Palliative care for Enduring Conditions - Essay Example

Table of Contents Introduction.......................................................................................................... 2 Philosophy of Palliative Care.............................................................................. 2 Gold Standards Framework................................................................................ 3 Philosophy of Palliative Care and the current clinical practice.......................... 7 Recommendations............................................................................................. 8 Take Notes Activity One.................................................................................... 9 Take Notes Activity Two.................................................................................... 11 Conclusion......................................................................................................... 14 Reference......................................................................................................... 16 Palliative Care for Enduring Conditions Introduction Palliative care has been described in a variety of ways, but the more common application of this type of care has revolved around the importance of delivering comfort to the dying, to ease the final days up to repose, and to live such days with dignity (Doyle & Hanks, 2004, p. 951). It is a practice rooted on improving the psychological and the physiological well-being of the patient. It is also founded on what the community can offer to the dying patient. This paper shall now discuss the philosophy of palliative care and how such philosophy is applied in the current clinical practice in either a general or specialist setting. The recommendations for future practice shall also be discussed in this paper. Philosophy of Palliative Care in Community Specialist Setting The philosophy of palliative care is firmly rooted on improving or maintaining the quality of life to the very end (Randall & Downie, 2006, p. 143). It is concerned with making the last few days of the patient’s life as comfortable as possible. The World Health Organization (1990, as cited by Berger, et.al., 2007, p. 490) points out that palliative care is “the active total care of patients whose disease is not responsive to curative treatment”. It mostly involves the control of pain and other symptoms (psychological, social, and spiritual problems) often associated with terminally ill patients. The philosophy of palliative care in the current specialised setting is about paying equal focus on the physiological as well and the psychological issues of a terminally ill patient (Hopkins, 2004, p. 427). Palliative care is rooted in the hospice movement, mainly on the care of the dying cancer patient (Clark & Seymour, 2008). According to the World Health Organization, (2002) it is based on the principles of affirming life, viewing dying as a normal process. It neither hastens nor postpones death; it provides relief from pain and other symptoms; it integrates the psychological and spiritual aspects of patient care; and it offers a support system for the patient and his family until the patient’s death (WHO, 2002). Palliative care essentially also includes care administered to those with life-limiting and enduring conditions such as multiple sclerosis, motor neurone disease, dementia, and end-stage respiratory and cardiac disease (WHO, 2002). Gold Standards Framework and community palliative care The delivery of palliative care in the community setting was assessed by a study conducted by Ahlner-Endqvist, et.al., (2004, p. 585). Their study basically assessed the principle of palliative care, that of making the last few days of the patient as comfortable as possible. In this case – time spent at home, the place of death and the difference in sociodemographic and medical data of patients with terminal care receiving hospital-based advanced home care and conventional hospital care (Ahlner-Endqvist, et.al., 2004, p. 585). The study revealed that out of the total 297 patients included as respondents in this study, 280 of them died during the study period of 2 and a half years; there were 117 who died in the advanced home care group and 163 in the conventional care group (Ahlner-Endqvist et.al., 2004, p. 585). Death at home was preferred by many patients and it was also related to the act of living with someone else. This enabled patients to be in a place they desired and to be with a strong support system in the last days of their life (Ahlner-Endqvist, 2004, p. 585). This study points out that even with the knowledge that conventional care may improve their chances of survival, for patients under palliative care, they are now more concerned in being among familiar things and familiar people. And with improved comfort and psychological well-being, many patients have proven to display improved patient outcomes as compared to patients under conventional hospital care. This brings us to the discussion of the Gold Standards Framework in community palliative care. The adoption of the Gold Standards Framework for palliative care has been geared towards adopting the philosophy of palliative care through the delivery of good health to the patient (Amass, 2009, p. 353). The framework has been focused on being in accord with the patient’s preferred place of care; to ensure safety and security and fewer crises; to make carers feel supported, involved, empowered, and satisfied; to ensure staff confidence, teamwork, satisfaction, and coordination with specialists (Amass, 2009, p. 353). Consequently, the Gold Standards Framework has been mainly concerned with seven areas: communication (improved liaison with staff, with agencies, with carers, and with patients); coordination (with team and with patient through regular feedbacks); control of symptoms (awareness of symptoms, proactive prescribing, checklist, and assessment charts); continuity (handover forms and out of hospital