Prepared by:

AUBREY C. ROQUE RN, MAN

It is designed to give supportive care to people in the final phase of their lives 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

Affirms life and regards dying as a normal 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 patient’s

families to cope during the patient’s illness and in their own bereavement.

Uses a team approach to address the needs of the patients and their families, including bereavement counselling, if indicated.

Will enhance quality of life and may also positively influence the course of illness.

Is applicable even in the early course of the illness in conjunction with other therapies and may also involve studies that may better understand and manage the disease.

To palliate physical symptoms

To maintain independence for as long and as comfortably possible

Alleviate isolation, anxiety and fear associated with advancing disease.

Provide a dignified death.

Support those who are bereaved.

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.

PALLIATIVE CARE- is designed to give support and comfort rather than cure of the illness or problem.

SPECIALIST PALLIATIVE CARERequires a high level of professional skills

from trained staff It refers to a service provided by a

multiprofessional team led by clinicians led by clinicians with recognised specialist palliative care training.

Nurses Doctors Physiotherapists Occupational therapists Social workers Chaplains and volunteers

“Team work” is the key to a successful and efficient palliative

care.

Current licensure in the state of practice

Minimum of one year of clinical practice in nursing. OncologyPsychiatryHome 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 nurse’s self-care needs with the complexities and intensities of repeated encounter with death.

1.) PALLIATIVE CARE IN HOSPITALSThe most common place to die for peopleThe ways in which staff perform their care

for the dying is usually determined by the hospital’s policies and routines.

2.) PALLIATIVE CARE IN THE COMMUNITY20th century – majority of people died at

homeCurrent trend – a rise of 66% of death in

institutionsDying patients usually prefer to die in a

“home setting”

3.) DAY CAREUnits based in hospices where patients

with advancing disease can attend on a day basis.

Care provided includes social and therapeutic benefits for the patient (eg: aromatherapy, wound dressing, bath)

CARE HOMESThese nursing homes provide care for

elderly patients who require constant medical treatment, but do not require advanced care and specialized doctors in a hospital.

COMMUNICATION- is the essential process by which individual share something of them, whether it is thoughts, feelings, opinions, ideas, values, or goals. (chapter 5)

The first impression of people towards us is determined by 45% of our verbal communication

skills and 55% of non verbal skills.

The greater part of an individual’s personality is developed and maintained through social interaction.

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

It’s 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).

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.

One of the most important messages that we need to convey to a person with advanced illness is hope.

Barriers to good communication 1. 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 the subject, such as telling jokes or changing the subject.

Barriers to good communication

2. Poor communication skills of the 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 armsmiling gesturing leaning forwardcaring 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.

Barriers to good communication

3. Depth of the physician–patient 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.

4. Personal experiences of illness and death: May affect their ability to care for a person who is at the end of life.

5. Physical, emotional and psychological stress and depletion: May affect ability to communicate caring, empathy and compassion.

Barriers to good communication

6. 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.

7. 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 patient’s feelings and reactions or inability or fear of discussing these emotions.

8. Fears of emotional outbursts: HCPs are often not taught how to show empathy and caring and may fear emotional outbursts.

9. 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.

Barriers to good communication

10. Guilt and self-blame due to introgenic 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 patient’s situation.

11. 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.

Barriers to good communication

12. 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 one’s 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; patient‘s 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 open 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

Practical aspects of communicating at the end of life

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

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 one’s own mortality

NOTE: it is often the doctor’s 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.

AUTHORITATIVE INTERVENTIONS – are practitioner-led strategies wherein the practitioner(nurse) takes responsibility for the client, with the aim of guiding their behavior.

PRESCRIPTIVE – the helper seeks to direct the nehavior of the client.

INFORMATIVE – the helper gives the client information

CONFRONTING – the helper tries to raise the client’s consciousness about an attitude or behavior.

FACILITATIVE INTERVENTIONS – aim to help patients be more autonomous through emotional release, self-knowledge and learning, and affirmation of their value and being.

CATHATRTIC – the helper encourages the client to release painful emotions such as fear.

CATALYTIC – the helper elicits self-discovery and problem solving in the client.

SUPPORTIVE – the helper affirms the worth of the client’s attitudes, qualities and actions.

