Dept of Family Medicine Braite Waite Memorial Specialist

DEPT. OF FAMILY MEDICINEDEPT. OF FAMILY MEDICINEBRAITHE WAITE MEMORIAL BRAITHE WAITE MEMORIAL

SPECIALIST HOSPITALSPECIALIST HOSPITAL PORT HARCOURTPORT HARCOURT

CLINICAL CLINICAL PRESENTATIONPRESENTATIONTOPIC:- TOPIC:- PALLIATIVE CARE PALLIATIVE CARE

BY BY DR. SORGIA M. C. DR. SORGIA M. C.

AND AND

DR. MRS ONUA F. DR. MRS ONUA F.

TABLE OF CONTENTTABLE OF CONTENT 1.1. IntroductionIntroduction

2.2. Definition and Explanation of palliative careDefinition and Explanation of palliative care

3.3. Aim of palliative care Aim of palliative care

4.4. Palliative care as different from hospice care Palliative care as different from hospice care

5.5. Palliative care and end of life care Palliative care and end of life care

6.6. Providers of palliative care Providers of palliative care

7.7. Specialist palliative care servicesSpecialist palliative care services

8.8. Principles of palliative care managementPrinciples of palliative care management. .

a a Support for patients and carersSupport for patients and carersb b Symptom control Symptom control c c Control of pain Control of pain d d Treatment of other symptom Treatment of other symptom ee the dying phasethe dying phaseff Spiritual issues Spiritual issues g The special role of the family Doctor g The special role of the family Doctor

9. Nursing aspect of palliative care 9. Nursing aspect of palliative care 10. Conclusion. 10. Conclusion.

PALLIATIVE CAREPALLIATIVE CARE

INTRODUCTIONINTRODUCTION

Family medicine practice is a medical specialty that Family medicine practice is a medical specialty that provide continuing and comprehensive health care for provide continuing and comprehensive health care for the individual and the family. the individual and the family.

Continuing health care is an ongoing responsibility for Continuing health care is an ongoing responsibility for managing a patient's medical care regardless of the managing a patient's medical care regardless of the patient’s state of health or the disease process. patient’s state of health or the disease process.

comprehensive medical care spans through the comprehensive medical care spans through the spectrum of medicine. It involves varying depth of spectrum of medicine. It involves varying depth of knowledge in many disciplines and its application in knowledge in many disciplines and its application in problem solving in the care of the patient.problem solving in the care of the patient.

A family physician is responsible for care of the patient A family physician is responsible for care of the patient from cradle to grave and takes care of unselected and from cradle to grave and takes care of unselected and undifferentiated care. undifferentiated care.

DEFINITION AND EXPLANATION OF PALLIATIVE CAREDEFINITION AND EXPLANATION OF PALLIATIVE CARE

Palliative care is an approach that improves the quality of Palliative care is an approach that improves the quality of life of patients and their families facing the problem life of patients and their families facing the problem associated with life threatening illness, through the associated with life threatening illness, through the prevention and relief of suffering by means of early prevention and relief of suffering by means of early identification and impeccable assessment and treatment of identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and pain and other problems, physical, psychosocial and spiritual. spiritual.

Palliative care: Palliative care: - Provides relief from pain and other distressing symptoms; Provides relief from pain and other distressing symptoms; - Affirms life and regards dying as a normal process; Affirms life and regards dying as a normal process; - Intends neither to hasten or post phone death. Intends neither to hasten or post phone death. - Integrates the psychological and spiritual aspects of patient Integrates the psychological and spiritual aspects of patient

care; care; - Offers a support system to help patients live as actively as Offers a support system to help patients live as actively as

possible until death. possible until death.

- Offers a support system to help the family cope during the Offers a support system to help the family cope during the patients illness and in their own bereavementpatients illness and in their own bereavement

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

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

- Is applicative early in the course of illness, in conjunction with Is applicative early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as other therapies that are intended to prolong life, such as chemotherapy or radiation therapies, and includes those chemotherapy or radiation therapies, and includes those investigations needed to better understand and manage investigations needed to better understand and manage distressing clinical complications. distressing clinical complications.

WHO defines palliative care for children as the active total care of WHO defines palliative care for children as the active total care of the child’s body, mind, and spirit, and also involves giving support the child’s body, mind, and spirit, and also involves giving support to the family. to the family.