protocols); continued learning (commitment to continuing education and skills training, reflective practice, and critical incident reporting); carer support (maintenance of carer register, improvement of bereavement services, practical support, and psychological support); and care in the dying phase (in the place of choice) (Amass, 2009, p. 253). In the application of this framework in the community, there were initially 12 GPs who participated in its implementation. The framework went on to introduce the supportive care registers and team meetings, and these were successfully able to improve patient care (Amass, 2009, p. 354). Improvements were also seen in the communication, teamwork, planning, and awareness. In the second phase of the project, eight practices under the GSF were then matched with practices that were not using GSF. The users pointed out that with the GSF, they were able to receive more consistent care and less possibility of other users being neglected (Amass, 2009, p. 354). Those who were able to use the GSF also benefited from anticipatory prescription of medicines which reduced their hospital admissions and more importantly, the patient’s anxiety. More GPs have now taken to adopting this approach in their administration of palliative care. NICE also endorsed it as a viable approach to palliative care, thereby increasing its applicability in the community (Amass, 2009, p. 354). It is important to note that the Gold Standards Framework is geared towards delivering consistent and high quality palliative care in the community. In a study by King, et.al., (2005, p. 619) they set out to evaluate the practitioners’ perspective on the GSF for community palliative care. They covered about 68 respondent-GPs and district nurses involved in the community GSF. The study revealed that most of the GSF participants felt that the GSF was able to improve the delivery of community palliative care. The study was also able to emphasize that communication within primary health care teams is important in order to achieve coordinated services and better GSF practices (King, et.al., 2005, p. 619). The Gold Standards Framework also points out the importance of improving community resources and services for palliative care patients (Thomas, et.al., n.d., p. 10). The preference for community and home-based care has been studied by various authors; and recipients of community-based care remained positive about the care that they received (Hawker, et.al., 2006, p. 544). Families valued the easy access they were able to maintain with the community-based care and the frequent and long-stay visiting they were able to experience with the Gold Standards Framework. The Gold Standards Framework is one of the most essential means of adhering to the philosophy of palliative care in the sense that it focuses on the importance of rendering community palliative (Fallon, et.al., 2006, p., 68). Some patients have even been known to live longer in their own homes even as they faced a looming life sentence (Fallon, et.al., 2006, p. 68). It is therefore important to render community palliative care because improved patient outcomes can be reached when the patient is psychologically more relaxed and more receptive to patient care. “Sensitively facing the reality of dying and making a plan for the final stage of life is as important in end of life care as planning for pregnancy and labour are in antenatal or early life care” (Fallon, et.al., 2006, p. 68). Applying the community care approach in palliative care ensures that the care rendered to the patient is not always reactive; instead, it is pro-active -- as more preparation is involved in the delivery of health care services. Philosophy of palliative care and the current clinical practice The factor of communication and coordination among the members of the palliative care team is another element required in keeping with the philosophy of palliative care. A study by Donnelly (2008, p. 18) points out that “effective communication and coordination between professionals, especially across organizational boundaries, systems and structures, can play an even more crucial role in ensuring the quality of care and enhancing patient and carer experience”. He also noted that patients who slowly advance towards long-term care require services from primary care teams, and then later as their condition progresses, by a specialised team. The care required during these cases is for the administration of out-of-hours services and automatic updates in order to ensure patient-centred services. Noting the various philosophies involved in the delivery of palliative care, Faull, et.al., (2005, p. 4) emphasized that specialized palliative care needs call for training for health professionals in nursing, medicine, and occupational therapy. “It also undertakes research, and suggests and implements where appropriate, innovations in palliative care and palliative care services” (Faull, et.al., 2005, p. 4). There is a holistic approach to the fulfilment of the philosophies espoused by palliative care. And the patient-centred approach to palliative care is also crucial to the delivery of effective end-of-life care (Thomas, 2003, p. 68). The management of symptoms for terminally ill patients, as discussed by Twycross, (as cited by Faull, et.al., 2005, p. 7) involves anticipation, evaluation and assessment, explanation and information, individualized treatment, re-evaluation and supervision, and attention to detail. Recommendations Various authors also point out that the assessment of pain in palliative care is very important (Scottish Intercollegiate Guidelines Network, 2008). It should be based on the patient’s perspective while taking into consideration his worries and concerns about his condition. This problem-based approach “will give clues to other treatable causes of distress and enables support to be focused on areas of difficulties identified by the patient” (Kinghorn & Gaines, 2007, p. 35). Consequently, after applying