It is a requisite skills for care providers in the end-of-life care to determine the two important psychological complications of being terminally sick. These skills are:

Assessing DepressionDEPRESSION is 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 personSadnessResignationApathyHopelessnessOr may become cheerful when decision

come to end suffering

2. Assessing Suicide potential Requisite skills for end-of-life care is the

ability to identify depression and assess for suicidal potential

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.

Quality and compassionate care at the end of life

Based on its definition, it includes a distinct, comprehensive cluster of services for terminally individual and their families which are provided on a continuum of intensity or LEVEL OF CARE.

1. Routine Home Care The most common level of care, the heart of

hospice of care The full scope of hospice service is provided in

the patient’s personal home/residence Care begins in admission process

Assessment and admission of the patient’s status and appropriateness for hospice care

Also focus on the concerns and issues that troubles the patient and family and how hospice can help them

It is directed towards the relieving of specific problems Pain Symptoms of disease Anxiety

There is a continuous reevaluation and reappraisal on the specific needs of the patient and family to ensure that support and comfort oriented services are offered in a timely manner

There is a significant involvement of the family or primary support person in providing direct hands-on care for the patient

With routine home care the patient are able to die as they prefer at home.

2. Continuous Home Care

Is an expanded level of care in the home

A skilled nursing of 24 hours is allowed to ease and prevent hospitalization for management of acute symptoms

The chief reason is management of acute physical symptoms, or may also be used when the burden of care giving for families is greater than their resources

3. Respite Care Supports the patient’s family and the caregiver The family can have rest, vacation or attend

events while the patient is cared for in an in-patient setting.

Respite care is limited to five day period Care is similar to home care but is rendered in

an in-patient setting in a contracted room with basic activities of living assisted by nurses and nursing assistants.

Patients are often very ill or have need for assistance with activities of daily living, which is often the precipitating factor for respite care

Respite care is expensive due to the intensity of care

4. In- patient Care or Acute Symptoms Management

A short term admission to a medicare certified facility for medical problems requiring nursing and medical management

Candidate for in-patient care are those:Whose care are so complex or demanding that

the family can no longer continue to provide home care

PATIENT Problems for in-patient Palliative Care Admission Imminent death under specific conditionActive and potential bleedingSepsisSeizures Impending delirium tremensUncontrolled painAny uncontrolled symptomsCentral nervous system dysfunction

Delirium Coma Dementia

Fractures of weight bearing bonesManagement of complex medicationsAcute cardiac symptoms

Myocardial infarction Arrhythmias

Complex treatment schedule requiring frequent dressing changes or procedures that require the time, skills and observations of a professional nurse

Terminal agitation

NON-MEDICARE LEVELS OF CARE is being provided to expand services to

meet identified patient care needs.

A. Residential Care - is provided in hospice/palliative inpatient

settings for patients who require supportive care related to safety needs, weakness or the inability to perform self-care.

-Also provides a way to offer better continuity for patient who are no longer appropriate for in-patient care status

B. Day Care Designed to provide relief to the caregiver and

diverse activities for the patient There are planned activities, meals, and

observation and assistance as needed. Patients are transported to the day care site by family or by hospice.

C. Extended Caregiver Services or in-home respite care The programs offers a shift s of nursing

assistants to a patient to supplement or substitute for family caregivers

The goal is to keep the patient at home Usually used by working families, frail

caregivers, and in situations where the physical demands for care-giving are beyond the strength of the caregiver.

Also a way to supplement care when residential care beds are not available.

CHAPTER 3

It is a philosophy of care based upon a belief that all aspects of a person must be considered during the treatment of illness and the promotion of quality of life.

This is a recent trend when it comes to principles of treatment in the 21ST century.

BIOMEDICINE – a medical model that says that illness is a dysfunction of the corporeal body wherein the mind is separate from the physical body.

The biomedical approach requires the patient to submit their diseased body to the care of health-care experts for treatment. The view

that the mind had no influence upon physical health meant that it was not usually considered by the physicians.

One fascinating area of scientific study that seeks to demonstrate the body-mind link is the PSYCHONEUROIMMUNOLOGY.

PNI has conducted studies how life events are evaluated as stressors and investigated how stress alters the effectiveness of the body’s immune system.

Factors that may influence health and the course of the disease according to PNI:

ThoughtsFeelingsEmotionsPersonality Beliefs

HOLLISTIC ASSESSMENT IN PALLIATIVE CAREAssessment is the key to effective care

plan. It must be a comprehensive and sensitive

assessment.Holistic assessment may only be done when

the nurse gains idea about personhood.