- It begins when illness is diagnosed, and continues regardless of It begins when illness is diagnosed, and continues regardless of whether or not a child receive treatment directed at the disease. whether or not a child receive treatment directed at the disease.

- Health providers must evaluate and alleriate a child’s physical, Health providers must evaluate and alleriate a child’s physical, psychological and social distress. psychological and social distress.

AIM OF PALLIATIVE CAREAIM OF PALLIATIVE CARE Palliative care aims to relieve symptoms such as Palliative care aims to relieve symptoms such as

pain, shortness of breath, fatigue constipation, pain, shortness of breath, fatigue constipation, nausea, loss of appetite and difficulty sleeping. It nausea, loss of appetite and difficulty sleeping. It helps patients gain the strength to carry on with helps patients gain the strength to carry on with daily life. It improves their ability to tolerate medical daily life. It improves their ability to tolerate medical treatments. And it helps them better understand treatments. And it helps them better understand their choices for care. Overall, palliative care offers their choices for care. Overall, palliative care offers patients the best possible quality of life during their patients the best possible quality of life during their illness. Palliative care benefits both patients and illness. Palliative care benefits both patients and their families. Along with symptom management, their families. Along with symptom management, communication and support for the family are the communication and support for the family are the main goals. The team helps patients and families main goals. The team helps patients and families make decisions and choose treatment that are in line make decisions and choose treatment that are in line with their goals. with their goals.

PALLIATIVE CARE AS DIFFERENT FROM PALLIATIVE CARE AS DIFFERENT FROM

HOSPICE CAREHOSPICE CARE Palliative care is not dependent on prognosis Palliative care is not dependent on prognosis and is appropriate at any point in an illness. and is appropriate at any point in an illness. It can also be provided at the same time as It can also be provided at the same time as treatment that is meant to cure the patient. treatment that is meant to cure the patient.

Hospice care always provides palliative care Hospice care always provides palliative care and it is focused on terminally ill patients-and it is focused on terminally ill patients-people who no longer seek treatments to people who no longer seek treatments to cure them and who are expected to live for cure them and who are expected to live for about six months or less. about six months or less.

PALLIATIVE CARE AND END OF LIFE CAREPALLIATIVE CARE AND END OF LIFE CARE Palliative care, also called comfort care can be primarily directed Palliative care, also called comfort care can be primarily directed at providing relief to a terminally –ill person through symptom at providing relief to a terminally –ill person through symptom management and pain management. The goal is not to cure, but management and pain management. The goal is not to cure, but to provide comfort and maintain the highest possible quality of life to provide comfort and maintain the highest possible quality of life for as life remains. Well rounded palliative care programs also for as life remains. Well rounded palliative care programs also address mental and spiritual needs. address mental and spiritual needs.

Palliative care addresses the physical and psychological aspects Palliative care addresses the physical and psychological aspects of end of life. It involves: of end of life. It involves:

- - Pain and other symptom management; Pain and other symptom management; - Social psychological, cultural, emotional and spiritual supportSocial psychological, cultural, emotional and spiritual support- Care giver support; and Care giver support; and - Bereavement support. Bereavement support.

Whether palliative care is offered through a formal palliative care Whether palliative care is offered through a formal palliative care program or a variety of other avenues, the focus of care is on program or a variety of other avenues, the focus of care is on achieving comfort and respect for the person nearing death and achieving comfort and respect for the person nearing death and maximizing quality of life for the patient, family and loved ones. maximizing quality of life for the patient, family and loved ones.

PROVIDERS OF PALLIATIVE CAREPROVIDERS OF PALLIATIVE CARE Palliate care requires an interdisciplinary team model (broad Palliate care requires an interdisciplinary team model (broad

multidisciplinary approach that includes the family) that multidisciplinary approach that includes the family) that provides support for the whole person and those who are provides support for the whole person and those who are sharing the persons journey in love. Usually a team of sharing the persons journey in love. Usually a team of experts, including palliative care doctors, nurses social experts, including palliative care doctors, nurses social workers, chaplains, massage therapists, pharmacists, workers, chaplains, massage therapists, pharmacists, nutritionists. Etc palliative care can be delivered in hospitals, nutritionists. Etc palliative care can be delivered in hospitals, hospice and home care settings. Working in partnership with hospice and home care settings. Working in partnership with the primary doctor the palliative care team provides: the primary doctor the palliative care team provides:

- Expert treatment of pain and other symptoms.Expert treatment of pain and other symptoms.- Close, clear communication. Close, clear communication. - Help navigating the health care system. Help navigating the health care system. - Guidance with difficult and complex treatment choices. Guidance with difficult and complex treatment choices. - Detailed practical information and assistance. Detailed practical information and assistance. - Emotional and spiritual support for you and your family. Emotional and spiritual support for you and your family.

