Palliative care by N7vJp41


									Living with serious chronic
  Personality as a predictor of the
     development of disease
• Health-aversive behaviors
• Genetic factors
    Problems of people with serious
           chronic diseases
•   Concerns with requirements of treatment
•   Concerns with ongoing symptoms
•   Increases in pain
•   Fatigue
•   Depression
•   Anxiety
      Psychosocial intervention for
•   Counselling
•   Psychotrherapy
•   Cognitive-behavioral therapy
•   Pain control techniques
•   Biofeedback
•   Relaxation
•   Hypnosis
•   Guided imagery
•   Music, art therapy
•   Group support
       Adaptation to cancer
Coping styles:
• Fighting spirit
• Helplessnesshopelessness
• Denial
• Avoidance
• Spirituality
  Prolongation of survival in cancer
             patients ()
Study Cunningham and Watson, 2004 revealed through
  interview and diary the following common themes along
  long-term survivors:
• A clear understanding of what is important in one’s life
• The perceived freedom to shape life around what was
• A perceived change towards enhanced self-esteem,
  greater tolerance for and emotional closeness to others,
  and a more peaceful and joyous affective experience
    Emotional problems in those who
•   Fear
•   Anxiety
•   Depression
•   Hopelessness
•   Fatigue
•   Stigma
•   Pain
•   insomnia
                          Cancer Nurs. 2006 Sep-Oct;29(5):391-9. Links

     Living with incurable cancer at the end of life--patients' perceptions on quality of life.
                           Johansson CM, Axelsson B, Danielson E.

•   This study describes incurably ill cancer patients' perceptions of the quality
    of life at the end of life. Purposeful sampling was used to get as
    comprehensive descriptions as possible about quality of life. Five patients
    participated in repeated focus groups. Content analysis showed that the
    patients emphasized what they could perform and enjoy in daily life, not
    their shortcomings. Five themes were developed: "valuing ordinariness in
    life," "maintaining a positive life," "alleviated suffering," "significant
    relations," and "managing life when ill." The themes describe that the
    patients could participate in daily and social life despite cancer. Relation
    with family and palliative team deepened during the progress of illness in
    such that a resonance developed in communication. Other important
    findings were that patients' memories helped them to maintain a positive life
    and that the patients used individual strategies to relieve pain by emotional
    and physical distractions. For the patients, managing life as ill meant taking
    actions with creative thinking in solving problems as a way to cope and
    achieve quality of life. These positive findings from the focus groups have
    led to continued research regarding how patients with incurable cancer
    perceive quality of life.
Palliative care
• To relieve the pain symptoms and the
  stress of serious illness whatever the
  diagnosis or prognosis
• It can be delivered along with meds that
• Team: doctors, nurses and social workers
• Customizes treatment to meet the needs
  of each individual person
• Cancer, chd, any condition that has pain
• Patients receiving palliative care are better
  receiving treatment their doctor has
  reccomended them
• Patients need care from people who are
  looking at them as a whole individual
WHO Definition of 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, 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. Palliative care:
• provides relief from pain and other distressing symptoms;
• affirms life and regards dying as a normal process;
• intends neither to hasten or postpone death;
• integrates the psychological and spiritual aspects of patient care;
WHO Definition of Palliative Care
• offers a support system to help patients live as actively
  as possible until death;
• offers a support system to help the family cope during
  the patients illness and in their own bereavement;
• uses a team approach to address the needs of patients
  and their families, including bereavement counselling, if
• will enhance quality of life, and may also positively
  influence the course of illness;
• is applicable early in the course of illness, in conjunction
  with other therapies that are intended to prolong life,
  such as chemotherapy or radiation therapy, and includes
  those investigations needed to better understand and
  manage distressing clinical complications.
    How Successful is Palliative
• When the objectives just listed can be realised, the
  patient will end his days in comfort, he and his family will
  be enabled to cope with dying, they will feel secure
  rather than anxious, they will be assured of competent
  care which will not be withdrawn, they will be
  encouraged and enabled to be open with each other,
  and the family will later be offered support, if needed, in
  their bereavement. The actual achievement will not
  always reach those heights, of course, and it will be
  dishonest and useless to pretend that dying will always
  be, or could be, made dignified and comfortable. When a
  person is socially isolated and alienated, it would be
  foolish to expect palliative care to work miracles, and so,
  sometimes, the outcome is meagre indeed.
       How Successful is Palliative
•   The usual result lies somewhere between those two extremes. While the patient is
    the proper centre of attention, the family will sometimes be the main recipients of the
    benefit from palliative care, before and after death. When a person dies after being
    negligently cared for, the family is left feeling angry, and they must carry that
    unalterable memory for the rest of their lives. When they are satisfied that good care
    has been provided, they have a better chance of resolving their grief normally and of
    experiencing a healthy bereavement.
•   We can only assist patients and families to meet their challenges, enabling them to
    use whatever resources they have already acquired up to this time, and perhaps to
    build on them. There may have been a lifetime habit of avoiding threats of all kinds, a
    psychological device which is commoner than may be supposed. In that case, the
    opportunity to learn the necessary skills to cope with challenge has never been taken
    up. Another factor of growing importance is the greater loss of religious faith in the
    community, whereby life is now experienced only in terms of its earthly dimensions. If
    there is no perception of life after death, and if one has failed to find a sufficient
    meaning in human experience, the end of life can be a barren time. But that is not
    always the case, and there is little direct association between professed religious faith
    and an ability to face death with acceptance.
   How Successful is Palliative
• Dying is always sad, it is often difficult and is
  occasionally overwhelming. The control of
  physical pain is probably the easiest part, when
  sufficient skill has been acquired, when one
  knows one's limitations and is then prepared to
  summon an expert, if necessary. Relieving
  severe pain is undoubtedly the single greatest
  boon which any person can offer another, and is
  often, of itself, enough to enable the patient to
  attend to other important aspects of his
  relationships of all kinds, which make the
  greatest contribution to personal contentment.
     How Successful is Palliative
• The patients who present the most difficult challenge are those with
  chronic, incurable illnesses which, while not presenting an
  immediate threat to life, will probably cause death at some future
  time. Such are those with quadriplegia, multiple sclerosis, some
  motor neurone diseases and so on. Some of them have an
  objectively low quality of life, and life for most of them will deteriorate
  as time passes. They evoke our pity and are the focus of much
  interest by those who favour euthanasia. Whatever we may think of
  their condition, they are generally content, and continue to value
  their life.
• But, like others with disabling chronic illness, they become
  depressed from time to time and may ask for release from life. What
  are we to do? Apart from continuing to provide excellent care, there
  are no agreed human answers to their problem, as indeed there are
  no answers to many of life's most difficult challenges. I shall return
  to this point again later.

