Care Giving Context and Quality of Life - Research Paper Example

 Part One Introduction: This paper focuses on the care provided to a terminally ill patient and the impact of the care on the quality of life of the patient. The patient was a 78 year old Catholic priest that had been admitted into the hospital and subsequently diagnosed as ailing from. The patient remained in palliative care in the hospital for a period of six weeks prior to his demise. During the period of his palliative care the patient experienced several areas of discomfort. Initially there was shortness of breath, evening fever, tiredness, and lack of appetite. Passage of time brought with it respiratory difficulties, continuous fever, dryness of mouth, abdominal pain and discomfort, total unwillingness to consume any food, constipation, lapsing into periods of delirium, and the initial signs of a bed sore. Care requirements included elevating these difficulties or assisting and providing comfort to the patient. General Information: The patient was transferred from the oncology acute care center to palliative care, from when the patient came under my care. Duration of palliative care was four weeks from the time of transfer till the demise of the patient. The patient was transferred to palliative care with the diagnosis of advanced stage IV aggressive Non-Hodgkin Lymphoma (NHL) with severe bone marrow depletion that had not responded to chemotherapy. Chemotherapy was the only treatment considered (Anderson-Reitz, 2006). Due the age of the patient and the advanced stage of the disease in the patient, the more aggressive interventions like bone marrow transplant were considered unsuitable by the clinical hemo-oncologist (Saha, 2001). The patient was a Catholic priest aged 78 years in good physical condition for his age, except for the difficulty of shortness of breath, tiredness, lack of appetite and anemia. He was fully conscious and self-ambulatory on arrival at palliative care. He communicated easily with the nursing staff, as they went about their care routine answering all their queries coherently, and even joking with them. He bore pain well and took all the intravenous infusions without any complaints. In a few months time fifty years would have elapsed since his ordination. He had served the Church very actively, with little concern for the strains and stress that he was taking. His physique reflected that he had remained active till hospitalization and had maintained healthy food habits. He was slightly underweight, which could be put down to his reduced appetite. Two years earlier he had started building a new church in place of the existing church in his parish, with minimal financial support from the diocese. He was active in ensuring that adequate contributions for the construction came in from his parishioners, friends, and relatives. Besides this, he was physically present at the construction site supervising the construction work, whenever he could spare time from his parish duties. At his age this was heavy physical toil. Eighteen months earlier he started falling repeatedly ill with the frequency increasing over time. It started with a lack of appetite that he had earlier, which he ignored. He then started feeling tired, which he put down to the increased physical effort that had become a part of his life in the recent past. Then he started experiencing respiratory discomfort and fever in the night. He was admitted into the Mission hospital that belonged to the diocese and was diagnosed with respiratory infection and anemia. He was treated accordingly for ten days and discharged. He immediately resumed his parish and construction supervision routine. After six months there was a recurrence of the same respiratory discomfort and fever at night. He was again admitted in the mission hospital with the same diagnosis treated and discharged. In the subsequent ten months approximately this process of admission for respiratory infection and anemia continued with increasing frequency. When queried, as to why better medical facilities were not sought. He replied that he decided so to avoid extra financial strain for the diocese for his treatment. Approximately three months prior to his demise the church construction was completed. Pressure from his friends and relative caused him to seek better medical advice. A series of laboratory tests including bone marrow biopsy and imaging of various parts of the body was done by the hospital, and the medical clinicians at the hospital based on the results of these tests diagnosed him as suffering from myelofibrosis. He was treated with drugs that promoted the production of red blood cells, white blood cells and platelets. When his condition deteriorated in spite of this treatment he was referred to the oncology department of the hospital in which I work. The oncology department of this hospital conducted additional tests and imaging and repeated the bone marrow biopsy. On the basis of the findings of the additional tests, imaging and bone marrow biopsy the hemo-oncologist gave the diagnosis as advanced stage IV aggressive Non-Hodgkin Lymphoma (NHL) with severe bone marrow depletion. The treatment initiated at the acute care of the oncology department consisted of supportive interventions of blood and platelet infusions to boost the levels of red blood cells, white blood cells, and platelets in the blood; saline and dextrose infusions to maintain body fluid and nutrient levels; and chemotherapy to fight the disease. Chemotherapy was