SPECIALIST PALLIATIVE CARE SERVICESSPECIALIST PALLIATIVE CARE SERVICES These services are provided by specialist multidisciplinary These services are provided by specialist multidisciplinary

palliative care team and include: palliative care team and include:

- Assessment, advice and care for patients and families in all care Assessment, advice and care for patients and families in all care settings, including hospitals and care homes. settings, including hospitals and care homes.

- Specialist in patient facilities (in hospices or hospitals) for patients Specialist in patient facilities (in hospices or hospitals) for patients who benefit from continuous support and care of specialist who benefit from continuous support and care of specialist palliative care teams. Intensive co-ordinated home support for palliative care teams. Intensive co-ordinated home support for patients with complex needs who wish to stay at home:- patients with complex needs who wish to stay at home:-

(a) This may involve the specialist care service providing specialist (a) This may involve the specialist care service providing specialist advice alongside the patient's own doctor and district nurse to advice alongside the patient's own doctor and district nurse to enable someone to stay in their own home enable someone to stay in their own home

(b) Many teams also now provide extended specialist palliative (b) Many teams also now provide extended specialist palliative nursing, medical, social and emotional support and care in the nursing, medical, social and emotional support and care in the patient’s home, often known as “hospice at home. patient’s home, often known as “hospice at home.

- Day care facilities that offer a range of opportunities for Day care facilities that offer a range of opportunities for assessment and review of patient’s needs and enable the assessment and review of patient’s needs and enable the provision of physical, psychological and social interventions provision of physical, psychological and social interventions within a context of social interaction, support and within a context of social interaction, support and friendship. Many also offer creative and complementary friendship. Many also offer creative and complementary therapies. therapies.

- Advice and support to all the people involved in a patient’s Advice and support to all the people involved in a patient’s care care

- Bereavement support for the people involved in a , Bereavement support for the people involved in a , patient's care following the patient’s death patient's care following the patient’s death

- Education and training in palliative care.Education and training in palliative care.

The specialist teams should include palliative medicine The specialist teams should include palliative medicine consultants and palliative care nurse specialists together consultants and palliative care nurse specialists together with a range of expertise provided by physiotherapists, with a range of expertise provided by physiotherapists, occupational therapists, dieticians, pharmacist, social occupational therapists, dieticians, pharmacist, social workers, and those able to give spiritual and psychological workers, and those able to give spiritual and psychological support. support.

PRINCIPLES OF PALLIATIVE CARE MANAGEMENTPRINCIPLES OF PALLIATIVE CARE MANAGEMENT

The fundamental principles of palliative care are:- The fundamental principles of palliative care are:- - Good communication Good communication - Management planning Management planning - Symptom control Symptom control - Emotional, social and spiritual support Emotional, social and spiritual support - Medical counselling and education Medical counselling and education - Patient involvement in decision making Patient involvement in decision making - Support for carers. Support for carers.

These principles applies not only to incurable malignant These principles applies not only to incurable malignant disease and HIV/AIDS but also other disease in their disease and HIV/AIDS but also other disease in their chromic stage or terminal stage such as end –stage organ chromic stage or terminal stage such as end –stage organ failure (heart failure, renal failure, respiratory failure, failure (heart failure, renal failure, respiratory failure, hepatic failure) hepatic failure)

A. A. SUPPORT FOR PATIENTS AND CARERSSUPPORT FOR PATIENTS AND CARERS

11.. Patient must be informed of the diagnosis and stage and Patient must be informed of the diagnosis and stage and prognosis for the disease.prognosis for the disease.

2. 2. Patients must be allowed to make a choice of treatment Patients must be allowed to make a choice of treatment option.option.