Personhood – it is one’s identity as a social person.

CULTURAL COMPETENCE refers to an ability to interact effectively

with people of different cultures.Cultural competence comprises four

components: Awareness of one's own cultural worldview Attitude towards cultural differences Knowledge of different cultural practices and

worldviews Cross-cultural skills

Is a patterned behavioral response that develops overtime and is shaped by the values, beliefs, norms, and practices that are shared by members of the same cultural group.

In the twentieth century, "culture" emerged as a concept central to anthropology, encompassing all human phenomena that are not purely results of human genetics

Dimensions Of Culture

GenderAgeDiffering abilitiesSexual orientationReligionFinancial statusResidencyEmployment and Educational level

Refers to a dynamic, continuous process of awareness, knowledge, skills, interaction and sensitivity.

It implies not only awareness of cultural differences but also the ability to intervene appropriately and effectively

To become more culturally competent, nurses are required to learn in the Affective (attitudes, feelings, and beliefs) Cognitive or intellectual or psychomotor or

behavioral domains and assumes skills in critical thinking

Cultural competence is demonstrated when the nurse: Shows respect for the inherent dignity of every human

being irrespective of their age, gender, religion, socioeconomic class, sexual orientation and ethnic or cultural group

Accepts the rights of individuals to choose their care provider, participate in care or refuse care

Acknowledges personal biases and prevents these from interfering with the delivery of quality care to persons of other cultures

Recognizes cultural issues and interacts with persons from other cultures in a culturally sensitive way

Incorporates cultural preferences, health beliefs and behaviors, and traditional practices into the care management plan.

1.) Cultural awareness- examination of one’s own heritage, family’s practices, experiences, religious or spiritual beliefs. Cultural awareness encourages us to examine

the influence of cultural stereotypes ( stereotyping occurs when one makes an assumption about an individual based solely on the individual’s groups membership) have on our beliefs, values and clinical practice

To avoid prejudice, discrimination and interference with holistic care

To find similarities rather than differences

An essential skill in the provision of culturally appropriate services, cultural awareness entails an understanding of how a person's culture may inform their values, behaviour, beliefs and basic assumptions.

Cultural awareness recognises that we are all shaped by our cultural background, which influences how we interpret the world around us, perceive ourselves and relate to other people.

2. Cultural Knowledge- serves as a guide to assist the hospice and palliative care team to gain a better understanding of the individual and family. It is to recognize the uniqueness of an

individual or the differences that exist even within the group.

Differences must be identified to provide culturally appropriate care to the patient and to the family

3. Cultural Skill- is important to assess cultural behavior and beliefs. such as skills in , cultural assessment,

cross-cultural communication, cultural interpretation and appropriate intervention

Working appropriately and productively with others

4. Cultural encounter – the actual experience or immersion to a culture.

When we meet people from other cultures there is the potential for development and change. How we handle this meeting- or a possible conflict- will often be the determining factor for the outcome of the cultural encounter.

1.)Communication-person may cause to return to their most familiar or native language when they are sick.

Recognize the ways in which people of different backgrounds communicate with each other, which includes

Identify the language spoken in the homeHow the patient prefers to communicatePatient’s speaking or reading ability

Interpreter must be necessary for language barrier

Important to recognize the overall characteristics of language and the communication process:

Respect the way a person wishes to be addressed

Be aware of the rules of communication within the culture

Listen to the quality of voice to help understand the message

It is necessary to vary the techniques of communication depending on the individual (communicate in a non hurried manner, listen carefully, and speak slowly and distinctly)

Be aware of acceptable practices; the use of touch, eye contact etc. Types of touch:

Functional professional- exam and proceduresSocial polite – greeting, handshakeFriendship Warmth – hug, arm in shoulderLove intimacy – tight hugs and kissesSexual arousal – by lovers

2.) Space – the dimension of comfort zone

The intimate zone 0-18 inches (whispering)The personal zone 18-36 inches (family and

friends)Social zone 4-12 feet Public zone – 12-25 ft.

Proxemics – study of distance zones between people during communication.

3.) Social organization - the different structures in various groups such as: family, religious groups, ethnic and racial groups.

4.) Time- implications of how cultural group views the concept of time, is important to understand the patient’s response to prognosis and duration of illness.

