Holistic approach to palliative care
When taking care of palliative patients, I would take a holistic approach where I would ensure the patients’ and families’ psychological, physical, emotional and social needs have been addressed from diagnosis to death, thus improving the quality of life of these individuals. Also, I would make certain close communication and collaboration exist between my palliative group, palliative patient and their family.
As Wiener, McConnel, Latella, & Ludi, (2013) states, religious and cultural beliefs shapes the lifestyles and experiences of pain, illness and palliative care. In this regard, the patients’ and family’s cultural beliefs on death and dying should be considered since they affect decision making. Moreover, their divine expectations should also be considered when planning their ongoing care. (Wiener, McConnel, Latella, & Ludi, 2013)
When a client has needs that are out of my scope of work, the first thing is to consult with the registered nurse regarding the identified need, and ensure the appropriate health care professional supposed to address the need is informed of this client’s need and they address it. If it is an urgent issue of concern, I would use my knowledge, research, explorative and critical thinking skills to tempolarily manage the issue before the intervention from the appropriate professional.
Advance care directive refers to a legal document outlining the wishes, instructions and preferences for end-of-life care or future health care of individials (Advance Care Directives, n.d). The document also shows healthcare provision regarding decisions in case in the future they are unable to make healthcare decisions. (Advance Care Directives, n.d).
For a patient in pain, the first step is to discover the type and natue of the pain they are experiencing, and depending on the discovered intensity provide analgestic relief. The next step will then be to assess effectiveness of the prescrived medication. However, I will inform the patient that the aim is to manage the pain and discomfort, since complete relief may be impossible. (IHNA, 2013)
In planning end-of-life care for a palliative patient, considerations of the cultural and religious beliefs of the patients and family should be made. Additionally, the wishes and preferences for the patients should be considered. Also, the needs of the patient as determined by the need assessment will play a key role in planning end-of-life care. (Wiener, McConnel, Latella, & Ludi, 2013)
Client’s lifestyle choices are decisions made by patients regarding their way of living. In palliative care, examples of lifesyle choices clients have to make are where they wish palliative care to be offered and how long to spend time with family
Cultural and religious considerations in palliative care
End-of-life ethical decisions are choices made regarding palliative care for patients after consideration of various aspects including the patient’s wishes and preferences and what is best for the patient’s health, especially when an ethical dilemma exist in that there lack clear wrong or right choice.
legal implications.of advanced care directive are conclusions or what the law insinuates regarding advance care directive. For instance, common laws in Australia recognize advance care directives although there lack any case laws that provides guidelines.
Advanced care planning referrals are offered to specialist services of palliative care when there are identified needs of patients that are not being addressed adequately in the current care.
Client education strategies are approaches or techniques used in delivering relevant information to clients or patients, or even their families, by health care providers or professionals.
Palliative approach aims refers to the desired outcomes or intentions of engaging in caring for individuals with life threatening conditions which do not respond to curative measures. The core aim of palliative approach is to improve the quality of life of these patients.
Upon diagnosis of a terminal illness such as cancer, anticipatory grieving is a common reaction related to perceived patient’s potential death or the expected psychological well-being loss. This may be evidenced by sleep pattern alterations, changes in such habits as eating, isolation from social life, anger and denial.
The desired outcomes of the care include appropriate identification and expression of feelings, resumption to normal life, verbalization of process of dying and supporting patients and family in grief. The nursing interventions will be several, among them first assessing the grief stage being experienced so as to help reinforce the feelings of patients and family to normal. To encourage and promote realistic dialogue about what the patients and family feel, an open, non-judgemental environment will be provided by utilization of therapeutic skills of communication as suggested by Vera, (2013). Additionally, supporting expression of family and patient’s honest feelings by encouraging thought verbalization and accepting anger, sadness and rejection expression as well as acknowledging that these feeelings are noirmal will further offer emotional support . Assessing the cultural, religious and personal preferences of patient and family and puttingv them into consideration will be done.