3.3. The initial consultation must be unhurried and com The initial consultation must be unhurried and com pathetic. This will achieve the followingspathetic. This will achieve the followings

- Detailed history which can assist in the managementDetailed history which can assist in the management- Allay patient fears. Give honest answers without Allay patient fears. Give honest answers without

labouring the point or giving false hope. labouring the point or giving false hope. - Establish good communication and a rapport with the Establish good communication and a rapport with the

patient patient - The variability in outcome and response to treatment The variability in outcome and response to treatment

must be discussed.must be discussed.

4.4. Adopt a whole person approach; attend to physical; Adopt a whole person approach; attend to physical; psychosocial and spiritual needs. psychosocial and spiritual needs.

Be prepared to take the initiative and call in Be prepared to take the initiative and call in other who could help e.g clergy; cancer support other who could help e.g clergy; cancer support group, massage therapists. group, massage therapists.

5.5. Give the patient a feeling of security but not Give the patient a feeling of security but not false hope. false hope.

- - The worst feeling a dying patient can sense is The worst feeling a dying patient can sense is one of rejection and discomforts on the part of one of rejection and discomforts on the part of the doctor the doctor

B. B. SYMPTOM CONTROLSYMPTOM CONTROL

Principles of symptom Principles of symptom

1.1. Determine the cause Determine the cause

2.2. Treat simplyTreat simply

3.3. Provide appropriate explanation of symptoms and Provide appropriate explanation of symptoms and treatment treatment

4.4. Provide regular review Provide regular review

5.5. Give medications regularly around the clock, not ad hoc. Give medications regularly around the clock, not ad hoc.

6.6. Plan breakthrough pain relieving doses Plan breakthrough pain relieving doses

7.7. Provide physical treatment as necessary e.g paracentesis;Provide physical treatment as necessary e.g paracentesis;

8.8. Pleural tap, nerve block. Pleural tap, nerve block.

9.9. Provide complementary conservative therapy e.g Provide complementary conservative therapy e.g massage, physiotherapy, occupational therapy dietary massage, physiotherapy, occupational therapy dietary advice, relaxation therapy advice, relaxation therapy

10.10. Provide close supervision. Provide close supervision.

CC CONTROL OF PAINCONTROL OF PAIN

Achieving relief of pain is one of the most Achieving relief of pain is one of the most important functions of palliative care and patients important functions of palliative care and patients need reassurance that they can expect such need reassurance that they can expect such relief. relief.

BY DEFINITIONBY DEFINITION Pain is an unpleasant sensory Pain is an unpleasant sensory and emotional experience associated with actual and emotional experience associated with actual or potential tissue damage or described in terms or potential tissue damage or described in terms of such damage. of such damage.

Pain perception does not therefore correlate with Pain perception does not therefore correlate with the degree of tissue damage and each patient’s the degree of tissue damage and each patient’s experience and expression of pain are different. experience and expression of pain are different.

PAIN CLASSES:-PAIN CLASSES:-11.. NORCICEPTIVE PAIN:- NORCICEPTIVE PAIN:- Due to direct stimulation of the Due to direct stimulation of the

peripheral nerve endings (e.g wounds, fracture burns)peripheral nerve endings (e.g wounds, fracture burns)

2.2. NEUROPATHIC PAIN:- NEUROPATHIC PAIN:- Due to dysfunction of the pain Due to dysfunction of the pain perception system within the peripheral or central nervous perception system within the peripheral or central nervous system as a result of injury; disease or surgical damage e.g system as a result of injury; disease or surgical damage e.g Diabetic neuropathy; Amputated limb (phantom limp pain)Diabetic neuropathy; Amputated limb (phantom limp pain) FEATURES OF NUROPATHIC PAIN:-FEATURES OF NUROPATHIC PAIN:-

- Unpleasant persistent burning sensation sometimes Unpleasant persistent burning sensation sometimes stabbing or burning & pain stabbing or burning & pain

- Pain is spontaneous without ongoing tissue damage Pain is spontaneous without ongoing tissue damage - Pain is located in an area of sensory loss Pain is located in an area of sensory loss - Presence of a major neurological deficit e.g spinal cord Presence of a major neurological deficit e.g spinal cord

trauma trauma - Pain in response to non painful stimuli- Allodynia Pain in response to non painful stimuli- Allodynia - Increased pain in response to painful stimuli _ Increased pain in response to painful stimuli _

Hyperalgesia. Hyperalgesia. - Unpleasant adnominal sensations - dysaeshesia Unpleasant adnominal sensations - dysaeshesia - Poor relief with opioids alone. Poor relief with opioids alone. 3. 3. Visceral pain. Visceral pain.