Future oriented-defer gratification of personal pleasure until future obligations have been met

Present-oriented group – focus on living on the present and are not overly concerned with the future; time is flexible

5.) Environmental control- is the ability of individuals to plan activities that control nature.

6.) Biological variations- physical differences affects assessment findings of individuals with varying skin color.

Nutrition- dietary pattern of cultural group, food is used to assess, treat and prevent illness

Decision making- with the Patient Self-determination Act (PSDA) of 1991 decision making shifted from the physician to the patient

Pain management Death rituals in mourning practices

MIDTERM TOPICS

Clinical encounter is influenced by ; the personal and cultural values of both the

patient and the providermoral traditions of the health professionssocial and political context of the health

care system

Ethical issues that arise in the care of the dying:

truthfulness and confidentiality decision-making authority in the professional –

patient relationship appropriate use and allocation of technology and

other health care resources decision to withdraw life-sustaining treatment decision making for patient who have lost their

own decision making capacity request for assistance in suicide active euthanasia

Expectation of patients, family and team

The conflicting expectations of patient, family and team is an ethical issue that needs to be addressed

It is important to assess and clarify the goals and expectations from the beginning of the relationship between the patient, family and hospice team

Palliative care is appropriate when a patient’s disease is no longer amenable to cure, when the burden of life-prolonging treatment outweigh the benefits.

Ideally it is the decision of the patient or family to enter hospice

The hospice team needs to know about the previous clinical course, and what the patient and family have been told and the understanding about the course.

Communication of information (about diagnosis and prognosis)

families who insist that the information be withheld from the patient or the patient insisting that the information be withheld from the family

it is important to remember individuality of patient and families

each request should be treated sympathetically and with respect : that is to find the concern for withholding the information, asked in sympathetic and understanding manner to elicit information.

Communication of information about illness and prognosis is a process, conversation will have to be repeated several times.

Pain managementthe patient and the family’s attitude

towards the use of narcotic analgesics can be a source of frustrations and ethical concerns for the hospice team: such as a. patient stoicism b. fear of addiction c. fear that admitting to pain means

admitting that the disease has progressed d. reluctance

Advance care directives allow patients to provide instructions about their preferences regarding the care they would like to receive if they develop an illness or a life-threatening injury and are unable to express their preferences.

Advance care directives can also designate someone the patient trusts to make decisions about medical care if the patient becomes unable to make (or communicate) these decisions. This is called designating “power of attorney (for health care).”

Federal law requires hospitals, nursing homes to provide written information regarding advance care directives to all patients upon admission.Advance care directives can reduce:

Personal worry Feelings of helplessness and guilt by family

members Futile, costly, specialized interventions that

a patient may not want Overall health care costs Legal concerns for everyone involved

Verbal instructions. These are any decisions regarding care that are communicated verbally by an individual to health care providers or family members.

Organ donation. This may be accomplished by completing an organ donation card and carrying it in your wallet. A second card may be placed with important papers (such as a living will, insurance papers, and so on). Most hospitals or other major health care centers have organ donor information available.

Living will. This is a written, legal document that conveys the wishes of a person in the event of serious illness. This document can speak for a patient who is unable to communicate. A living will may indicate specific care or treatment the person does or does not want performed under specific circumstances.

This may include specific procedures, care, or treatments such as the following: CPR (if cardiac or respiratory arrest occurs) Artificial nutrition through intravenous or

tube feedings Prolonged maintenance on a respirator (if

unable to breathe adequately alone) Blood cultures, spinal fluid evaluations, and

other diagnostic tests Blood transfusions

Special medical power of attorney. A legal document that allows an individual to appoint someone else (proxy) to make medical or health care decisions, in the event the individual becomes unable to make or communicate such decisions personally.NOTE: This document provides for power to

make medically related decisions only and does not give any individual power to make legal or financial decisions.

DNR (do not resuscitate) order. This states that CPR (cardiopulmonary resuscitation) is not to be performed if your breathing stops or your heart stops beating. The order may be written by the person's doctor after discussing the issue with the person (if possible), the proxy, or family.

Assisted suicide is the common term for actions by which an individual helps another person voluntarily bring about his or her own death. "Assistance" may mean providing one with the

means (drugs or equipment) to end one's own life, but may extend to other actions. It differs to euthanasia where another person ends the life. The current waves of global public debate have been ongoing for decades, centering on legal, religious, and moral conceptions of "suicide" and a personal "right to death". Legally speaking, the practice may be legal, illegal, or undecided depending on the culture or jurisdiction.