• Euthanasia is the intentional killing of a person,
  for compassionate motives, whether the killing is
  by a direct action, such as a lethal injection, or
  by failing to perform an action necessary to
  maintain life, called an omission. For euthanasia
  to occur there must be an intention to kill. This
  intention makes it murder.
• Physician Assisted Suicide involves providing
  a person with the means of committing suicide
  and then allowing that person to perform the act.
• Murder occurs when the death of a human being is
  caused by an unlawful act or omission with either intent
  to kill or to inflict grievous bodily harm or done with
  reckless indifference to human life.
• Manslaughter occurs when the death of a human being
  is caused by an unlawful act or omission, the act or
  omission being either criminally negligent or unlawful and
• Negligence is the failure to observe the standard of care
  required by the law of a sane and reasonable person in
  the given situation. Criminal negligence is the very high
  degree of carelessness going beyond mere civil
  negligence and satisfying a jury that the accused's
  conduct showed such disregard for the life and safety of
  another or others as to amount to a crime against the
•   1.1 Role of doctors, including psychiatrists
    How different is doctor-assisted dying compared with withdrawing life-prolonging
    Is it ethical to intentionally cause death?
    Is it compatible for a psychiatrist to work on preventing suicide, on the one hand, and
    take part in proceedings that may lead to doctor-assisted dying on the other?
    How should we help distressed people work towards decisions about their end of life
    1.2 Decision-making capacity
    How reliable is the assessment of capacity?
    What are the factors that affect capacity?
    1.3 Physical disability often coexists with mental disability (co morbidity)
•   Does this mean that psychiatric issues should always be considered in end of life
    decision making? Should psychiatrists be members of palliative care teams?
•   1.4 Depression and suicidal ideation in terminal illness
    How good are physicians at diagnosing depression? A failure to diagnose depression
    could put people requesting PAS at risk.
    Should treatment of depression always be offered to patients requesting doctor-
    assisted suicide?
    1.5 Further effects of legislation
    Will it be more harmful to deny those patients that want doctor-assisted suicide, or to
    expose vulnerable patients to the risk of wrongful determination of their mental
    capacity, and/or coercion? Would this legislation expose vulnerable patients to the
    risk that their desire for suicide may be taken at face value rather than treated?
    Would it expose all psychiatric patients to a culture where some patients are helped
    to die?
• Self-assessment of quality of life has a
  significant relationship to the choice of
  chemotherapy and survival thresholds.
• The physician's opinion regarding
  chemotherapy is the other important
• Consideration of the time pressures on
  physicians should be addressed urgently
  to improve doctor–patient communication
• Control of pain, of other symptoms,
  solution of the psychological, social and
  spiritual problems improve the quality of
  life in incurable cancer patients.

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