PAIN MANAGEMENT INCLUDEPAIN MANAGEMENT INCLUDE 1.1. A good detailed history to knows the diagnosis. A good detailed history to knows the diagnosis.

2.2. Necessary investigations are done to help in Necessary investigations are done to help in confirmation of the condition. confirmation of the condition.

TREATMENT OF PAIN TREATMENT OF PAIN

1.1. Pharmacological Pharmacological

2.2. Non PharmacologicalNon Pharmacological

PHARMACOLOGICAL:- PHARMACOLOGICAL:-

WHO Analgeisc Ladder WHO Analgeisc Ladder

Andgesic should be prescribed which is Andgesic should be prescribed which is appropriate for the degree of pain and increased appropriate for the degree of pain and increased until the pain is controlled. until the pain is controlled.

If pain remains poorly controlled, strong opiods If pain remains poorly controlled, strong opiods should be prescribed. should be prescribed.

MILD PAIN: Non opioid analgesics e.g paracetanol, MILD PAIN: Non opioid analgesics e.g paracetanol, Aspirin Aspirin

MODERATE PAIN: Weak opioid e.g codeine 60mg MODERATE PAIN: Weak opioid e.g codeine 60mg 6hrly6hrly

STRONG PAIN: Strong opioid e.g morphine, pethidineSTRONG PAIN: Strong opioid e.g morphine, pethidine

Note Note The side effects of opioids:- constipation, dry The side effects of opioids:- constipation, dry month, month, sedationsedation

Note Note ADJUVANT THERAPY:- there is a place for ADJUVANT THERAPY:- there is a place for antidepressant; antiepileptic for neuropathic antidepressant; antiepileptic for neuropathic

painpain

NON PHARMACOLOGICALNON PHARMACOLOGICAL1 Radiotherapy1 Radiotherapy2. Physiotherapy 2. Physiotherapy 3. Psychological techniques –simple relaxation 3. Psychological techniques –simple relaxation 4. Stimulation therapies e.g Acupuncture4. Stimulation therapies e.g Acupuncture5. Herbal medicine and homeopathy. 5. Herbal medicine and homeopathy.

TREATMENT OF OTHER COMMON SYMPTOMSTREATMENT OF OTHER COMMON SYMPTOMS CONDITIONCONDITION TREATMENTTREATMENT Anoresia Anoresia Metoclopramide 10mg tds Metoclopramide 10mg tds

or or Corticosteroid e.g dexamethasone Corticosteroid e.g dexamethasone 2-8mg tds, High energy drink 2-8mg tds, High energy drink

supplement supplement Anxiety Anxiety - - SSRI . B –BlockersSSRI . B –Blockers

DepressionDepression - - Antidepressant e.g Amitriptylin Antidepressant e.g Amitriptylin Breathlessness Breathlessness - - Oxygen by face mask Oxygen by face mask

-- Breathing techniqueBreathing technique-- treat the cause. treat the cause.

Cough (especially Cough (especially intractable)intractable) -- Change patient’s posture Change patient’s posture

especially at night especially at night -- opiods e.g morphine opiods e.g morphine -- Antitussives e.g cocteine linctusAntitussives e.g cocteine linctus

CONSTIPATION CONSTIPATION -- Give Laxatives Dulcolax Give Laxatives Dulcolax -- liquid paraffin liquid paraffin -- rectal suppositoriesrectal suppositories

CONFUSION CONFUSION -- Treat cause, haloperidol, Treat cause, haloperidol, chlorpromazinechlorpromazine

ORAL CANDIDASIS: ORAL CANDIDASIS: -- Nystatin or miconazole oral gel. Nystatin or miconazole oral gel. DEHYDRATION: DEHYDRATION: Rehydrate with iv fluids; the cause. Rehydrate with iv fluids; the cause. DIARRHEA: DIARRHEA: Loperaminde; treat the cause. Loperaminde; treat the cause. HICCUP: HICCUP: ANTACID with anti flatulent e.g ANTACID with anti flatulent e.g

Asilone Asilone suspension metoclopramide or suspension metoclopramide or chlorpromazinechlorpromazine

INSOMNIAINSOMNIA -- benzodiazepine e.g Diazepam benzodiazepine e.g Diazepam NAUSEANAUSEA -- anti emetic (e.g metoclopramide, anti emetic (e.g metoclopramide,

Haloperidol, cyclizine)Haloperidol, cyclizine) PRURITUS:-PRURITUS:- Anti histamine. Anti histamine.

