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Palliative Care Essay

1. What is Palliative Care? (150 words)

Palliative Care is a care provided when someone is living with, and dying from a fatal chronic condition where the primary goal is maintaining quality of life. It provides special supportive care for anyone who is suffering a life-threatening condition approaching the end of life. Palliative care is for any age, those with cancer or any other terminal diagnosis, people of any ethnic or cultural background, whether they may live in the countryside or the city. Palliative care maintains quality of life, provides comfort although it does not cure, It relieves pain and distress for patients who are on a terminal condition. Palliative care also offers support for the patient’s family members supporting them in bereavement

2. What is meant by a life limiting illness (50 words)

A life limiting illness is the term used to describe the illnesses where death is expected to be the foreseeable future of that specified illness. This can be both malignant and non-malignant illness. Such illness may include cancer, renal disease, dementia, heart disease chronic liver disease and chronic obstructive pulmonary disease.

3. Identify five members of a Palliative care multi -disciplinary health care team and briefly state what knowledge and skills each discipline contributes to the team .

1) Nurses – Nurses are the front liners in patient care and directly deals with the patient. Registered Nurses plan, direct, and coordinate care. License practical nurses works with RNs and other health professionals to provide direct care. 2) Pharmacists – The pharmacist can educate the patient and the family on how to take and manage side effects of the medications; give the doctor advice on how to administer the medication, prepare the medication, help set a schedule of taking medication, and provide ongoing monitoring of all medications. 3) Chaplains – Chaplains addresses the spiritual needs of patients like praying and answering theological questions.

The help with the search for meaning in the person’s life and in the reflection of matters of faith such as prayer and rituals 4) Physician/Family Doctor – The physician is the one in charge of a person’s medical care and works closely with the patient, patient’s family, and the palliative home care. The family doctor can refer the patient for palliative care consult. 5) Social Workers – Social workers help the patient and family in dealing with personal and social problems of illness. They assist in making referrals to community services, planning discharge to home or to a hospice, and completing advance directives in case a person loses the ability to speak for himself.

4. Describe how nurses could facilitate a “ good death” by following the palliative care approach (75 words) Nurses are the one that provide direct care to the patients. They are the one who assess the patient and the first one to see any improvements or any abnormalities on patient’s condition. Nurses are the one who manage the pain and any discomfort of the patient. They are the one whom the patient talks to about their feeling and nurses must use their therapeutic and non-therapeutic communications when handling palliative patients. Nurses must also provide a safe and comfortable environment to the patients and removing any stimuli.

5. Describe how respiratory and cardiovascular factors in terminal illnesses affect the clients ADLS ADL’s are greatly affected by respiratory and cardiovascular factors because they are unable to do things they used to do. In a simple walk they can be easily exhausted, fatigued and feeling weak. Sometimes they need assistance to do their daily routine because they cannot handle it by themselves. This is all because of the respiratory and cardiovascular factors that affected them, there will be decrease in circulation and oxygenation making them feel weak on doing simple tasks. In serious cases, patient might have other complications due to lack of exercise and immobility like pneumonia and pressure areas.

6. Research and summarise the practices of Aboriginal people in relation to death and dying (100 words ) Indigenous Australians have similar practices to the general Australian population the main differences that when they gather for the purpose to share their grief and sorrow they will never again speak the name of the deceased as they believe this may stop their spirit from moving onto the next stage of life. At the wake they paint themselves with ochre body paint and sing, dance pray assisting the soul of their loved one to move along and return to their birthplace to be re born. Their belief is that all things may posses a soul and that the soul of the deceased may return in any form even that of a rock. These ways are very traditional and differ even between tribal areas and current beliefs of the individuals.

7. What is an Advanced Health Directive and describe the advantages of having a directive in place? A written document stating ones wishes for care, primarily life sustaining measures when he or she is no longer capable to express him/herself/

8. What is meant by life sustaining measures? Put simply is when your bodies system fails and will not recover leaving the only outcome of death a machine is used to replace the function

9. What happens if a client has no AHD and becomes too ill to express their care wishes? (30 words) When a client has no AHD they are treated as normal under the health teams objective to preserve life meaning they will be resuscitated and all attempts will be made to maintain life. Alternatively this is where the decision-making can become that of the families or a member of family.

10. Can instructions be written for doctors to assist the client to die? and how (30 words ) Advance health directives are used by patients for their future treatment when they cannot be able to speak by themselves. Doctors cannot assist the patient to die unless it is the will of the patient. There cannot be written any instruction to assist the patient to die as currently this is illegal and the health practitioner that does perform such duties with be trialled for murder.

11 . Can a client change or revoke an AHD ?. (30 words ) Patient can change their advance health directive at any time, provided that they will still have the decision – making capacity. Patient can also revoke their AHD having their signature witnessed.

