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Palliative Care (Communication in Palliative Care (fundamental to the…
Palliative Care
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Aspects of Dying
Physiological:
- Decreased level of consciousness
- Alteration of breathing
- Alteration of mental status
- Circulation changes (extremities usually get colder to touch, BP usually lowers; HR may increase but weak; skin may become waxy and pale; cyanosis; purplish blotchy on knees and feet; just keep patient warm with light blankets and turn every 2 hours)
- Metabolism/Dehydration (decreased intake, eventually unable to swallow, decreased appetite, decreased urine/bowel movements; just give ice chips/sips of fluid and swab mouth with cool water)
- Social: distancing; withdrawal
- Emotional: fluctuations in emotions; flat affect
- Spiritual: suffering; existential concerns
- Cultural: rituals; ceremonies; information sharing
"Good death":
- Accepted
- Planned
- In keeping with the patient’s “wishes”
- Appropriate setting and site
- Adequate support/resources
- Good symptom control
How?
- Patient AND family agree on goals of care
- Care focus/extent of treatment is clear
- Nature of hope is realistic
- Patient/family are aware as to “what to expect” and can cope
- Anticipatory grief has been managed
- Adequate resources are available
- Symptoms have been anticipated and prepared for
Symptoms in the last 48 hours of life:
- Congestion (56%)
- dealing with the "death rattle" --> educate family, positioning, anticholinergics
- Pain (51%)
- Restlessness/Agitation (42%)
- Urinary (incontinence 32%, retention 21%)
- Difficulty swallowing (29%)
- Dyspnea (22%)
- Nausea/vomiting (14%)
- Muscle twitches, jerking, plucking (12%)
- Confusion (9%)
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- Hospice Palliative Care: aims to relieve suffering and improve the quality of living and dying
- Palliative Care: an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through prevention and relief of suffering by means of early identification and impeccable assessment
Palliative Care Appropriate for: any patient and/or family living with, or at risk of developing a life-threatening illness (due to diagnosis, prognosis, regardless of age, at any time that they have unmet expectations and/or needs and are prepared to accept care
Barriers:
- health care professionals: have a sense of personal failure; personal discomfort with death/dying
- patients/families: unrealistic expectations; reluctance to discuss issues other than curative therapy
Traditional Model: curative --> Palliative (Active or Terminal) --> Death (this is an older model and would suggest that there is a point in time that medicine is aware that treatments are no longer effective and that death is the expected outcome)
Current Model: Presentation --> therapies to modify disease --> therapies to relieve suffering and/or improve quality of life --> end-of-life care --> death --> bereavement care
- from the 1940s-1980s there was prolonged dying (a predictable decline); there are exacerbations and sudden dying; there is prolonged dwindling
Goals of Care Discussion: current, different every time; includes exploring patients goals and understanding of illness and treatment/care options, providing information according to patients information preferences and readiness
Decision-making or Consent Discussion: current; outcomes relates to a specific intervention or treatment (ex. code status, withholding or withdrawing treatment)
Role of the Nurse in Palliative Care:
- Aspects of care
- Structure and process of care
- Physical aspects
- Psychological and psychiatric
- Social
- Spiritual and existential
- Cultural
- Ethical legal
- Care of the imminently dying patient
Palliative Performance Scale:
- Gives a snapshot of patient’s functional status and rate of decline
- Suggests present and future needs
- Improves assessment; assist with prognostication