Sedation:- Sedation:- Weakness weight loss:-Weakness weight loss:- A A

patient with cancer loose weight due patient with cancer loose weight due to an alteration of metabolism by to an alteration of metabolism by tumour known as cancer cahexia tumour known as cancer cahexia syndrone Rx High calorie, High syndrone Rx High calorie, High protein diet. protein diet.

E E THE DYING PHASETHE DYING PHASE

Death is an inevitable end not only to the terminal cases Death is an inevitable end not only to the terminal cases but to all mortal being. but to all mortal being.

However discussion with the dying patient is a very However discussion with the dying patient is a very difficult task to the physician as it brings with it feelings difficult task to the physician as it brings with it feelings of failure; loss of hope and fear of causing distress. of failure; loss of hope and fear of causing distress.

Apply the principles of care and counseling which include. Apply the principles of care and counseling which include.

1. 1. Be available and be patientBe available and be patient

2.2. Allows them to talk while you listen Allows them to talk while you listen

3.3. Reassure them that the felling are normal Reassure them that the felling are normal

4.4. Accept any show of anger positively Accept any show of anger positively

5. 5. Avoid inappropriate reassurance Avoid inappropriate reassurance

6.6. Encourage as much companionship as possible; if Encourage as much companionship as possible; if desired. desired.

Management Management Once a patient has Once a patient has entered the dying phase:- bed band, entered the dying phase:- bed band, semicomatous, noisy breathing, fever semicomatous, noisy breathing, fever severe fatigue severe fatigue Significant and important change in Significant and important change in management management - - Symptom control Symptom control -- Relief of distress Relief of distress -- Care for the familyCare for the family

2. 2. Justifiable medications and investigation Justifiable medications and investigation e.g e.g opioids opioids

3.3. Iv Fluid is reduced so that it will not Iv Fluid is reduced so that it will not worsen worsen bronchial secretions. bronchial secretions.

CHECKLIST FOR THE DYING PHASECHECKLIST FOR THE DYING PHASE

1. 1. Stop non essential medication Stop non essential medication 2. 2. Stop routine observations Stop routine observations 3. 3. Ensure availability of parenteral Ensure availability of parenteral

medication for symptom relief. medication for symptom relief. 4. 4. Assess patient and family awareness of Assess patient and family awareness of

condition. condition. 5. 5. Assess religious and spiritual needs Assess religious and spiritual needs 6. 6. Ensure family understands plan of care Ensure family understands plan of care 7. 7. Ensure continued assessment and Ensure continued assessment and

management of management of symptomsymptom8.8. Arrange appropriate care after death Arrange appropriate care after death

F F SPIRITUAL ISSUESSPIRITUAL ISSUES

Approaching the end of life, every mortal being Approaching the end of life, every mortal being wonders what next? where next? and who next? wonders what next? where next? and who next? An attempt to answer this questions, the doctor An attempt to answer this questions, the doctor should be sensitive to the needs and that would should be sensitive to the needs and that would involve the search for a minister (by the physician involve the search for a minister (by the physician or the care giver) who will pray with the patient or the care giver) who will pray with the patient and give some words of exhortation of life after and give some words of exhortation of life after death. death.

EUTHANASIA:- (Mercy killing) this should not be EUTHANASIA:- (Mercy killing) this should not be practiced. practiced.

G G THE SPECIAL ROLE OF THE THE SPECIAL ROLE OF THE

FAMILY DOCTORFAMILY DOCTOR

The general practitioner is the ideal person The general practitioner is the ideal person to manage palliative care for a variety of to manage palliative care for a variety of reasons:- reasons:-

AvailabilityAvailability Knowledge of the patient and family Knowledge of the patient and family Relevant psychosocial influencesRelevant psychosocial influences A key feature is the ability to provide the A key feature is the ability to provide the

patient with in dependence andpatient with in dependence and dignity by dignity by managing palliative care at home. managing palliative care at home.