12. .A family is in conflict over the treatment of their family member who is dying .The patient is in a terrible amount of pain ,yet some members want less pain relief as they don’t want him to be too drowsy .Should the patient be able to die with dignity with controlled pain relief or live longer in pain ? Explain your rationale and reflect your thoughts on this .Also how would you support the family with this dilemma ? (100 words)

The aim of palliative care is to maintain integrity and quality of client’s life while he/she is battling an incurable illness. Quality of life includes ensuring that the patient is comfortable and pain free. In this situation, providing education to the patient’s family is important by trying to make them understand the advantages as well as disadvantages of providing pain relief to the client. Providing terminally ill patients adequate pain relief is vital in the outcome of palliative care.

13. The care plan states that your patient is to have a shower every day at the family’s request .You are helping to get out of bed and she states “ I don’t think I can shower today “You also note that she is short of breath. What is the appropriate response to this situation? What actions would you take? (50 words) I will assist the patient back in bed and elevate the head of bed to 45 degrees or higher then check her vital signs. In short, I will grant the patient’s wish of staying in bed and let the patient rest.

If she prefers a bed bath because she’s not feeling well, then bed bath should be rendered. I will also assess her vital signs and neurological observations then inform the RN and the attending physician. How would you communicate these events to the patients family when they arrive ? Once the family arrives, we could inform them that the patient is not feeling well and is short of breath so she refused to be given a bath. Explain to them that vital signs were checked, attending physician has been informed of the situation, and appropriate intervention was already given.

14…Consider the following symptoms and list strategies you could use to implement to assist the client (150 words)

Abdominal bloating and discomfort
Moist gurgling respirations
Reddened sacrum
Dysphagia
Opioid induced constipation

Strategies include:
Instruct client or family to avoid carbonated drinks and gas forming food such as cabbage and beans.
Advise to chew slowly and not to eat too much food at once
Inform the doctor about the condition for a medication to be ordered if not alleviated Maximising the client’s oxygenation through positioning the client upright Providing supplemental oxygen and maintaining patent airway through deep breathing exercises Suctioning if required

Physiotherapy

15. Describe how you would respond to the following questions /request for information

Why is he continuing to have pain when he is barely conscious? Although the client is barely conscious, it doesn’t mean that he is not in pain. The manifestations of pain could not only be appreciated through verbal or physical gestures but also through vital signs. Pain could cause the blood pressure to shoot up as well as the respiration and pulse rate.

Why does her breathing sound so bad?

The breathing is due to the decrease in oxygenation that causes the respirations to be rapid or slow, shallow and irregular. Breath sounds may become wet and noisy, which are due to the accumulation of mucus in the airways and the patient’s inability to expectorate their secretions due to muscle weakness and decreased gag reflex. How much longer will this go on for? (50 words)

This kind of breathing will go on until the vital organs and systems stop functioning. Generally, respiration ceases first.

16 . Palliative care can be challenging environment to work in. Discuss ways in which you could ensure you care for yourself and why this is so important It is important to maintain a healthy body & mind if you are to be working in such an environment as you are a key element of care to both the patient and their family. Ways to maintain your own health are to maintain a journal and to actively seek out and debrief or find a professional to discuss your personal concerns with. Fitness and physical activities or simple stretches and/or yoga or pilates sessions can also be just as beneficial as much as it is about your physical benefits it can also assist in relinquishing any built up stressors.

17…Mr J ones care plan states that he must have a blood transfusion if his HB falls below 8.0 .Hi test today shows 6.5 .He is short of breath and fatigued .As the RN leaves the room after informing Mr Jones that he is to have a transfusion he says that he does not want the transfusion and that he has had enough and just wants to die .What are your actions and response to this situation ? (50 words)

As it is already established why he does not wish to receive the treatment I would simply discuss why the transfusion is done and how non invasive the process is and its benefits. However in saying this the situation presented is one where the patient is obviously in emotional distress. I would notify the RN, MO &/or Doctor. Depending upon the end resolve next of kin may also be notified should treatment cease so as they can be prepared for any outcome. In my scope I would notify & document.

Provide education where needed and support the patient making referral to social services or identified individuals who have already had dealings with the patient on a faith or belief basis it may also be beneficial. The MO/Doctor will deem if the patient is of sound mind to make such decisions and/or discuss with the patients substitute decision maker/s.

18. .Access a local group or organization in your community and identify what resources the organization offers to patients and their families for bereavement counselling ,education and support .How can clients access the information (50 words)? A good provider of a full range of services is the Salvation Army as being already well established they have an extensive knowledge base and well thought processes being implemented. Counseling and education is available over the phone 24/7 and can be useful for any circumstance from distress & grief to suicidal moments.

