End of Life Palliative Care

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					                       End of Life / Palliative Care
                       Meets Florida Requirement
                              2 contact hours
                               Course # 103
                      Author: Monica Oram, RN, BSN

This course is intended for the reader to be able to achieve the following
1. Understand the difference between palliative care and curative treatment.
2. Understand Advance directives, and living wills.
3. Use of pain management and comfort techniques
4. Emotional and psycho-social and spiritual needs of terminally ill patients
   and their families.
5. Understand what is involved for palliative care.
6. Appropriate use of medications in terminally ill
7. Methods of communication with families regarding anticipated grief and
   Loss of loved one.

                             What is Palliative care?

Palliative care is when the focus of treatment shifts from cure to comfort.
Patients who are terminally ill and their families may consider this choice
when providing comfort would be of greatest benefit. Palliative care helps
ensure this time can be lived as fully as possible, in peace- physically and
emotionally. Searching and fighting for a cure becomes less of a benefit as
compared to maintaining a quality of life through comfort measures. Due to
some medical treatments taking too long and too much of a toll on
terminally ill patients, it is becoming more of a choice to seek out palliative
care. Often times curative treatments are far to aggressive for the terminally
ill, and the side effects associated with curative treatment modalities are far
more than the patient can tolerate. Therefore, palliative care is a decision
often made while receiving hospital care for the terminally ill. Palliative care
is a positive choice being made by both the patient and the families, as it is a
choice for quality of life.
                     What is involved for palliative care?

Palliative care involves caring for the whole patient- not just the illness. This
means that healthcare workers need to be more focused on the individual
and be aware of pain management concerns, helping to ease symptoms of
illness, and caring for conditions that cause discomfort.

The patients emotional and spiritual well being is just as important as the
patient’s physical comfort. As the patient’s medical and physical condition
begins to change, there is often more focus on palliative care.

Pain control is a big focus of palliative care. ( More on pain management to
follow) Medical measures to help reduce pain can include the use of pain
medications, radiation to shrink tumors, surgery to remove growths and
masses, nerve blocks to deaden the pain.

Palliative care involves making a pain management plan. The patient has the
right to adequate pain control. The patient should feel comfortable enough to
be able to discuss needs and concerns with those who are involved in his/her
care. Healthcare professionals have the obligation to make sure the patient is
comfortable and not be judgmental by labeling the patient as a “complainer”.

Palliative care can and should also provide comfort in other areas than just
pain management. For instance, the patient should be comfortable in regards
to their breathing ability. They may require bronchodilators, nebulizer
treatments, or the use of oxygen to facilitate better respiratory status. They
may need to be assessed and monitored for the need of diuretics as well.
Some may need the benefit of anti-anxiety medications. Increased anxiety
will cause increase in difficulty breathing. In addition, the healthcare
professional should be mindful to the need for anti-emetics/anti -nausea
medications. The focus is on the comfort of the patient.

Palliative care can also focus on the need for antibiotics for infections, and
IV therapy as appropriate. Remember, choosing comfort over cure does not
mean less care. It means more care for conditions that affect the patient’s
physical comfort.

Part of Palliative care is offering emotional support. Some suggestions
would be to:
 Offer and arrange for counselors, volunteers, involvement with
  community support groups and community resources.
 Help make it possible for families to spend quality time with their loved
 Find ways for the patient to share feelings, thoughts, and ideas
 Help make it possible for the patient to continue to enjoy activities and
  interactions as much as possible.

Healthcare professionals should be mindful to the patient’s concerns
regarding worry and anxiety. The use of medications may be appropriate, but
there are other methods that could be implemented.
Such as :
 allow the patient to discuss his fears and concerns
 Guide the patient through relaxation exercises to help calm him down
 Answer questions and concerns regarding treatment and comfort

Spiritual support should be an important focus in palliative care and
treatment. Offer clergy or a religious advisor to spend time with the patient.
This can be useful, valuable insight for the patient, as well as a good way to
relief fear and anxiety.

                   Making Choices About Palliative Care

When it comes to patient choices in regards to palliative care, the patient
essentially has two choices:
1. The patient must decide if they believe in fighting the course of the
   illness, no matter what the cost- even if a cure is not likely.
2. The patient must decide if they believe that quality of life is most
   important, right up to the final moments of life.

The patient who is in favor of choice one, wanting to fight for cure, even if a
cure is not likely is probably not one who is ready to accept palliative care
measures. They have more of a focus on medical treatment of the condition.