NURSING ASPECT OF PALLIATIVE CARENURSING ASPECT OF PALLIATIVE CARE During the care of dying patient factors like During the care of dying patient factors like odors, confusion, disfigurements, odors, confusion, disfigurements, combativeness and inconvenience may turn combativeness and inconvenience may turn the nurse away from the required care of the nurse away from the required care of the dying patient but nurses should be the dying patient but nurses should be extremely careful that you do not neglect extremely careful that you do not neglect general rules of care of the dying patients general rules of care of the dying patients as follows: as follows:

1. 1. Nurse should provide a calm and peaceful Nurse should provide a calm and peaceful environment. environment.

2.2. Make the dying patient comfortable in bed Make the dying patient comfortable in bed with side rides to prevent it patient from with side rides to prevent it patient from falling. falling.

3. 3. Take a full his of the patient and report Take a full his of the patient and report where necessary. where necessary.

4. 4. Half hourly observation of vital signs Half hourly observation of vital signs e.g e.g temperature pulse, respiration and temperature pulse, respiration and blood blood pressure and report to the pressure and report to the physician any physician any deviation from normal . deviation from normal .

5. 5. Maintain patient air way; lying patient Maintain patient air way; lying patient on his on his side and suck with suction side and suck with suction machine as machine as directed. directed.

6.6. Position the patient every 2 hours but Position the patient every 2 hours but note note that due to slow metabolic rate and that due to slow metabolic rate and

perfusion of distal body parts is also perfusion of distal body parts is also slow as death near, turning patient slow as death near, turning patient suddenly to a new suddenly to a new position might over position might over tax their circulation. tax their circulation.

7. 7. The nurse should move the patient’s limbs to The nurse should move the patient’s limbs to prevent circulatory, muscular and joint complication prevent circulatory, muscular and joint complication provided the patient’s general condition permits it. provided the patient’s general condition permits it.

8 8 Make sure that the patient chest is not Make sure that the patient chest is not compressed compressed by pillow or light cloths because by pillow or light cloths because they optimal lung they optimal lung expansion. expansion. If their swallowing reflex is impaired position to allow If their swallowing reflex is impaired position to allow saliva to drain form the mouth and prevent saliva to drain form the mouth and prevent aspiration.aspiration.

- - Give special care to pressure areas as you change Give special care to pressure areas as you change the position of the patient. the position of the patient.

9. 9. Personal hygiene of the patientPersonal hygiene of the patient- The nurse should maintain a 4 houdy oral hygiene to The nurse should maintain a 4 houdy oral hygiene to

prevent the tongue and gums becoming coated and prevent the tongue and gums becoming coated and to remove saliva that could have forms a good to remove saliva that could have forms a good medium for bacteria to multiply.medium for bacteria to multiply.

- The nurse should apply a lip balm to prevent it from The nurse should apply a lip balm to prevent it from crackingcracking

- Maintain daily bathing in bed with application of a Maintain daily bathing in bed with application of a lubricating lotion or talcum powder to the entire body.lubricating lotion or talcum powder to the entire body.

- Nurse should cut the patient fingers and toe nails and brush Nurse should cut the patient fingers and toe nails and brush their hairs.their hairs.

- Nurse should maintain a sterile condition from urinary Nurse should maintain a sterile condition from urinary catheterization.catheterization.

- Observe bladder and bowels for retention of urine and facesObserve bladder and bowels for retention of urine and faces- Dress any wound presentDress any wound present- Assist the doctor to set intravenous line and monitor all the Assist the doctor to set intravenous line and monitor all the

intravenous fluids set up and chart. intravenous fluids set up and chart. - A dry mouth leads to cracking and secondary infection and A dry mouth leads to cracking and secondary infection and

pain, prevent it by frequent cleaning of mucous membrane pain, prevent it by frequent cleaning of mucous membrane with swabs and clean water.with swabs and clean water.

- If eye conjunctivae appear dry, ask the physician to If eye conjunctivae appear dry, ask the physician to prescribe moistening eye drop to prevent dryness that prescribe moistening eye drop to prevent dryness that might lead to ulceration. might lead to ulceration.