They also offer face to face counceling and can cover a full topic range, along with those already mentioned they can also discuss and assist with finance, drug abuse, domestic violence, homelessness, youth issues and even hostel and aged care assistance. The salvation armies care line phone number nationally is 1300 36 36 22 19…Care of the body after death is a vital aspect of palliative care and is based on cultural and religious beliefs, which includes issues of organ donation ,post mortem and autopsy .Briefly provide some information on the above in regards to – The Jewish community ( 40 words )

From the time of death to the funeral the body is to always be accompanied and never alone. Jewish religious law also preserves the respect for the dead. These rites may include:

Closing of eyes and mouth
Applying clay over the eyelids
Facing the body toward the door
Placing the body on the floor for 20 minutes
Placing the arms alongside the body rather than folded over the chest
Purification of the body
Wrapping the body in a white shroud and (for men) in a prayer shawl Customarily, only members of the same sex are permitted to touch the corpse These rituals may be facilitated by family members, the funeral home, and/or the Chevrah Kadish (burial society)

Keeping with the Jewish laws of not mutilating a body autopsies and organ donations can also be prohibited but it has been known on occasion for organs to be donated to family members.

– The Muslim community (40 words )
For those of Islam the process is quiet simple the body is to be bathed and shrouded (3 pieces of cloth for men and 5 for women) and buried as soon as possible. In the meanwhile prays will be made and loved ones begin grieving and the mourning process over 3 days. The main points of interest is that the grave is to be aligned perpendicular to Mecca as for other burial traditions they vary between regions. Cremation is forbidden and organ donation is permissible generally as long as it is to save life. Autopsies are a grey area in that there is no religious decry but many would prefer not to as a quick burial is preferred however if it where for legal reasons it has been allowed.

20. Discuss three legal and ethical issues that are related to Palliative. Briefly discuss (80 words) http://www.adelaidenow.com.au/archive/news/giving-my-dad-final-dignity/story-e6freah3-1111118720637?nk=5be06e19d7df58d1a484641fb445fb30

Legal Issues: Currently under law and a part of all practitioners industry acts is to do no harm as I have discussed previously any practitioner under current legislation to participate in euthanasia would be tried for murder. I don’t agree with this personally and even more so that should the individual perform the duties themselves it would be considered suicide negating any legacy or insurances taken to look after their families as part of their comfort in knowing the family will be cared for. Ethically: I agree with the article (link above) in that humans do play god in most aspects of the anatomy and health care we provide interventions that would cease the natural course of any ailment, we preserve the life of those inflicted with chronic illnesses, we intervene in every aspect even without knowing the full course or purpose of the health issue in the first place.

The results of intervention are starting to become clear in our society, reduced immunity, fragile and susceptible bodies I believe may only be the beginning what happens after a couple generations of this. Yet we will sit on our hands when the individual is left with no dignity, pride or human rights and wait for what could now almost be looked as The Miracle of Death.

Did the gather hunters have it right back in the beginning? I think if I where void of all senses and only had very basic neurological activity and being kept alive for the sole purpose of viewing and an observation tool I think if I could speak I would speak of cruelty and probably win a court case for it. Don’t get me wrong though, I am not pro euthanasia either however if we are to take a debate on that topic then why stop intervening in nature and playing god when it comes to end.

21. List some of the ways that you can manage the hydration and nutritional requirements of the client during the end of life stage (80 words ) A fluid balance chart, cardiovascular and visual observations of skin turgor, lips and mucousal linings would be a good indication for both hydration and nutrition. Depending how long the client has been in your care you may also be able to view changes in nails, hair and eyes these may also be good diagnostic tools and also ensure regular visits from the dietician and adherence to the plan.

22. Pain management is an important aspect of palliative care. Discuss six ways that pain symptoms can be managed without medication (50 words ) Any distraction can assist in removing the focus from pain. Massage can assist in relieving muscles, has a diversion and therapeutic effect also. Hot & cold packs, sleep, exercise, music, essential oils and simple stretches all can contribute in alleviating or reducing pain.

23 . List five barriers to effective pain management (30 words ) A barrier is as defined is anything that can restrict the patient from achieving an outcome. Given this as a starting point and making the target to be effective pain management or free of then the barriers are endless. They can range from family members to low medication supply through to increased resilience to medications or organ failure. Not to mention the individuals psyche emotion and physical state, they may manifest pain that doesn’t exist or they may be overly stressed causing pain to increase they may also be in blatant refusal of care, have fears, language & cultural differences, communication the barriers are endless and should I have a full education in multiple fields and endless time to study and read random information I’m sure there would be many others to add to the list.

24. List the five stages of dying according to Dr Kubler -Ross ( 10 words) The five stages of dying are Denial- this is natural and defence mechanism where people may not accept the fact that they are dying or will die. Anger- Upon realisation of the situation to they may get frustrated and angry about their predicament, how and why it has happened. Bargaining- in this stage they realise that they are dying soon and pray for more time. Such phrases like ‘I’ll be a better person, father or Partner’ would be commonly heard. Depression- The person has accepted the fact and is sad about the fact they are dying. They have realised the ultimatum and may have regret over past choices or behaviours and can do nothing about it. Acceptance- People realise that they are dying and finally accept it and have come to a kind of peace with the situation.