this method of assessment, it may be possible to determine the cause of the pain – especially if other causes or worries may exacerbate the patient’s pain experience. Support on a more emotional or psychological front may be then administered to the patient while using this problem-based approach to health care (Kinghorn & Gaines, 2007, p. 35). It is also important for practitioners to note that pain is a very subjective experience. Its effects on a person largely depend on the social, psychological and spiritual aspects of the experience (Scottish Partnership for Palliative Care, 2005, p. 3). In order to be in line with the philosophy of palliative care and with the GSF, it is important to note that in managing pain, the care givers must ensure that patients take an active participation in its management (Abu-Saad, p. 2001, p. 67). Since pain is a subjective experience, its management must take on a more patient-centred approach. Regular review of a patient’s pain levels and preferred interventions must also be undertaken in order to ensure individualised treatment and planning (Scottish Partnership for Palliative Care, 2005, p. 3). Take Notes Activity One In palliative care, the members of the health care team are often called on to coordinate with each other in terms of health care services and health care responsibilities (Ferrell & Coyle, 2006, p. 1113). Limited coordination between the members of the health care team can often lead to unfavourable patient outcomes (Speck, 2006, p. 205). With this in mind, there is a need to illustrate an instance whereby the application of this multidisciplinary approach was applied, showing its implications for the nurse as a member of the health care team. During my clinical placement as a nurse, I was sometimes called on to care for patients who were obviously under palliative care. In one such instance, I was called in to care for a patient who was in the final stages of brain cancer. The patient was male and 55 years of age. When I went to check on him, he was in severe pain. As a palliative care nurse, I knew that my role was to make him as comfortable as possible. I consulted with my head nurse about the possibility of giving the patient a higher dose for pain relief. She said that the patient was not due for pain meds or opioids until after two more hours. When I checked the patient’s chart, it indicated that pain relievers were to be given to the patient as necessary. With the patient almost screaming in pain, I felt that it was necessary to give him opioids. As I was about to check again with the head nurse, the patient’s physician came in for rounds and saw for himself that the patient was indeed in pain. He insisted that I should have already given the patient the pain medications because the orders were PRN or as needed by the patient. In this instance, it was within my responsibility as a nurse to coordinate the efforts of the different members of the health care team. Although the PRN order is a standing order for the patient, the administration of powerful opioids must still be verified with the physician. This is important to note considering the fact that the patient was already exceeding his maximum daily dose of opioids. In the above instance, my role as a nurse was to coordinate the pain relief for the patient. Coordination in palliative care calls for nurses to inform the physician and the immediate supervisor regarding the patient’s pain complaints (Daniels, 2005). This coordination must be “not just between herself and the patient and family, but also with all the pertinent members of the team, which in turn ensures effective and goal-driven supportive communication and patient outcomes” (Matzo & Sherman, 2006, p. 136). The ultimate goal in palliative care is to ensure that all the efforts of the health care team are directed towards better patient outcomes. There are different team members who deliver palliative care. It is important to note that the “multidisciplinary team is a group of professionals, disciplines or services that are brought together to create a seamless continuum of care across organisational departments as well as across all segments of the healthcare system” (Sierchio, 2003). The physician role in the team is to follow the progress of the patient throughout his illness (Gallagher-Allred, 1989, p. 70). For the clinical nurse specialists, it is to manifest specific skills in order to assist the patient and the practitioner in delivering the needs of the palliative care patient (NICE, as cited by the NCPC, 2009). The pharmacist in the palliative care team keeps track of the patient’s medication and he ensures that possibly undesirable interactions in the medications are avoided (World Health Organization, 2002, p. 1). The social worker provides support and counselling to the patient and the family (CareSearch, 2008). The physiotherapist is involved in improving the mobility, nutritional status, communication, and in improving the confidence of the patient in his everyday living (National Healthcare Services, 2008). The pharmacist’s role in the palliative care team is important because he eventually develops a trusting relationship with the patient and his family. He also is able to note what the medicines the patient is taking and to recommend to the physician the need to adjust such medicines. He can also give advice to the patient and to the patient’s family about each medicine being taken in and the possible side effects which might be expected from the medicines (World Health Organization, 2002, p. 1). The other members of the health care team coordinate with him in order to ensure that the symptoms being manifested are not due to adverse effects from medications. Take Notes Activity Two Euthanasia is one of the most controversial topics in health care. In Scotland, the end of Life Assistance Bill has been attacked numerous times by those who advocate the person’s right to life, especially those who are disabled and who are on long term