Euthanasia: the intentional killing by act or omission of a dependent human being for his or her alleged benefit. (The key word here is "intentional". If death is not intended, it is not an act of euthanasia)

Voluntary euthanasia: When the person who is killed has requested to be killed.

Non-voluntary: When the person who is killed made no request and gave no consent.

Involuntary euthanasia: When the person who is killed made an expressed wish to the contrary.

Assisted suicide: Someone provides an individual with the information, guidance, and means to take his or her own life with the intention that they will be used for this purpose. When it is a doctor who helps another person to kill themselves it is called "physician assisted suicide."

Euthanasia By Action: Intentionally causing a person's death by performing an action such as by giving a lethal injection.

Euthanasia By Omission:Intentionally causing death by not providing necessary and ordinary (usual and customary) care or food and water

“A protection for everyone concerned”

The law that affects the entire community

It is a strict, principle-based reasoning that uses the circumstances of a case to evaluate the laws that are applicable.

Also known as civil law, was used to compensate people who suffered wrongful acts known as TORTS.

Rules of conduct shared by the community

It creates categories that distinguished one person from another and one situation from another situation. It solidifies the lines that draw these distinctions into fences, trying to assure that everyone understands the either/ or nature of their choices how to behave.

in science it is a result of research and investigations

A court rules only upon issues that ripened into full conflict and only when the parties whose actual interests are at stake stand before it.

Are grounded in underlying, discoverable realities from which facts can be established by experimentation, issues can be discussed and debated in abstract terms , problems can be anticipated and disputes can be avoided

Legal thinking uses inductive reasoning to sort issues by similarities and differences to bring the right result for the case at hand.

Science relies on logic

Rights are boundaries that others are forbidden to cross

Trespass against property or person The current laws that govern the

health care practice relies on precedents to the medieval concept of trespass against a person, a common law tort. Free from being touched without consent The law of negligence was born as a partner concept

implying the duty of care for those to whom consent to touch is given

It is only through the trial of actual cases, decisions made after actual harm has been done, that the common law grows and changes.

In the spirit of the modern age, right is now what we called as powers, dignities or privileges.

Right to live Right of choice Right to die

Governed by the law of professional negligence, sometimes called MALPRACTICE.

Negligence-refers to the commission or omission of an act, pursuant to a duty, that a reasonably prudent person in the same or similar circumstance would or would not do, and acting or the non-acting of which is the proximate cause of injury to another person or his property.

The law of professional negligence is all about the right of a patient to receive care that meets the objective standards established within the professional community

Four elements of professional negligence What was the duty of care Was the duty breached Was the harm to the patient actually caused by

the breach of duty What is the loss or harm

NOTE: the first two questions establish liability for negligence and the final two establish damages and the share attributable to the negligence of the tort-feasor

Punitive damages-extra measure of damages, depending on the facts of the case, the skills of the lawyers, and the influential voices of the jury. This amount could be very extravagant

Compensatory damages- the amount is victim specific, meaning that the monetary recovery depends on financial values associated with the loss to the actual victim and the victim’s family, including loss of earnings. E.g. the younger the victim with promising

future is higher in compensation than a poor old person.

A patient communication with the physician is privileged, (privilege communication)

The doctor could not disclose the information learned in the course of treatment to anyone outside of the medical team without the consent of the patient

The issue in breach of confidentiality only arises if there is financial harm to the patient as the result of breach.

Judges can do allow queries of the medical team when a medical facts is in controversy

In Hospice-it is important to recognize that only members of the team should have access to privileged information unless the patient has given permission for information to be shared with family and friends

The privilege and the right to release it, passes to an appointed surrogate in the event of a patient’s incapacity

A right to consent or to refuse consent to being touched

Touching someone without consent constitutes tort of battery

Consent may be implied from circumstances, however when touching can be invasive and cause pain or harm, the issue of consent come into play

The tort of battery arises most often in contemporary medical case law in instances of mistaken identity where a patient is subjected to surgery intended for another person.

The tort of battery arises most often in a medical case law in instances of mistaken identity where a patient is subjected to surgery intended for another person.

The more common issue in hospice is the Doctrine of Informed Consent, this doctrine has found ground in malpractice where patients experienced unexpected outcomes that in hindsight, they learned foreseeable risk of treatment.