In implementing advance care directive, the nurse has the responsibility of respecting the wishes of the patients legally and ethically. Advance care directives are protected by certain laws while the nurse is guided by certain ethics. However, in a dilemma where there is no provision of what is expected, ethical decision making is expected to prevail after consultation with care providers, patient and family. (Vera, (2013), IHNA, 2013)
Implementing advance care directives
For palliative patients, nursing interventions should be modified to fit their needs since their conditions are severe than those of patients in normal wards. For instance, while managing depression, therapies chosen should be of proven efficiency such as tricyclic antidepressants coupled with psychosocial interventions for cancer patients (Qaseem, Snow, DE, Cross, & Owens, 2013). For normal ward patients, psychosocial interventions alone may prove effective without antidepressants. (Qaseem, Snow, DE, Cross, & Owens, 2013).
For effective need assessment of the palliative patient, firstly is to define the assessment scope by deciding the purpose for undertaking the need assessment and the source of information. Information will be collected using checklists, rating forms and observation schedules. Information may be obtained from the patient, family or health professionals who have treated or cared for the patient. Secondary information sources such as books indicating the supposed needs of patients with similar illness as your patient may also be a helpful information source. Additionally, through observation of the patient’s reactions and behaviours can indicate their needs. Based on the information gathered, the needs are listed and may be categorised in groups such as physical, social, psychological and behavioral. Evidence based interventions are then identified to address these specific needs. To ensure effectiveness in the whole process, a condusive environment for patients and family to freely express themselves will be provided and encouraged to be honest for their own good. Also, enough exploration of secondary sources of information will be done to guide in what is expected and also guide establishment of research questions. (Potter & Frisch, 2007)
Ethical issues in palliative care include autonomy, decision making, nutrition, treatment and dehydration (Mohanti, 2009) . To address these issues, patients should decide about their care, their decisions respected together with their beliefs. Also, being aware of the changing needs of patients as their conditions progresses and addressing them is ethical. (Mohanti, 2009)
Life limiting illnesses are conditions where there lack reasonable hope of being cured and as a consequence, they are associated with death. Life limiting illnesses affect activities of daily living in different ways. Some patients may loose total independence rendering them unable to perform simple basic tasks such as eating, bathing, walking or dressing. Others may affect some parts of the body rendering patients able to do some activities and failling to do some. In most cases, the effect on activities of daily life deteriorates as the disease progresses.
Ethical decision making in palliative care
Facility assessment checklists is a series of individual evaluation for nurses to evaluate decline of activities of daily living (ADLs) processes so as to determine areas that require improvements (NHQI, 2003).
The four impacts of loss and grief are altered cognitions, emotional responses such as sorrow and depression, physical sensations and altered behaviours (IHNA, 2013).
Some legal issues related to palliative care approach include advance care directives, and issues related to euthanasia, who to make end-of-life decisions in case there is no advance care directive, and medical futility (McGowan, 2011)
Pain should be managed depending on its intensity. In palliative care, pain assessment should be thorough to ensure appropriate management strategies are developed (MacLeod, McAllum, & Swire, 2014). In managing pain, a drug use guideline, pain or analgestic ladder, has been provided by World Health Organization. This is a schema that guide symptomatic relief of pain (MacLeod, McAllum, & Swire, 2014). On the ladder’s first step, a non-opioid is utilized-in most cases paracetamol or non-steroidal anti-inflammatory drug- for analgestic. A weak opioid is then added in step two and taken together with the paracetamol. In step three, a strong opioid such as morphine is utilized in severe and moderate pain (MacLeod, McAllum, & Swire, 2014).
Holistic assessment of patients is essential in nursing as it provides the patient’s care foundation. Since nurses have the responsibility of caring for the whole patient, including their physical body, soul and mind, it is important that they assess carefully all the patients needs ranging from psychological and social to emotional and physical needs.In this regard, an enrolled nurse is expected to use creativity, knowledge, intuition and expertise in ensuring a holistic assessment of the needs of patients (Potter & Frisch, 2007). Consultation with the registered nurse makes more effective the assessment outcomes. (Potter & Frisch, 2007).