CASE STUDY # 2

Using this case study
Outline some nursing interventions that demonstrate applying a palliative care approach using the following headings (150 words)

– Spiritual: Patient in a palliative care often spend their time praying and they become closer to God as they get old. Always respect the patient’s beliefs and values. If the patient is praying do no interrupt him and to the procedures when he is finished praying. Ask him if he want a priest to visit him and give him some prays. Always know the patient’s religion and his beliefs to avoid conflict on giving care

– Comfort: The main goal of the palliative care is to give provide comfort to the patient. Always ask the patient how they are feeling or if they need some help. Simple chat with the patient makes them comfort, a simple questions like “How are you?” can make them feel special and they might think there is still someone who cares to them. Giving what patient’s need and attend to those needs makes the patient feels comfortable.

– Legal: Patient at this stage have their Advance Health Directives, it is a legal document for that the patient did for his future treatment and must be implemented. Always provide patient’s autonomy. We as EEN must always maintain confidentiality and privacy of the patient.

– Pain management: Pain assessment is important for management of the pain. We must always assess the patient’s pain and must have intervention to the pain not only in a pharmacological way but also in a non-pharmacological way because some of the patient cannot take too much medicines. Always ask the patient how are they and report to us if they feel any pain.

– Elimination bowel and urinary: At this time patient’s elimination changed unlike before, some of the patient are incontinent of urine and faeces due to deterioration of the body. Make sure to educate the patient about normal aging that incontinence is a normal process of aging. We must monitor their Input and Output and document it on a Fluid Balance Chart if necessary. If the patient is constipated encourage them to increase fibre in diet and have some exercise. Assist the patient always in the toilet early in the morning and use toilet chair if necessary.

– Skin Integrity: As the patient goes old, their skin becomes dry and fragile. Encourage the patient to use lotion or moisturiser on their skin so that their skin will not be dry. Prevent the patient to have pressure areas by repositioning the patient to different sides every 4 hours. Assess the skin for pressure areas and put some cream on those areas. Document any abnormalities to patient’s skin such as redness and bruise.

– Mobility: Provide patient independence on their care to promote range of motion. Refer patient to physiotherapist if necessary. Encourage the patient to exercise daily. If the patient have mobility aids educate the patient on how to use it properly.

– Mental health physiological support: Patients at this point becomes depressed and feels alone. Always provide communication to the patient using therapeutic and non- therapeutic approach. Always talk to the patient or ask the family to visit the patient.

Describe how you could improve the room and environment for Alexander (100 words) Ask the children to bring pictures of themselves and the parents to bring in any items they think would make the room more comfortable but allow Alexander to decide if they stay… Greenery never hurts and/or a fresh breeze through the window and perhaps a couple science orientated magazines on the side table to peak his curiosity as if you do a trade long enough you will always have a professional interest whether you want it or not.

Reference:

Crisp, J, Taylor, C, Douglas, C & Rebeiro, G 2013, Potter and Perry’s Fundamentals of Nursing 4th Ed. Elsevier Mosby, Sydney.

Brown, D., & Edwards, H. (2012). Lewis’s Medical Surgical Nursing (3rd ed.). Sydney, Australia: Mosby, Elsevier

Department of Attorney General 2014, Advance Health Directives, viewed 10 September 2014, http://www.publicadvocate.wa.gov.au/A/advance_health_directives.aspx

End of life Care Network, Life limiting illness, 2011, Viewed on 09 September 2014 http://www.endoflifecumbriaandlancashire.org.uk/info_patients_carers/life_limiting_illness.php

Hibbert C 2014, Dealing with grief:The 5 Stages of Grief, viewed 10 September 2014, http://www.drchristinahibbert.com/dealing-with-grief/5-stages-of-grief/

O’Connor, M & Aranda, S 2003, Palliative Care Nursing – A Guide to Practice 2nd Ed. Ausmed Publications, Melbourne.

NSW Board of Jewish Education 2012, Autopsy, Transplantation, Insemination and abortion, viewed 10 September 2014, http://www.bje.org.au/learning/judaism/ethics/bioethics/autopsy.html

Palliative Care Council, What is Palliative Care, 2012, Viewed on 09 September 2014 http://www.pallcare.asn.au/about/what-is-palliative-care

Tasmania Department of Health and Human Services 2013, Palliative Care Team, viewed 10 September 2014, http://www.dhhs.tas.gov.au/palliativecare/about/team

World Health Organisation 2014, WHO definition of Palliative Care, viewed 10 September 2014, http://www.who.int/cancer/palliative/definition/en/


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