Courts have ruled that patients must be afforded the choice of alternatives to recommend treatments and a prospective of the risks.

Dying patient often lose their mental capacity to make rational choice

Durable power of attorney for health care in anticipation of fate- patient appoints surrogate or proxy decision makers.

The legal document serves to delegate the right of consent to the surrogate or proxy decision makers

Not only at the end of life but with all the proposed medical treatment to refuse or to withdraw their consent once given

The right is extended to their surrogate decision maker and was the basis for allowing the discontinuance of artificial ventilation in the case of Nancy Cruzan also called Right to Die

Not only logically connected to treatment that prolong life but also with regards to patient s with religious or philosophical beliefs that bring moral and ethical criteria to aspect of medical care

The common law recognizes NO RIGHT to choose to die and no power to seek the assistance of a physician to carry out the suicide

The law requires medical service providers to supply more and better information about proposed treatments so the patient can exercise judgment and choice.

Contracts and agreementsAdvance directivesReleases and consents

Agreements that are executed follow a legal standards of mental competence , a spouse may enter agreement to act for the benefit of a spouse but circumstances of intimacy and specialized knowledge between patient and her/his health care providers will require special caution in matters where legal or financial interest of the patient may involved

a.DNR / DNI- part of the treatment plan and are placed prominently in the medical records. The patient’s consent to these papers is a refusal of medical treatment in advanced of it’s proposed intervention.

b.Right to die statement- a patient may refuse to give consent to the treatment, which remains in effect even after the patient loses consciousness or capacity and is self-executing.

c. Instructions regarding cremation and embalming- the statement have legal effect over the rights of survivors to dispose of the body

d.Power of attorney for health care- a power of attorney for health care appoints a surrogate or proxy to consent to treatment in the event of the lack of capacity of the principal

the primary purpose for obtaining consent to palliative care treatment plans is to document the existence of INFORMED CONSENT.A releases of legal document / medical

information, where patientReleases should always be in writing

The duty of care of health care providers is to the patient, the consent to treatment or refusal to treatment is legally considered to be the action of the patient. Whether the proxy actually carries the wishes

of the incompetent patients is not a cause that a court will entertain, however as long as the decision is made by the person with the legal authority to make.

The court will hear and decide cases when the authority of the proxy is challenged ( rather than the proxy’s decision)

CHAPTER FOUR

Careful history taking

Careful review of symptoms and thorough physical examination

Set realistic goals as you plan the care for the client

the absence or loss of energy or strength

“fatigue”

The general causes of fatigue are: Infection Anemia Chronic hypoxia Metabolic and electrolyte disorder Psychogenic Pharmacologic Malnutrition

Treatment = improve the client’s sense of well being (address each cause of fatigue individually)

General measures = goal setting

MEDICATIONS:

Corticosteroid- used to produce a feeling of well being and increased energy in patient with terminal cancer (improvement usually seen after 10 to 14 Days of therapy)dexamethasone and prednisone

Psychostimulants –fatigue associated with depression or opiod-induced sedation may respond to psychostimulants.

Methylphenidate may be initiated at 5 mg in the morning and at noon, avoiding doses later in the day to prevent interference with sleep and titrated to 40 mg per day

Erythropoietin ( the growth factor)– to increase hemoglobin, hoping to reverse the fatigue associated by anemia

Antibiotics – to all episodes of infection for it does not only causes fatigue but they are also often life threatening

Associated with clinical conditions where

Respiratory system is subject to an increased mechanical workload

Ventilation needs to be increasedThere is respiratory muscle

weakness due to fatigue, paralysis or lung volume increase

Treatment = treat the underlying causes of dyspnea

the infrequent, difficult passage of small hard stool.

Probable Causes of Constipation:Decreased fluid and fiber intake in the

dietPoor blood circulation in the GITDecreased physical mobilityMedication (eg. Calcium supplements)Any condition that increases colonic

absorption

What are the principles in using Laxative Therapy

It is better to prevent constipation than wait to treat it.

If there is fecal impaction, evacuation will not occur until manual rectal disimpaction is performed

Intestinal obstruction must be ruled out

Combining agents with different mechanism of action often will improve results

Bulk forming laxative-Contains polysaccharide or cellulose derivatives resistant to bacterial breakdown, more than 24 hours to effect and often Ineffective in the terminally ill patient.