undertaken in spite of the minimal chances of it proving to be useful at the advanced stage of the disease in the priest (Nelson, 2008). He remained in the acute care unit for ten days. In finding that there was no response for the treatment provided and his condition was worsening, the priest and his relatives were informed that there were no treatment options available and that he would succumb to the disease. There was the option of taking him home and providing whatever support was possible employing a home nursing professional for his palliative care or the palliative care services available in the hospital could be made use of. The priest and the relatives took the decision of admitting him into the palliative care unit of the hospital, as they wanted him to have the maximum support in his last period of life and were not confident of being able to [provide this to him from the home environment. He was admitted into the palliative care unit of the hospital and thus came under my care. Palliative Care Provided to the Patient: The patient arrived at the palliative care center requiring assistance to move around, conscious and with slight fever. He complained of shortness of breath, pain and discomfort. The primary concerns initially with the patient were addressing his shortness of breath, weak condition and low blood count of red blood corpuscles, white blood corpuscles, and platelets. In palliative care dyspnea is a frequently encountered with patients stricken by cancer (Indelicato, 2006). The protocol for managing dyspnea in this health care institution is three fold. The first consists of providing oxygen to reduce the hypoxemia being experienced and providing positioning support by elevating the head and chest of the body. The second is providing therapeutic support through bronchodilators given through a nebulizer. The first and second steps were repeated each time extreme discomfort was reported by the bystander. The final step is to identify the cause of the respiratory discomfort and treat the cause. In the case of this patient the dyspnea managing protocol was put into place and oxygen was provided. Unfortunately the oxygen facility in the room where the patient was admitted was malfunctioning and an additional facility for oxygen had to be created by running a tube from the adjacent room to the patient’s room. A bronchodilator was administered through a nebulizer. The administration of both oxygen and a bronchodilator were seen to have an immediate effect on the patient, and the harsh breathing reduced, but did not go away. Infection was considered to be the cause of the dyspnea and so a course of antibiotics was prescribed by the clinician and the first course administered. In addition it was decided to restrict visitors, as visitors were considered to be a possible route for infection transmission to the patient. This was to prove a difficult step to enforce, as the priest had a host of visitors streaming in consisting of members of the family, clergy, and well-wishers. In addition proper mouth hygiene was considered necessary to prevent oral thrush and to this objective the care givers standing by were advised on the methods of maintaining oral hygiene and use of mouthy washes. Movement of the patient was restricted. He was allowed a bystander from the family, who was to use a bed pan and other toilet facilities were to be done at the bed with the patient allowed to sit up. The bystander at all times was to wear a face mask. These steps consisted of addressing the immediate distress steps of dyspnea. Addressing his weakened body condition due to poor intake of food and fluids was also taken on a priority basis. Since the patient showed reluctance to consume food and required fluids, it was decided to parenteral nutrition through infusions as a therapeutic option (Zanuy et al, 2006). Central venal catheterization was decided on as all the accessible veins in the upper and lower limbs had collapsed, as a result of the numerous parenteral infusions had been through. In addition parenteral infusion protocol of this institution followed the use of central venous access, due to the frequency and nature of infusion fluids and drugs. (Taylor & Palagiri, 2007). In addition to this on the initiative of nursing, a dietician was sent to advice the family on enhancing the nutrient content of the limited food intake of the patient. Assessment of the possible causes of the reluctance for the patient to take solid food by nursing led to the finding that the patient had severe dental problems that affecting the patient’s ability to chew food and was a contributory factor to the reluctance to have solid food. Three points of advice formed the core of nutritional advice to the family members. This advice consisted of no dietary restrictions, to encourage the patient to eat by giving him foods that he liked, and to ensure that the food given to him was soft or minced to reduce the chewing effort, like cheese, cutlets and soups that he liked. Managing his general condition was the next area of concern. The low blood count of red blood cells, white blood cells, and platelets needed to be addressed on a regular basis. Blood count was monitored on a daily basis and blood transfusion and platelet transfusion initiated, when the blood count was low. The impact of the side effects of the chemotherapy given to the patient was also considered. Neutropenia and infectious complications are the most potent side effects that could result from chemotherapy (Anderson-Reitz, 