care. Those who advocate euthanasia argue that a person’s right to self-determination – a right which includes one’s sovereignty over one’s life (Prouse, 2005, as cited in Webb, p. 104). Those who argue against the bill point out that it unfairly targets those who are terminally ill and disabled, qualifying their life as not worth living. It also creates a danger for those who do not wish to be euthanized leading to an “erosion of their trust in health care provides, increase their discomfort and thus increase their suffering” (Hurst & Mauron, 2006, p. 108). In countries where euthanasia is considered legal, non-voluntary euthanasia sometimes follows and those who are vulnerable to its application are made even more helpless because they are told in seemingly unequivocal terms that they are the target (Independent Catholic News, 2010). Simply said, since these elderly and vulnerable individuals are no longer contributing anything valuable to society, and since they are also draining society’s resources, they should be put to death. Many patients who are sufferers of debilitating conditions have expressed that with the threat of euthanasia hovering over their heads, they often feel like committing suicide (Drickamer, 1997, p. 146). In Holland where euthanasia is legal, “despite any number of so-called strict safeguards such as that the killing must be voluntary, it is likely to go on to include victims who either did not, or could not volunteer” (Independent Catholic News, 2010). For advocates of euthanasia in Scotland, they point out that euthanasia is an “easily administered, inexpensive solution for the very expensive lingering maladies experienced by the terminally ill” (Scherer & Simon, p. 21). They also emphasize that euthanasia is a person’s right and privilege. They advocate that “there is no greater arrogance than acting in the belief that society knows best how one should conduct one’s life and death” (Forster, as cited by Millard, 1995, p. 746). Moreover, these advocates point out that euthanasia often eases patients’ fears about being made to go on living their lives to a point where their circumstances become unbearable. They see no dignity in living in intolerable and helpless conditions. And having that option of choosing to end their suffering gives them control over their life – control that they lost when they were afflicted with their terminal illness (Loudon, as quoted by Millard, 1995, p. 746). Considering the above arguments, I believe that euthanasia should not be legalised because the choice of living or dying should stand up to the very end. The options which have now been available for health care givers involved in palliative care have also improved. As care givers, these patients have improved chances of living longer and more productive lives (Farrell, as quoted by Millard, 1995, p. 746). With our improved options for the delivery of health care services, the options offered for patients under palliative care should also be improved. “No civilised society should have to contemplate terminating life as a substitute for caring and supporting, even at the very end” (Rodway, as cited by Millard, 1995, p. 746). When euthanasia is a made an option under health care, it opens up so many risks and dangers for the vulnerable patients. I also consider the study by Georges, et.al., (2005, p. 578), where the authors were able to evaluate how requests for suicide mostly came after symptoms of pain, nausea, and general feelings of illness were felt before requests for suicide were expressed. This study points out that there is a link between the symptoms felt by the patient and euthanasia (Georges, et.al., 2005, p. 578). And when palliative care is improved, it may be possible to eliminate requests for suicide. There is a decreased guarantee that they would be receiving quality health care even to the very end (Poncet, 2007, p. 698). Moreover, the standards for designating who should be euthanized are subjective standards which are largely not within physicians’ or even patient’s control (Welie, 1992, p. 419). Euthanasia should not be legalized in Scotland because there are other better options which health care professionals and patients can take in order to ensure that the last days of a patient’s life are comfortable and peaceful (Asch, 1996, p. 1374). Dying with dignity cannot be honestly ensured by euthanasia. It violates a person’s individual right to life and to living. Conclusion The challenge that this current generation is facing as far as healthcare is concerned is on enabling people to live and to die well in a manner of their choosing (Thomas & Meehan, 2008, p. 100). The GSF has been developed in order to support teams working in primary care for the delivery of coordinated healthcare for patients and the counselling of grieving families (Cutliffe, 1998). In the years since the standard has been implemented, it has so far managed to improve the reliability of home care by implementing the basic philosophies of palliative care thereby, improving the delivery and the quality of palliative care for the community and for the patients. In the end, through the GSF at home and in the community-setting, it has managed to “embrace what is noble in medicine: sometimes curing, always relieving, supporting right to the end” (Gomas, as cited by Thomas & Meehan, 2008, p. 100). In general, this should be the attitude that all health care givers should adopt in order to achieve the best patient outcomes for the palliative care patient. References i. Books Abu-Saad, H. & Courtens, A. 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SIGN Guideline 106. http://www.sign.ac.uk/guidelines/fulltext/106/index.html Scottish Partnership for Palliative Care, (2006), Making Good care Better: National Practice Statements for General Palliative Care in Adult Care Homes in Scotland, Palliative Care Scotland, Available from: http://www.palliativecarescotland.org.uk/publications/index.htm [Accessed 15 March 2010] Read More