- Inappropriate for use in opiod-induced constipation

Emollient laxative (eg. Mineral oil)-this lubricate the stool surface and penetrate the feces to soften and promote easier passage.

-Also acts to decrease colonic absorption of water.

-15 to 30 cc daily is given which takes effect in 8 to 48 hours, given at bedtime but caution should be observed for aspiration is a common problem in the elderly that might cause acute or chronic lipid pneumonitis.

Fecal softeners -composed of surfactant agent not absorbed by the gut. -Act as detergent to increase water penetration in the stool bolus, making it softer and easier to expel. -Also promote water and electrolyte secretion, with an effect from 24 to 72 hours- Docusate, Poloxamer

Stimulant or irritant laxative -stimulate the myenteric plexus to induce peristalsis, commonly used preparations to stimulate bowel movement. -Include senna, bisacodyl (brown discoloration of acidic urine may occur in senna or cascara sagrada.)- All stimulant may cause severe cramping and abdominal discomfort, but may be avoided by careful dosage titration and by using in combination with stool softeners

Osmotic laxative - exert osmotic effect by increasing the intra-luminal volume by retaining water, increase water secretion and stimulate increase peristalsis. -Lactulose and sorbitol -15 to 30 cc one to two times daily. - Flatulence is the undesirable effect. -Glycerin is the rectal preparation

Saline laxative - sulfate and citrate salts of magnesium-Continuous use may lead to electrolyte imbalance for patient with hypertension, CHF or significant renal dysfunction

Enemas-enemas may be available formulated with sodium phosphate, bisacodyl or mineral oil. -Oil retention enemas are especially useful in the setting of very hard impacted stool-should be used as an adjunct to a prophylactic oral regimenUses of enema includes: for surgical

preparation and diagnostic purpose

To recognized patient’s rights to pain assessment and management

Assess the nature and intensity of pain Record results of assessment to aid in

follow-up Ensure competency in pain assessment

and management Support appropriate prescribing of pain

medications Address the need for pain management

in discharge planning

Unrelieved pain is associated with considerable detrimental physiologic and psychosocial consequences

Pain can affect every aspect of a person’s quality of life

Unremitting pain can consume every aspect of life

Pain may lead to feelings of isolationEmotionally: pain can be an expression of

hopelessness, helplessness, anger, anxiety, depression, and frustration

Whatever the person says it is, and existing whenever the person says it does

This definition of pain designates the patient as the authority about pain

Pain is inherently subjective phenomenon

It is a sensation that is influenced by physical, psychosocial and spiritual circumstances.

Examples: the experience of pain can be impacted

by knowledge and beliefs about pain;Previous pain experiencesParticular styles of copingEducational levelAge . genderAvailability and type of social support

systemsRole models and family membersCultural, religious and social influences

ACUTE- pain typically has a well-defined onset, lasts a relatively short period of time, and responds well to treatmentOften signals an injury and when the injury

heals, the pain disappears

CHRONIC- or persistent pain may have a defined onset, can be mild or severe, and is present for an extended period of time.Often responds unpredictably to treatment In the dying, this pain can be unrelenting and

is often progressive

A person in painbody attempts to respondbrain (pituitary gland)

produces protective natural opioids (endorphins and enkephalins) to lessen

the perception of painful nerve signalsthis chemicals help to stop

neuron from sending a pain message

Somatization disorder Characterized by multiple physical symptoms

Pain disorder Has primarily physical symptom of pain,

unrelieved by analgesic

Palliation - easing the severity of a pain or a disease without removing the cause.

To palliate a disease is to treat it partially and insofar as possible, but not cure it completely.

In hospice – enrollees should be terminal or having a prognosis of six months or less

In palliation of non-cancer it is unpredictable for they tend to become stable until exacerbation occurs. Cancer patient responds to definitive therapy – e.g.

surgery. Radiation, chemotherapy for only a period of time, it can be discontinued.

In non-cancer disease active treatment is effective until very near death Example of active treatment is the use of diuretics for

CHF to relieve pulmonary edema, Intubation and mechanical ventilation for COPD

Prognostic uncertainty makes it difficult to determine when non-cancer patients are actually dying It reduces the length of stay in hospice

programs, almost one third of the patient die before the end of their first week in hospice.

It is important to remember that symptom management, advance care planning and psychosocial/spiritual support are appropriate regardless of apparent stage of disease.

This will determine which patients have end-stage illness.