2006). Since hematopoitec support and an antibiotic regimen were already a part of the palliative care being provided, no additional steps to manage these possible side effects were taken. A decision was taken by the clinicians that no painkillers or sedation were warranted at this initial stage of palliative care Kidney function was monitored by maintaining a record of the intake of water and liquid diets and measuring the output on a daily basis. Kidney function tests were done every three days to further confirm satisfactory functioning of the kidney. Liver function was monitored through blood tests regularly. Respiratory function was measured through visual assessment of the patient. No scale was used and the nursing professional’s judgment based on bystander reports and visual status was the measure used. In addition to pulse rate, monitoring of heart function was found not essential, as the history of the patient from the acute care showed satisfactory heart functioning. In addition there were no electrocardiogram facilities in the proximity and it was considered not advisable to move the patient. Brain function was assessed by visual assessment of the clinicians and nursing. No scale was used. Palliative care requirements changed rapidly over the period four. With the patient restricted to the bed, age, nutritional status and poor physical condition, pressure ulcers were an area of concern. Body hygiene, application of powder, reducing shear and friction during changing of bed linen and clothing, reducing moisture on the body, and preventing continued pressure at specific points were the steps taken to reduce the risks of pressure ulcers. In addition the body of the patient was examined on a daily basis to evaluate whether there were any initial signs of the onset of pressure ulcers (Reifsnyder & Magee, 2005). The first week saw further deterioration on three aspects, though there was marked improvement in the respiratory discomfort. There was further reluctance to take food and fluids, increasing the use of parenteral infusion for providing nutritional and hydration support. The second was the development of mild hepatitis requiring reduction in a correction of whatever diet was consumed by the patient. No oily foods or meats were advised. No fried foods or fatty foods or meat were to be given. Leafy vegetarian food and fruits were advised. In the second week the blood counts for red blood cells, white blood cells, and platelets were dropping faster after the infusion of blood and platelets requiring increased frequency of these infusions. There was increased pain and discomfort both expressed and visible on the patient, and lack of sleep was reported. Yet, no change in the pain management was advised by the clinicians and no sedatives prescribed. Hepatitis continued to present itself. The third week was a period of serious concern, as complications were starting to express themselves. Gastro-intestinal discomfort became obvious, but a gastro-intestinal special consult caused just an addition of antacids, with the report that gastro-intestinal blocks were developing, but no intervention was possible. Periodic delirium was starting to occur, showing that the higher brain functions were gradually being negatively impacted on (Panke, 2003). Respiratory discomfort was on the increase, requiring increased periods on oxygen support and broncho-dilation support. Blood count of red blood cells, white blood cells and platelets continued to diminish rapidly. The most poignant visible signs were the enhanced pain and discomfort demonstrated in the demeanor, with longer durations of delirium. The issue of sedation came to the forefront. The clinicians were not in favor of sedation. They argued against sedation on the grounds that they lacked the confidence that the patient would regain consciousness once sedation was initiated. Members of the clergy and some members of the family supported non-use of sedation arguing that it would tantamount to mercy killing. Other members and nursing supported the use of sedation, arguing that there was no point in keeping him conscious and forcing him to experience all the pain and discomfort, when the end result would be the same. At no time in the patient’s coherent state was the patient ever asked his opinion on the manner in which palliative care should be provided. The consequence of the pressure for sedation, led to mild analgesics being used, which hardly produced any profound effect on the pain and discomfort of the patient. This dispute on sedation continued into the fourth week of the patient in palliative care or rather till five days before the demise of the patient. The condition of the patient has worsened causing even the clinicians bend to the view to the use of sedation, and the patient was sedated. All visible signs of pain and discomfort were no longer visible. The only visible sign that something was wrong with the patient was the harsh breathing in spite of oxygen support. Otherwise the patient appeared to be in deep slumber. Other support continued in the same manner as earlier. On the fifth day after sedation the patient passed away without regaining consciousness. Spiritual and social issues that improve the quality of life of the patient are also key elements in palliative care (Claessens et al, 2007). Lessons on use of sedation, and spiritual and social issues are what stand out in my experience with the patient. In usual circumstances issues of spirituality and social support add to the