Knowledge of pathophysiological changes associated with life-limiting illnesses is important as it helps in identifying the needs of the clients as the illness progresses. This is because nurses will have an understanding of abnormal physiology of the life limiting illnesses. Additionally, pathophysiology knowledge helps enrolled and registered nurses in their practice understand, develop and apply suitable treatment plans (LSUA, 2016).
Understanding the physiological changes by enrolled nurses in the dying process is vital in supporting client and family and catering for their needs. physiological changes understanding enables nurses to better develop appropriate nursing interventions to emotionally, physically and socially support clients and family. Also, by effectively communicating to the family on the progress and what is expected gives the client and family an opportunity to make informed cultural, spiritual, emotional and lifestyle decisions.
Nursing interventions for life-limiting illnesses
Paliative care has different impacts on clients and their family members. With regard to psychosocial impacts, it helps clients retain their self esteem and dignity even during their last days of their life. Also, through palliative care, such emotions such as anger and depression by clients and family members resulting from the effects of the diseases are managed through palliative care nursing intervetions. Through palliative care, stigmatization cases of clients and their family are dealt with and eliminated. Therefore, palliative care improves the life of both clients and their families by ensuring their psychological and emotional issues have been addressed. (Anthony, et al., 2012)
During the bereavement period, the involved parties may require bereavement care. In Australia, this is provided by various Australian and International Bereavement Services such as Australian Center for Grief and Bereavement, the Bereavement Care Center, Canberra Grief Center, Good Grief, Hope Bereavement Care, among others (ACGB, n.d). These support services provide bereavement care by offering support groups, berieved information, workshops, and individual and family grief counselling support which is centered on mental, emotional, spiritual and physical wholeness (Tuckers, 2016). These support services can be acquired by contacting specific centers where attendance of counselling sessions will be arranged. Others provide their services through telephone calls and others through the internet. (ACGB, n.d) and (Tuckers, 2016).
There are various concerns that arise regarding caring for a body after death. These concerns range from legal and cultural, to religious and personal. Among the concerns is who is responsible of performing what tasks. Caring and body preparation may be the responsibility of the family, friends or nursing staff, depending on the beliefs of the client and family. Some families may need time with the body, others may prefer to wash and dress it, while others may not want to be associated with it at all. Other concerns pertain to the environment the care of the body is provided. As Hospice, (n.d) suggests, the body should be cared for with dignity. The cultural and religious wishes of clients and family are another concern that should be respected, preparing the body for viewing where applicable and also for transfer to the mortury. Other concerns pertain to ensuring that those who come into contact with the body are protected and timely death verification (Hospice, n.d).
For individuals with life-limiting illnesses, barriers to performing activities of daily living (ADLs) are contributed by pain, balance and strength, depression, fear of falling, poor communication with caring nurse and medication management (Anthony, et al., 2012). In this regard, interventions should focus on eliminating these barriers. Such interventions include appropriately managing pain using the suitable analgesia options, holistic assessment of causes of imbalance and weakness and addressing the identified needs, using anti-depressants or other involving the patient in social activities to reduce solitude and depression, and creating a good relationship between nurses and clients to allow effective communication between them. Additionally, the independence can be increased by reducing the barriers in the physical environment of clients (Anthony, et al., 2012). This will ensure clients of their safety thus eliminating fear of falling. (Anthony, et al., 2012)
To identify that death is imminent, the death rattle sound is an indicator, as respiratory secretions of the patient are alter breathing, vision becomes blur with upward rolling eyes, and cold extremities. Documentation of these events should be done consistently as they occur so that they may be used to report the events that occurred. (IHNA, 2013).
