there is a pause in the conversation before speaking

 use

understandable terms ask patient what they want use silence liberally support varying emotional response accept denial , usually accept symbolic language encourage patient to tell their life stories tell people what to expect at the very end of life, assume that hearing is still intact

4. Breaking bad news -- All the communication skills discuss apply to the very difficult task of breaking bad news
Factors that add to the distress of the situation:

Fear of being blamed for the bad news Fear of not knowing all the answers Fear of showing emotions Fear of being reminded of ones own mortality

NOTE: it is often the doctors responsibility to break the bad news but it is helpful to be present when the bad news is initially shared, that is to understand the real situation/condition of the patient.

5. Assessing suicide potential

Requisite skills for end-of-life care is the ability to identify depression and assess for suicidal potential

Depression

A psychiatric disorder characterized by an inability to concentrate, insomnia, loss of appetite, anhedonia, feelings of extreme sadness, guilt, helplessness and hopelessness, and thoughts of death. The condition is also called clinical depression.

NOTE: Anhedonia: Loss of the capacity to experience pleasure. The inability to gain pleasure from normally pleasurable experiences. Anhedonia is a core clinical feature of depression, schizophrenia, and some other mental illnesses.
Subtypes of Depression:
Major depression severe, lasts for at least 2 weeks (decrease energy, feeling of worthless, guilty) Dysthymic depression less severe (lasts for 2 years or more).

General appearance of a depressed person

Sadness Resignation Apathy Hopelessness Or may become cheerful when decision come to end suffering

For assessment of suicide potential a direct approach is recommended.

Eg. Have things gotten so bad that you are thinking of killing yourself.

Risk factors for SUICIDE: S Sex (more female attempts suicide but more males commits). U Unsuccessful previous attempt. I Identification with a family member who committed suicide. C Chronic I Illness Ex. Cancer D depression/dependent personality A age (18-25 and 40 above) and alcoholism L Lethality of previous attempts/looses.