difficulties faced in palliative care (Byock, 2006). In the case of the patient being a priest, spirituality was strong and his almost fifty years of life in the service of people provided strong social support and improve the quality of life of the patient. Walking a patient through the end of life processed is not easy for nursing, as it brings with it emotional and personal issues in communication and interaction with the patient and family care givers (Lowey, 2008). Yet, with this patient the strength of spirituality in the patient and the family care givers was so strong that though there was grief in knowing that death was imminent there was acceptance of it as the Lord’s will and nothing could prevent. Prayers were the solace, which were resorted. The patient did not complain of the pain and discomfort that the palliative care was causing him, but resorted to cries of “Jesus save me”, when the pain was unbearable. Social support was immense, with any number of family members, well wishers, nuns, and priests available and was the source of comfort to the patient. It was this support that helped reduce the consequences of the disease and provided some form of quality of life for the patient. It was a lesson to me on what spirituality and social support could do at the end stages of life of a terminally ill patient. Assessment of Palliative Care Provided on the Basis of Person Centered Care: Person centered care owes its place in patient care to Tom Kitwood, who developed this approach to the care of patients, which has emerged as a key concept to improve care provided to all kinds of patients. Elements that make up this concept are personhood, knowing the person, maximizing choice and autonomy, comforting, and a supportive physical organizational environment. This has led to a framework for patient centered care that begins with assessment of the personhood of the patient, communication to know the person and understand the choice of the person in terms of care needs, so that the autonomy of the patient becomes a part of the care provision, and implementing care based on comfort needs of the patient. (Crandall, et al, 2007). Addressing the first two components in the framework of person centered care, which is the assessment of the personhood of the patient and knowing the patient, there was a distinct lack of these two components. Assessment was essentially done on the clinical condition of the patient, treatment provided earlier, disease impact on the proper functioning of the body, and the steps required to maintain functions of the body and extend life as much as possible, knowing the terminal condition of the patient. Personhood assessment was limited to the interaction between the nursing professionals in the providing of decided care of the patient, and not as an objective exercise. Communication to know the patient, provide the patient with options of care and the outcomes were extremely limited. Enquiries to the patient were limited to knowing how the patient was feeling and information provided was limited to measures being initiated to alleviate distress. Other options of treatment and care were not discussed with patient and it was not the patient’s choice of treatment and care, raising issues of patient autonomy. The terminal nature of the illness was intimated at the acute care center. The manner of the journey to the end of life and the options that could be provided were not given to the patient. Instead this communication was with the family members, a couple of whom belonged to the medical fraternity and decisions taken there. By not providing the options of medical and nursing care, the autonomy of the patient not just in terms of patient centered care, but also in terms of ethics were denied (Valente, 2004). An example here highlights the denial of autonomy to the patient and the impact on the dignity of the patient. In this patient suffering resulted from pain and dyspnea. Pain and dyspnea are two common occurrences in palliative care and objectives in palliative care include alleviating pain and dyspnea, which is seldom done effectively (Bruce, Hendrix & Gentry, 2006). Striving for the best quality of life for the patient is an essential element in palliative care (Claessens, et al, 2007). In this case sedation was an option that was not offered earlier to the patient in spite of the severe pain and dyspnea, and finally given to the patient in the last five days of his life. Palliative or controlled sedation is recommended when refractory symptoms cannot be controlled adequately through other therapies in terminally ill patients to reduce their suffering (Bruce, Hendrix & Gentry, 2006). This option was not discussed with the patient and was denied when few of the family members and nursing suggested it, on the ground that they may not be able to bring the patient out of sedation. By presenting this option as similar to physician-assisted suicide to the family members, the strong Catholic spirituality in the family members made them go along with the decision not to use sedation earlier. The clinicians failed to differentiate between palliative controlled sedation and physician-assisted suicide to the family and their intent. In physician-assisted suicide medication is prescribed for the patient to be used when chosen, with the express intent of ending the life of the patient. Whereas, in palliative controlled sedation the physician prescribes and monitors the medication, making adjustments appropriately to make sure that pain and