Palliative Hospice Care Wks 10-12

8/3/2019 Palliative Hospice Care Wks 10-12

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Palliative Hospice careWeeks 10-12

1. Advanced Care Planning and End-of-life Decision Making

2. Ethical And Legal Aspects of

Palliative Care3. Spirituality in Palliative Care


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Objectives

8. Apply guidelines of advanced care planning

and end of life decision making (Creative

Thinking and Teamwork)

9. Identify bioethical and cultural beliefs and

practices of a client/family/career with

palliative care (Creative Thinking and Ethical

Reasoning)

10. Apply spirituality in palliative care.(Pro

active and spiritual values)


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Advanced Care Planning and End-

of-life Decision MakingAdvanced care planning is a collaborative

process among patients, family members,

and health care professionals whereby

patients :

clarify their goals, values and preferences for

future medical treatment. (Tulsky, 2005)


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Part of advanced care planning process patients

may choose to complete advance directives

e.g. living will, andformally appoint decision-making surrogates

e.g. durable power of attorney for health care.

- Advanced care planning may help patientsincrease knowledge about and perceived

control over the dying process.


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Challenges in Advanced Care

PlanningHealth system issues, including professional

time limitations on visits with patients and

families, and patient engagement with

multiple providers can impede professionals

capacity to build rapport and trust.


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PlanningClinicians may lack specific training in

communication skills and willingness to

broach and maintain discussions about

potentially sensitive, emotionally charged

issues with patients and families.


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PlanningOver use of medical jargon can also interfere

with patient education, comprehension, and

meaningful clear discussions.

Patients and families may be reticent to ask

clarification questions, not wanting to appear

ignorant or to step outside the expected role

of good patient.


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PlanningPsychological barriers such as fear and anxiety

may influence the quality of advance care

planning discussions.

Patients and families may also become

emotionally stressed during discussions that

convey bad or sad news and their abilities to

process and respond to information can be

limited.


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Communication Strategies for

Advanced Care Planning

Development of a trusting relationship

with patients and families is integral

to high-quality medical care,

especially at end-of-life.


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Advanced Care PlanningQuality of the patient-clinician relationship trust

and rapport can be enhanced by:

Encouraging patients to share their concernsand questions using active listening,

demonstrating respect, talking in an honest

and straightforward manner, being sensitive

when delivering difficult news, and

maintaining engagement about advanced

care planning issues with patient and family

throughout the disease process.


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Advanced Care PlanningActive listening involves the use of open-ended

questions and appropriate reflection back

about the content of the speakers message.Allow sufficient time for patients to respond and

to avoid the tendency to interrupt.

Reflecting the main ideas and feelings of thepatients statement can be helpful.


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Advanced Care PlanningLo and colleagues (1999) remind clinicians that

they do not have the sole responsibility for

responding to the patients suffering.

Referring troubled patients and families to a

social worker, psychologist, member of the

clergy, or another mental health professional

can be helpful and appropriate.


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Advanced Care PlanningWhen patients and families becomes emotional,

Tulsky (2005) suggest that providers:

1. Acknowledge the affect (This must be...)2. Identify loss (It must be hard...)

3. Legitimize feelings (I think that is normal...)

4. Offer support (I will be here...)5. Explore (What....)


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Values Clarification and Discussion of Goals

Various tools have been developed to guide the

discussions such as:

1. Making Medical Decisions (American

Association of Retired Persons, 1996)2. Five Wishes (Commission on Aging with

Dignity, 1998)

3. Talking about your choices (Choice in Dying,1996) and

4. Your Life, Your Choices (Pearlman, Starks,

Cain et al, 2001)


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Sample Advanced Directive


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Sample Advance Directive / Living Will


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Sample Advance Directive with Living Will


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Advance Directives

Patients should think about choosing a

surrogate decision-maker who is able to cope

with potential conflict.

When patients complete advance directives,

they should be informed that they are free to

change the documents at any time.


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To help you live until you

die.

-Cecily Saunders, 1960


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Judgement and action

Making the decision and acting upon it.


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Theoretical approaches

Value Judgement

A Judgement that, in the broadest sense, ismad on behalf of someone else but may not

necessarily reflect the right decision for the

individual patient and family.


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Deontological Ethics

Doing what is right

Unconditional respect for persons and in

doing what is right regardless of the

consequence. What is right however may not

necessarily be good. A good action can also

have a bad outcome.

Eg whether to keep a confidence or to protectsomeone who is vulnerable by breaking that

confidence.


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Ethical Pronciples

Respect for the individual

Autonomy

Justice and utility Beneficence

Non-maleficence


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Respect for the Individual

Due regard for the feelings or rights of others,

avoiding harm or interference.

Whnen we have seen and acknowledged our

own hostilities and fears without hesitation, it

is more likely that we will also be able to sense

from within the other pole towards which we

want to lead not just ourselves but ourpatients as well.

- Nouwen (1976)


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Questions to ask in establishing

autonomy in health-care ethics

Are all individuals equally autonomous?