Those who are in favor of quality of life, and supportive care measures are
more favorable for palliative care modalities.
Sometimes a patient may be mixed, with deciding between the two choices.
In this case the patient will then need to decide how to best balance medical
treatment and palliative care.

Some of the options available for palliative care include:
1. Home Health Care
2. Hospice
3. Be as pain free as possible
4. Be as alert as possible
5. Maintain as much independence and cognition as possible
6. Be free of artificial means of survival ( Tube feeding, Ventilators, Ect)
7. May choose to be a Do Not Resuscitate

When a patient/family is faced with the choice of palliative care measures it
is important to consider the following:
1. Does pain threaten to make end of life less fulfilling?
2. Will a change in treatment make it more possible for the patient to do
    things he/she enjoys?
3. Will this allow quality time to spend the last days with family, and to get
    affairs in order?
4. Will there be support of healthcare and family to manage pain issues,
    anxiety, or any other discomforts?

                       Insight On Advance Directives

One important issue in regards to palliative care and end of life issues
involves the implementation of advance directives. Advance directives help
ensure the patient’s wishes are followed when they become unable to speak,
and/or make choices on their own.

Two specific types of advance directives include:
1. Durable power of attorney
2. Living will

A durable power of attorney gives a person who is designated by the patient,
the right to make choices and healthcare decisions on behalf of the patient
when they are unable to do so.
A living will is created while the patient is alive, and therefore this is why it
is called a living will. Simply put, a living will outlines the kinds of care the
patient wishes to receive, and what they do not want in certain situations.

State Laws allow patient’s to be able to make their own choices. Laws vary
from state to state, but they still have the ability to make healthcare decisions
and choices.

                          Focus on Pain Management

Pain management is a very important part of palliative care. Pain is defined
as a complex subjective sensation reflecting real or potential tissue damage
and the response to it. Pain can be described as acute or chronic,
somatogenic or psychogenic. Recurrent acute pain, such as with sickle cell
crisis, and continuous pain is an unending pain with out remission or relief.
Acute pain only lasts a short time. (less than a month) It is a protective
mechanism that warns about potential bodily injury and problems.
Chronic pain is pain that lasts more than a month after occurrence of an
acute tissue injury or physical medical condition. Pain is considered to be
chronic if it persists more than three months, or is expected to continue to
get worse or progress. Chronic pain serves no biological warning or
protective purpose. Chronic pain is often accompanied by depression, lack
of sleep, and limited mobility. Other complications can include constipation,
decreased appetite, and loss of taste. ( to name just a few)
Somatogenic pain is organic in nature and is caused by organic patho-
physiology, meaning it is pain originating from within the body.
Psychogenic pain occurs in the absence of any organic pathology that can
not explain the presence or extent of the pain. It is said to be a result of a
psycho-somatic etiology for cause of pain.

In contrast, Pain management is defined as the systematic study of clinical
and basic science and its application for the reduction of pain and suffering.
The blending of tools, techniques, and principles taken from the discreet
healing art disciplines and reformulates pain to be viewed from a holistic
approach for reduction of pain and suffering. Holistic approach to pain
management is focused on the whole patient, mind, body and soul.

One of the primary goals of Healthcare professionals is to provide relief
from needless suffering and pain that affects so many of our acute, chronic,
and terminally ill patients, and diminishes their ability to enjoy optimal
quality of life.

                         Assessing Pain Management

Methods to assess pain should begin with a base line assessment.
 This assessment should include an understanding of how the patient
   describes his pain. ( dull, ache, sharp, ect.)
 Also assess for other methods that the patient or family has sought out as
   a treatment modality to help with pain control.
 The healthcare professional would want to also assess the patient’s
   cognitive ability by determining mental status and orientation.
 Assess pain level by using the scale of 1- 10.( With one being minimal, to
   ten being the worse pain imaginable)
 It would be helpful to assess the patient/family beliefs and attitudes
   related to pain, and treatment modalities.
 Take in to consideration the history of past failures or successes and/or
   adverse side effects experienced with different pain management
   treatments, including analgesics.
 Determine any barriers that could lead to the patient not being able to
   report pain, such as fears, ethnical origin, culture, diminished cognition,
   or inability to speak.
 Assess for history of any chronic disorders that could contribute to or
   cause pain.
 Assess for anxiety and depression, and ways in which the individual has
   coped with pain in the past.
Part of doing an adequate pain assessment includes reassessment. As part of
reassessment, the healthcare professional should assess and document the
pain in terms of duration, characteristics, location, intensity, and frequency.
Also note the time, pain rating on the pain scale of 1-10, and any use of pain
medication followed by the effectiveness of the medication, if given.
Other pain interventions include monitoring and documenting vital signs,
effectiveness of all interventions, and any side effects or adverse reactions.
                    Non- Invasive and Medication Options