distress are minimal to the maximum extent, thus improving the quality of the limited life period of the patient. The intention of palliative controlled sedation is relief of the suffering and improving the quality of life of the patient (Bruce, Hendrix & Gentry, 2006). Controlled sedation was ultimately given to the patient, but could have been provided much earlier and the patient would not have suffered so much. Moving on to the social and spiritual requirements of the patient for improved quality of life there were limitations. Strong spirituality was an inherent quality of the priest and family and well wishers. In addition there was strong social bonding and support from the family and well wishers. Nursing observed that the priest preferred comforting from family members and was more at ease, when well wishers, nuns and priests came to pray for him. Visitors were barred by the clinicians on the grounds of transmission of infection easily to the patient. They could only view him through the glass partition to his room. Discussions were held between the nursing professionals and the medical professionals on the issue of permitting visitors. The medical professionals finally relented to the pressure of nursing on this issue with the suggestion that nursing would ensure that visitors wore masks to minimize the risk of infection. This was the only instance when nursing advocacy was employed in favor of the autonomy of the patient. The presence of family, well wishers, nuns and members of the clergy made a whole difference to the demeanor and quality of life of the patient. It may well be argued here that nursing failed to live up to its advocacy role in providing person centered care to the patient and improve the quality of life of the patient. Terminally ill patients and their family require someone to guide them in their search for information, stand up for their wishes and objectives in patient care, and support them in their decisions on the palliative care to be provided and how their lives should come to an end. When strong nursing advocacy is in place, it increases the quality of life of the patient, and ensures that patients die in comfort and security, maintaining their dignity, and having their values respected. (Bruce, Hendrix & Gentry, 2006). However nursing advocacy gets limited to the extent of nursing power within the organizational structure (McSteen & Peden-McAlpine, 2006). This is particularly so when the nature of the care requirements are intensive and believed to be beyond the ability of nursing as in palliative care. The power of nursing to advocate on behalf of the patient is conditioned by the position of nursing within the organization, capability to contend with the effects of external and internal environmental forces, the importance that the organization gives to nursing and the role it performs, and the resources that nursing has at its disposal to meets its objectives (Ponte, et al, 2007). Nursing power and its capacity in this palliative care institution suffers from impact of these factors. The outcome for the patient was known, yet with a more powerful nursing performing its required role, the quality of life and the dignity of the patient may have been given better attention. Conclusion: The patient passed away peacefully however there remains issues on the quality of care that was provided that would have improved the quality of life during his tenure in palliative care. Reflection on the care provided to the patient shows that the patient would have experienced better quality of care had the framework and elements of person centered care been a part of the planning and execution of the care needs of the patient. The blame for this falls on the medical professionals, the nursing professionals, and the organizational structure and culture. Such poor quality of palliative is likely to continue unless steps are taken to orient the palliative care provided to patients in this institute towards person centered care by considering its framework and elements of care. This would call for change and change has to be lead. With onus of patient care being essentially a nursing function, the discipline that is best suited for leading this change is nursing. This calls for the nursing management of the institution to seriously consider how patient centered care could be orientation of nursing care in the institution and take the necessary steps to implement it and monitor the progress. It is only then that quality palliative care could be accepted as provided to the patients coming to this institution. Part Two – Recommendations To The Director of Nursing Subject: Recommendation for Implementing Patient Centered Care This recommendation for patient centered is based on the evaluation of palliative care provided to a 78 year old male patient from the time of his admission in palliative care till his demise and the benefits that patient centered care would have provided in enhancing the quality of life in the last four weeks of his life. Though palliative care is a multidisciplinary function, this recommendation is being sent to the Director of Nursing, as it is nursing that is essentially responsible for the care provided to the patient and owing to the proximity that develops between a patient and nursing in patient nurse relationships nursing professionals are best placed to assess the difficulties of the patient and the care needs of the patient (Indelicato, 2006). Recommendations: The rationale for recommending the patient