Are different decisions made by the same

individual equally autonomous?

To what extent are we obliged to respect

these autonomous decisions?

Consider the rights of the patient who

chooses to die at home especially if its the

clients wish.


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Equity and Justice

Nurses who are committed to the principle of

equity and justice have a duty to campaign for

further resources to improve services and to

maintain standards of care.

Justice demands that care provision is based

on current evidence and best practice.


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Advanced directive (living will)

A formal written advanced statement by a

patient refusing treatments in specific stated

situations that may occur in a future illness.

This tales effects if:

The maker of the advanced directive should

become able to communicate at some future

time. The circumstances specified in the advanced

directive arise.


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Implications for Nursing Practice

Professional nursing is all about having the

knowledge and skills to do things, an

awareness of the relationship between how

you act and about the potential outcome

result of those actions.


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Ethical choices should be guided not only by

roles and principles but also by thoughtful

analysis of feelings, intuitions and

experiences.

- Cooper, 1991


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Culture the learned and shared beliefs,

values, and lifeways of a designated or

particular group that are generally transmitted

intergenerationally and influence ones

thinking and action modes.

Cultural competence the ability to performand obtain positive clinical outcomes in cross-

cultural encounters.

Spiritual care competence the ability toperform and obtain positive clinical outcomes

in spiritual care encounters.


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NHS in Scotland issued guidelines on the

definition of spiritual and religious care

Religious care given in the context of the

shared religious beliefs, values, liturgies and

lifestyle of a faith community.

Spiritual care given in a one-to-one

relationship, is completely person-centered

and makes no assumptions about personalconviction or life orientation.


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A Sense of meaning

Relationship


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Hope

Our way of coping with lifes variety of

experiences, especially the difficult and

uncertain times.

Influenced by current and past life

experiences.

In times of illness hope is focused on an

available treatment and that it will bessuccessful.

I hope my family will be OK.


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Being There

Can counter feelings of abandonment but it

can also be challenging.

To be there without doing is not easy and

demands time and experience.


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Spiritual Issues in Palliative Care

The WHY questions

* Why did I get Cancer?

* Why me?* What have I done to deserve this?

* Why did God allow this to happen?

- When faced with these types of questions,one should utilize effective communication

skills.

Six Step framework for responding to spiritual


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Six Step framework for responding to spiritual

distress

1. Do not rush with an answer.2. Listen actively.

3. Explore what has prompted this question.

4. Respond to the patients feelings.5. Be aware of your own feelings.

6. Refer to other professionals when

appropriate.


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Hopelessness

Characterized by a lack of interest and

involvement in everyday life and a withdrawal

from the company of others.

This is a part of clinical depression


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Family Distress it is important to recognize

that the family can also be a source of stress

and distress to the patient.

Spiritual self-awareness One needs to

appreciate our own essence of self. Be aware

of our own feelings and spirituality, aware of

the personal and professional limitations.

S i it l A t d C


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Spiritual Assessment and Care

The Multiprofessional Team

Made up of:

In the community: general practitioner, district

nurse, clinical nurse specialist and others as

required. In a nursing home: the GPs, nursing staff, district

and clinical nurse specialists and others.

In hospices: the core team comprises chaplain,

doctors, nurses, occupational therapist,

pharmacist, physiotherapist and social worker.

In hospitals: doctors, and nurses with ready

access to a list of other named professionals.


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Skills and Boundaries It is the patient who

will choose to whome they will talk and when

and where. Privacy is often preferred and this

explains why so many deep and spiritualconversations take place with nursing staff in

intimate setting.

Chaplaincy responds to the needs of theother person regardless of their faith,

background or life stance.


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Assessing Spiritual Needs

5 Rs of spirituality

Reason

Reflection Religion

Relationships

Restoration


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Assessing Religious needs

Many people will find comfort and meaning in

their faith and associated sacraments and rites

at such time.


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Competence in Spiritual Care

1. Staff and volunteers with casual contact with

patient/family

2. Staff and volunteers whose duties require

personal contact with patients / families

3. Staff and volunteers who are members of the

multiprofessional team.

4. Staff and volunteers whose primary

responsibility is the spiritual and religious

care of patients, visitors and staff.


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Expected competencies

Appropriate understanding of the concept of

spirituality at that level.

Awareness of their own personal spirituality

Recognition of personal limitations

Recognition when to refer on

Documentation of perceived need and referral

options.


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Expected competencies

At level 3 assessment, interventions and

outcomes should be documented.

Confidentiality is also introduced.

At level 4 a competency framework for the

expertise required of the chaplain or director

of spiritual care, which includes being a

resource, offering staff support, providingeducation and training and influencing the

deleopment of national initiatives.

Limitations of assessment tools


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Limitations of assessment tools

and Competency frameworks

Focus of care need to be individual to each

patient and family, with care being provided

by the multiprofessional team.

Palliative Hospice Care Wks 10-12

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