Family meetings are a useful channel for conveyance of information, discussion of care plans and strategies between health care professionals and clients and family. To make them effective, a number of areas should be considered and include outlining clear agenda and overt purpose, proper choosing of meeting place to ensure privacy, suitable planning and deep consideration of who to attend, and a proper disseminating method for the meeting’s outcomes (Hudson, Quinn, O’Hanlon, & Aranda, 2008).
Palliative care is an approach that aims to improve the life of clients with serious illnesses that cannot be cured, but rather reducing their detrimental effects by releiving the patients the symptoms as well as stress associated with these diseases. Through palliative care, the client and family are also supported emotionally, psychologically, physically and socially. Care and support are provided from the time of diagnosis to the time of death, reducing pain, increasing independency of clients and ensure death is approached with dignity.
For curative care, it is offered with an aim of curing certain diseases when patients are suffering from diseases that are treatable. Although pain and stress may be managed during curative care, other medications and care practices are focused on curing the conditions rather than controlling the symptoms.
References
Advance Care Directives. (n.d ). What is Advance Care Directive.Retrieved on April 14 from https://www.advancecaredirectives.sa.gov.au/about
Anthony, T., Tanner, E. K., Roth, J., Greeley, M. E., Dorsey, C. D., & Szanton, S. l. (2012). Nursing Strategies for Promoting and Maintaining Function among Community-Living Older Adults: The CAPABLE Intervention. Geriatric Nursing , 33(6): 439-444.
Australian Center for Grief and Bereavement, ACGB. (n.d). Other Bereavement Services . Retrieved on 13 April from https://www.grief.org.au/ACGB/Bereavement_Support/Other_Bereavement_Services/ACGB/Bereavement_Support/Other_Bereavement_Services_1/Other_Bereavement_Services.aspx
Hospice. (n.d). Care After Death: Guidance for Staff Responisble for Care after Death.
Hudson, P., Quinn, K., O’Hanlon, B., & Aranda, S. (2008). Family Meetings in Palliative Care: Multidiscuplinary Clinical Practice Guidelines. BMC Palliative Care , 7:12.
Institute of Health and Nursing Australia, IHNA. (2013). Provide Nursing Care for Clients Requiring Palliative Care, Version 3
Louisiana State University at Alexandria, LSUA. (2016). What is Pathophysiology?Retrieved on April 13 from https://online.lsua.edu/articles/healthcare/what-is-pathophysiology.aspx
MacLeod, R., McAllum, C., & Swire, T. (2014). Pain Management in Palliative Care. New Zealand : Hammond Care.
McGowan, C. M. (2011). Legal Aspects of End-of-Life Care . The Journal of High Acuity , Progressive and Critical Care Nursing , 31(5):64-69.
Mohanti, B. K. (2009). Ethics in Palliative Care. Indian Journal of Palliative Care , 15(2): 89-92.
Nursing Home Quiality Initiatyive, N. (2003). Activities of Daily Living (ADL) Decline: Facility Assessment Checklists. Primaris
Potter, P. J., & Frisch, N. (2007). Holistic Assessment and Care: Presence in the Process . Nursing Clinics of North America , 42(2): 213-228.
Qaseem, A., Snow, V., DE, P. C., Cross, J., & Owens, D. (2013). Evidence-Based Interventions to Improve the Palliative Care of Pain, Dyspnea, and Depression at the End of Life: A Clinical Practice Guideline from the American College of Physicians . Annals of Internal Medicine , 148(2): 141-146.
Tuckers. (2016). Counselling Support .Retrieved on April 13 from https://www.tuckers.com.au/after-funeral/bereavement-care/people-need-support
Vera, M. (2013). 13 Cancer Nursing Care Plans. Nurseslabs .Retrieved on April 14 from https://nurseslabs.com/cancer-nursing-care-plans/
Wiener, L., McConnel, D. G., Latella, L., & Ludi, E. (2013). Cultural and Religious Considerations in Pediatric Palliative Care . Palliat Support Care , 11(1):47-67.
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