With all of the focus on treating the “whole” Patient, we have discussed
several methods for providing palliative care. Though the focus is on ways
to make certain the patient is kept comfortable, and needs are met physically,
emotionally, spiritually, and socially sometimes the need for medication has
its place in comfort measures.
A number of non-pharmacological therapies are available as a form of mind
diversion to take the focus off of pain. They include non-invasive techniques
such as TENS units, massage therapy, physical therapy, chiropractic therapy,
and acupressure. The application of heat and cold are also effective
alternatives. Research has shown that a supportive environment is very
effective in controlling pain. Participation in activities and plan of care gives
the patient a sense of control over the pain. This will also show the patient
that the healthcare team is sincerely striving to provide comfort and is
willing to implement or modify the pain care plan based on the patient’s

In reference to medication choices, depending on the nature, source and
intensity of pain, pharmacological interventions may be necessary.

Non-opioid and opioid analgesics are commonly ordered.

Non- opioid medications include acetaminophen, and NSAID’s ( Non
Steroidal Anti-inflammatory Drugs) such as ibuprofen and other common
over the counter type analgesics. They are useful for mild to moderate pain

Opioid medications are a synthetic or natural narcotic medication that
produces an antagonist action by binding to the opiod receptors in the central
nervous system. They are successful in the management of severe pain
management. Although they create physical dependence in those who use
them for a prolonged period of time, virtually all patients who take them for
chronic pain management , addiction is actually rare according to research
conducted by the Federal Drug Administration. Opioids should be used
properly when chronic pain is a serious reality.

The most common opioids are morphine, Demerol, hydromorphine, codeine,
and oxycodone. There are many types with the similar compound makeup.

Of these, Morphine is usually a better choice than Demerol for the elderly
because it has a higher duration rate of action, and less total dose is generally
required. A lower total dose decreases the risk for hemodynamic alterations
and other associated adverse reactions and toxicity.
                        The Need For Improved Care

Back in the early 1900’s, healthcare professionals had little to offer the
terminally ill, sick and dying. Most of what to be offered was focused on
palliative care even back in the time period of the early 1900’s. Easing
symptoms associated with disease and offering emotional support through
the presence of family members caring for the dying was about the best one
could hope for. Many died within days of onset of symptoms of illness.

As science and technology began to bring about changes, such as
improvements in living and working conditions, sanitation, and an emphasis
on disease prevention, the outcome of patient illness proved to be a benefit
as people were then beginning to live longer, more productive lives.
Science and technology has come along way, bringing antibiotics, life saving
techniques, CPR, and advanced medical treatments which has shifted the
focus from easing suffering to curing disease. As we are living in a very
evolved society, technology and medicine has continued to make miraculous
changes in our healthcare industry. Still, medical modalities are far from
perfect. As long as we continue to have sickness and pain in our society,
there will always be the question as to what treatment is best. With the
ability to make choices and decisions we will see that palliative care will
lead the healthcare industry as our focus shifts once again, from medical
treatments to patient comfort and supportive care measures.


End of life issues and palliative care is a changing way patient’s are
choosing for their healthcare needs. As healthcare providers, we need to be
aware of how to meet these needs. At the end of life, nursing care should
shift from a focus of “wellness” to an understanding of “healing” in ways
that will enhance the quality of the individual’s life. Not all deaths are
peaceful. It may be difficult to control symptoms, or to resolve all issues that
the patient or family wishes to address. Working with the dying is never
easy. At the same time, the satisfaction of having helped a person with his or
her fears of death generates a new understanding, a new level for personal
self- awareness and a new capacity for giving.

Mosby Year Book, 2000 Mosby drug Reference

Springhouse Publishers Nursing Procedures and Assessment, Third edition
Springhouse, Pennsylvania

Brunner and Sudderath’s Medical and Surgical Nursing, JP Lippencott, 1998
Philadelphia, Pennsylvania

Mosby Year Book Mary M. Cannobis, Handbook of Patient Teaching,
Mosby Year Book, St. Louis, Missouri, 1998

American Academy of Pain Management

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