centered care approach is due to its emergence as a key concept for addressing the care needs of patients (Crandall, et al, 2007). Furthermore, according to Hagenow, 2003, patient centered care “is the only model for a better way of providing health care in America. Implementing patient centered care in out institution will require change and nursing is the most suited discipline to lead this change (Indelicato, 2006). However, the power that nursing has in this institution is limited, owing to the organization structure and culture and will be a limiting factor (McSteen & Peden-McAlpine, 2006). Enhancing the power of nursing will be required to overcome the limitation on nursing currently. Enhancing the power of nursing means that nursing will have to show that it is capable of meeting the challenges it faces in meeting the difficult and complex elements of palliative care (Ponte, et al, 2007). This calls for enhancing the knowledge and skills of nursing in palliative care (Boettcher, Kemeny & Boerman, 2004). Enhancement of skills required are not the just the knowledge and skills received from education in nursing classes. The additional enhanced knowledge is the knowledge of the patient as a person. Skill requirements include communication skills to for understanding the patient as a person and the medical, physical and psychological care needs of the patient (Hermansson & Ternestedt, 2000). So, where is this enhanced knowledge and skills to come from? It comes from conducting post-mortem sessions to evaluate the care provided on the basis of physical, medical and psycho-social needs of the patient. (Hermansson & Ternestedt, 2000). This means such an exercise will have to be carried out by nursing at the end of every patient that uses the palliative care of the institution. In addition to this the work-place of nursing will have to be made conducive to patient centered care, for according to Tellis-Nayak, 2007, it is when the work-place provides additional quality of life to the care givers, the care givers provide added quality of life to the patients. Literary Reference Anderson-Reitz, L. (2006). Dose-dense Chemotherapy for Aggressive Non-Hodgkin Lymphoma. Cancer Nursing, 29(3), 198-206. Boettcher, F. I., Kemeny, B. & Boerman, R. (2004). Training for and Sustaining Person-centered Dementia Care. Annals of Long-Term Care, 12(12), 26-28. Bruce, D. S., Hendrix, C. C., Gentry, H. J. (2006). Palliative Sedation in End-of-Life Care. Journal of Hospice and Palliative Nursing, 8(6): 320-327. Byock, I. Where do we go from here? A palliative care perspective. Critical care Medicine, 34(Suppl 11), S416-S420. Claessens, P., Genbrugge, E., Vanuffellen, R., Broeckaert, B., Schotsmans, P. & Menten, J. Palliative Sedation and Nursing: The Place of Palliative Sedation Within Palliative Nursing Care. Journal of Hospice and Palliative Nursing, 9(2), 100-106. Crandall, L. G., White, D. L., Schuldheis, S. & Talerico, K. A. (2007). Initiating person-centered care practices in long-term care facilities. Journal of gerontological nursing, 33(11), 47-56. Hagenow, N. R. (2003). Why not person-centered care? The challenges of implementation. Nursing administration quarterly, 27(3), 203-207. Hermansson, A. R. & Ternestedt, B. M. (2000). What do we know about the dying patient? Awareness as a means to improve palliative care. Medicine and law, 19(2), 335-344. Indelicato, A. R. (2006). The Advanced Practice Nurse's Role in Palliative Care and the Management of Dyspnea. Retrieved Aug 10, 2008, from, Topics in Advanced Practice Nursing eJournal, 6(4), Medscape Today Web Site: http://www.medscape.com/viewarticle/551364 Lowey, E. S. (2008). Communication Between the Nurse and Family Caregiver in End-of-Life Care: A Review of the Literature. Journal of Hospice and Palliative Nursing, 10(1), 35-45. McSteen, K.& Peden-McAlpine, C. The Role of the Nurse as Advocate in Ethically Difficult Care Situations With Dying Patients. Journal of Hospice and Palliative Nursing, 8(5), 259-269. Nelson, R. (2008). Survival Benefit of Palliative Chemotherapy Often Not Discussed With Patients. Retrieved Aug 10, 2008, from, Medical News. Medscape Today Web Site: http://www.medscape.com/viewarticle/578491 Panke, J. (2003). Difficulties in Managing Pain at the End of Life. Journal of Hospice and Palliative Nursing, 5(2), 83-90. Ponte, R. P., Glazer, G., Dann, E., McCollum, K., Tyrrell, S., Branowicki, P., Noga, P., Winfrey, M., Cooley, M., Saint-Eloi, S., Hayes, C., Nicolas, K. P. & Washington, D. (2007). Retrieved Aug 10, 2008, from, OJIN: The Online Journal of Issues in Nursing, 12(1) Web Site: http://www.medscape.com/viewarticle/553405 Reifsnyder, J. & Magee, S. H. (2005). Development of Pressure Ulcers in Patients Receiving Home Hospice Care. Wounds, 17(4), 74-79. Saha, I. H. (2001). Myelodysplastic Syndromes in the Elderly. Cancer Control, 8(1), 79-102. Taylor, W. R. & Palagiri, V. A. (2007). Central Venous Catheterization: Concise Definitive Review. Critical Care Medicine, 35(5), 1390-1396. Tellis-Nayak, V. (2007). A person-centered workplace: the foundation for person-centered caregiving in long-term care. Journal of the American Medical Directors Association, 8(1), 46-54. Valente, M. S. (2004). End-of-Life Challenges: Honoring Autonomy. Cancer Nursing, 27(4), 314-315. Zanuy, M. A. V., Nido, R. A., Rodriguez, P. J., Gonzales, R. S., Villares, J. M. M. & Sanz, M. L. (2006). Should hydration and artificial nutrition be accepted as a palliative care? Nutricion hospitalaria, 21 (6), 680-685. Read More