It will also help with the cost/benefit analysis of palliative intervention

Criteria as adapted from the National Hospice Organization: 1. End-stage heart disease

Usually manifested by heart failureFor those with systolic failure- left ventricle has

become weakened and dilatedFor those with preserve systolic function – who

have a small poorly compliant(stiff) left ventricle that cannot tolerate pressure or volume stress and cause multiple episodes of flash pulmonary edema, without ventricular enlargement

Treatment for end-stage heart diseaseDiuretics and angiotensin converting

enzymes (ACE) inhibitors -- (ACE inhibitors are medications that slow (inhibit) the activity of the enzyme ACE, which decreases the production of angiotensin II. As a result, the blood vessels enlarge or dilate, and blood pressure is reduced. This lowers blood pressure and makes it easier for the heart to pump blood and can improve the function of a failing heart.

angiotensin receptor blockers (ARBs)- The angiotensin receptor blockers (ARBs), also called angiotensin (AT1) receptor antagonists or sartans, are a group of anti-hypertensive drugs that act by blocking the effects of the hormone angiotensin II (Ang II) in the body, thereby lowering blood pressure.

2. Heart failure is advance if patients continue to decline after hospitalization that involved invasive monitoring with Swan-Ganz catheter.

Any patient failing an inotropic infusion of dobutamine ( stimulates the B- receptors of the heart, increasing myocardial contractility thereby increasing cardiac output) should be considered for hospice evaluation or a primarily palliative approach

3. Lung disease- considered advance when patient have disabling dyspnea, with blood gas deficit, arterial pO2 below 60 on room air and pCO2 above 50.

Intubation and mechanical ventilation are necessary because the patient is already resistant to bronchodilators.

4. Dementia including Alzheimer - is difficult to determine the prognosis. The dementing process is not fatal but medical

complications are. ,that the patient is said to be nearing death.

Indicators of severe dementia – increased incidence of complication, they become bed ridden prone to pneumonia, lung atelectasis, sepsis etc.) Loss of the ability to ambulate independently and loss of the ability to carry on meaningful conversation.

5. End-stage liver disease Bleeding from esophageal varices

particularly for advanced liver disease Elevation of prothrombin time due to

shortage of liver-dependent clotting factors

6. End-stage renal disease (ESRD) Treated with dialysis For severe renal function abnormalities

without dialysis, and to those whose serum creatinine is over 6.0 or creatinine clearance under 10 ml/min (15 ml/min for diabetics) short term mortality

Grief Refers to the subjective emotions and affect that

are a normal response to the experience of loss.

Grieving/Bereavement Refers to the process by which a person

experiences the grief.

Anticipatory grieving Is when people facing an imminent loss begin to

grapple with the very real possible loss or death in the near future.

Mourning Is the outward expression of grief.

Kubler-Ross stages of grieving1.Denial—is shock and disbelief

regarding the loss “NO NOT ME”.2. Anger—may be expressed toward

God, relatives, friends or health care providers. “WHY ME”

3. Bargaining—person asks God or fate for more time to delay inevitable loss. “WHY ME”.

4. Depression—results when awareness of loss becomes acute. “STAGE OF SILENCE”

5. Acceptance—shows evidence of coming to terms with death. “YES, IT’S ME”.

NOTE: it is important that grief and bereavement is a normal transition or opportunity to grow rather than a problem

To provide care in the end of life it is important to recognize suffering (grief and bereavement) and what are the growth opportunities it may afford the patient

Byock ‘s areas for patient to grow and find meaning: Sense of completion with wordly affairs Sense of completion in relationships with

community Sense of meaning about one’s individual life Experienced love of self Experienced love of others Sense of completion in relationship with

family and friends Acceptance of the finality of life- of one’s

existence as an individual Sense of a new self beyond personal loss Sense of meaning about life in general Surrender to the transcendent, to the

unknown- “letting go”

It is not necessary for patients to examine each of these areas.

The goal is to develop sense of closure or resolution, the patient may find meaning and identity at a time when his or her connection to the world is slipping away.

Techniques to develop the sense of closure: Storytelling Life review Reframing problems

In hospice we aim for our patient to die well- which suggest that some preparation and work may be necessary in order to realize the ending state.

The process of dying well is living life fully while dying.

Be physically present.

Be non-judgmental.

Encourage verbalization of feelings.

Allow the patient to cry.

Recognize your own thought about death and dying.