- Keep skin surface from rubbing against one another by Keep skin surface from rubbing against one another by supporting pillows and good position. supporting pillows and good position.

- Keep skin dry of urine or faces from incontinence. Change Keep skin dry of urine or faces from incontinence. Change the patients cloths and beddings regularly. the patients cloths and beddings regularly.

11. 11. DIET:- DIET:- Give patient adequate nutrients and fluid, by Give patient adequate nutrients and fluid, by supporting patient to eat or pass an N. G. tube as a supporting patient to eat or pass an N. G. tube as a recommended and tube feed the patient accord to recommended and tube feed the patient accord to

the the condition. condition.

12. 12. PROVISION OF ADEQUATEPROVISION OF ADEQUATE VENTILATION VENTILATION - The nurse should provide good ventilation by The nurse should provide good ventilation by

opening of opening of windows for fresh air and standing fan at bed windows for fresh air and standing fan at bed side. The side. The screens if any should be position in a way screens if any should be position in a way that air can get to that air can get to the patient. the patient.

13. 13. Communication with the dying is often one of Communication with the dying is often one of the the most important element of care you can give most important element of care you can give

remembering that hearing is the last sense remembering that hearing is the last sense lost, lost, patient even minutes away from death are patient even minutes away from death are capable capable of hearing every thing you say, of hearing every thing you say, continue to explain continue to explain procedures to a dying procedures to a dying patient as if they are patient as if they are conscious. Never make conscious. Never make commence in their presence commence in their presence that this patient that this patient cannot make it or can he or she cannot make it or can he or she make make it?it?

14. 14. Apply communication skills, expressing Apply communication skills, expressing empathy and empathy and compassion.compassion.

- - The nurse should accept the help of other The nurse should accept the help of other professionals including clergy and social workers . professionals including clergy and social workers .

SUPPORTING THE GRIEVING FAMILYSUPPORTING THE GRIEVING FAMILY - The nurse should acknowledge their grief, The nurse should acknowledge their grief,

understand the value of the patient to the family understand the value of the patient to the family and assist them with the following. and assist them with the following.

- Giving information, sharing concern and Giving information, sharing concern and expressing empathy. expressing empathy.

- Assist in planning a visitation schedule for dying Assist in planning a visitation schedule for dying patient and family from becoming fatigued. patient and family from becoming fatigued.

- Allow young children to visit a dying parent when Allow young children to visit a dying parent when the patient is able to communicate. the patient is able to communicate.

- Continue to use gentile touch as holding a hand Continue to use gentile touch as holding a hand or brushing hair from the fore head as if the or brushing hair from the fore head as if the patient is fully conscious, they may be fully aware patient is fully conscious, they may be fully aware of your action even though the patient can give of your action even though the patient can give no indication of it. no indication of it.

- Urge family members especially the love ones to Urge family members especially the love ones to visit as desired apparently comforting the dying visit as desired apparently comforting the dying patientpatient

15. 15. MEDICATIONMEDICATION- Give prescribed drugs as instructed by the Give prescribed drugs as instructed by the

physician. physician. - Remind the physician to prescribe an analgesic to Remind the physician to prescribe an analgesic to

control pain. control pain. - Use accurate injection technique and medication Use accurate injection technique and medication

dosages. dosages. - Nurse should employed a useful means of Nurse should employed a useful means of

assessing pain and evaluating the effectiveness assessing pain and evaluating the effectiveness of analgesia. of analgesia.

CONCLUSIONCONCLUSION

Palliative care is appropriate for any patient at Palliative care is appropriate for any patient at any stage of a life threatening illness, regardless any stage of a life threatening illness, regardless of age. Palliative and end –of life care touches all of age. Palliative and end –of life care touches all parts of the health care system, from hospital to parts of the health care system, from hospital to hospice to community to home and usually hospice to community to home and usually involves an interdisciplinary team of care givers involves an interdisciplinary team of care givers that deal with the medical and psycho-social, that deal with the medical and psycho-social, spiritual and economic needs of the patient and spiritual and economic needs of the patient and the family.the family.

THANK YOU FOR YOUR AUDIENCE. THANK YOU FOR YOUR AUDIENCE.