Palliative Care as One of the Most Demanding Health Care Services - Essay Example

Palliative Care Palliative Care Introduction The ever-growing concern in the community regarding the cost and quality ofhealth care has exerted a lot of pressure on health care services delivery, where expectations for cost-effectiveness and high quality of health care services are so high (Burt, Shipmanand White, 2006). There are high expectations for well-coordinated healthcare services with clarity of roles within service delivery and with minimal duplications. Among the most demanding health care services in the community has been palliative care, which is the approach meant to enhance the life quality of the patient concerned, together with alleviating the different types of problems the family and the patient undergo during the course of a life-threatening illness (Coupland et al., 2010). Palliative care, in this case, is achieved by way of relief and prevention of suffering by ensuring problem identification is done early enough and by execution of impeccable assessment, treatment of pain, as well as offering psychological, physical, and spiritual relief for the patient (Penrod et al., 2006). This essay seeks to demonstrate the critical knowledge regarding the external influences that directly influence end-of-life care, together with the strategies applied by concerned practitioners in facilitating the delivery of palliative care services of the required quality. On the other hand, the essay also seeks to evaluate the variable factors, including the social, physical, and psychological factors, together with their respective impacts on the experience of the client in relation to the provided palliative care. The information, analysis, and proposals are made in relation to the case study provided herein. In essence, the references made to the case study are strictly within the context of care delivery, together with the related issues, which have a direct impact on the health outcome of patients. Patient’s case study The palliative health care focused on herein concerns a patient in a hospital in the United Kingdom. For the purposes of data protection and confidentiality, the patient will be referred to by the name Janet throughout the discussion. Mrs. Janet was admitted into the palliative care unit 28 years following the diagnosis that revealed she had cervical cancer. Her suffering from this had taken quite a long time and exhibited a significant level of complexity, together with a painful history of the cancer illness course. The cancer diagnosis had been done and approved when she was 30 years of age, and this was followed by a hysterectomy. A year afterwards, she experienced a cervical cancer recurrence in the pelvis, which was handled using 5-fluorouracil and cisplatin as the form of chemotherapy. After this, the patient was subjected to radiation therapy after it was noticed that the condition was not getting better. Mrs. Janet then underwent persistent proctosigmoiditis that was radiation induced, which was most likely to have been exacerbated by the radio-sensitizing action effects of the 5-fluorouracil. She underwent surgery for colostomy placement. In addition, she experienced frequent damage to the bladder and radiation cystitis and eventually had to undergo urostomy placement nine years following the radiation therapy. Due to the strictures to the ureter, there was need for the patient to undergo replacement of the bilateral nephrostomy tube, and she also required a regular change of stents at intervals of six weeks. A year later, after the patient had developed an obstruction on her bowel, there was need for her to undergo exploratory laparotomy. She also underwent extensive restriction of the bowel, followed by replacement of the gastrostomy. What was ascertained was the insufficiency of the bowel in absorbing the ingested nutrients, and this meant there was a need for total parenteral nutrition. The patient was also subjected to a total replacement of the right hip through a surgery following the development of a fracture in her hip. Some years afterwards, the patient was discovered to have a vesicovaginal fistula. Even with the aggressive management of the condition, the patient demonstrated persistence in the skin excoriation as a result of the leakage of urine. Mrs. Janet underwent numerous hospitalizations after the original diagnosis she had gone through, together with an endless experience of admissions to the intensive care unit. She also went through a host of infections, among which was the abdominal abscess, together with the many ulcerations of the skin she experienced. Other medical complications discovered included deep vein thrombosis, chronic renal insufficiency, depression, and pulmonary embolism. The patient had a constant pain problem even with the extensive treatments she underwent. She complained ofa low pain in the lower backand also had radiculopathy in her left leg. Mrs. Janet complained of a persistent throbbing sensation within her lower extremities bilateral to the neuropathy. Additionally, she complained of pain in the nephrostomy tubes, which was so intense at some moments, resulting in sleepless nights. The constant excoriation of the skin caused by leakages from her vesicovaginal fistula caused her extreme pain, and this posed a significant challenge in the treatment. She had multiple wounds on her skin, together with other cellulitis areas. She was undergoing both immediate and extended release pregabalin, morphine, and methadone for the purpose of alleviating the areas in which she experienced chronic pain, since the neurolytic blocks had shown no effectiveness in managing the condition. Mrs. Janet was admitted to this facility when she was 58 years of age, a widow, and a mother of four children, all of which were adults. Due to her bed-bound condition that required daily 24-hour care, the children had the obligation of providing the needed care every night. However, following their work commitments, a caregiver was hired to provide the required care services during the day when they were away. After it was decided that the patient had to spend extensive hours in bed, she was admitted to the palliative care unit for inpatients following a successive fall at home. Mrs. Janet informed the team of her desire not to continue undertaking the therapies that were meant to prolong her life and also wished that the artificial nutrition be discontinued. The patient was absolutely convinced that the cancer condition had been completely cured, but the aftermath adverse effects were unbearable and had become overwhelming and unmanageable. It was as a result of this that Mrs. Janet requested the withdrawal of the artificial nutrition support as she opted for a comfortable end of her life as opposed to the endless painful experiences she had been suffering. The team concerned was obliged to seek assistance from social services in order to determine whether any extra resources could be offered. However, upon determination, it was concluded that no additional resources were required and that all the needed care had been made available in line with the patient care procedures. The team sought psychiatry opinion, and the result of the examination proved that the patient was effectively competent. She was capable of understanding and making decisions on her own. Her children, who constituted her immediate family, held a meeting and agreed to offersupport for her decision. Despite the difficulty in the prediction of her prognosis, it was thought to take about two weeks;and this was significantly determined by the number of oral intakes she could comfortably sustain. Due to the amount of care she needed, the family was no longer able to offer the care from home, prompting her transfer to the inpatient hospice. She passed on comfortably two weeks following her admission to the facility. External influences which have a direct effect on end-of-life care Palliative care is generally meant to condition (Pyenson et al., 2004). For instance, the patient under study experienced endless pains which came as a result of the continuous skin ulcerations due to the leakage of urine (Twycross, 2003). In essence, the palliative care given to herwas thus meant to affirm her life as well as recognizing the dying process as a natural event. Similarly, the care was meant to alleviate the different forms of suffering, particularly psychological and economic, through which the family of the patient went. The dying process is thus not meant to speed up nor postpone the death of the person (Kinley, Froggattand Bennett, 2013). Palliative care is inclusive of the psychological and spiritual state of the patient. For instance, the patient had to undergo numerous psychiatric examinations during the process of care in order to ascertain her competence in making decisions that directly affected her medical condition (World Health Organization, 2009). A multidisciplinary team meeting, for instance, would be important in reflecting the needs and profile of the stakeholders within the local settings of the patient, and this varies from the carers of the patient, the volunteers, as well as the healthcare providers(Richfield, Jones and Alty, 2013). The MDT meting is also designed by the models within other General practice divisions, all of which promote the patient’s ability to access coordinated and quality palliative care services. In this context of the MDT, the care provided is meant to ensure that the treatment team members can comprehensively discuss the aspects of the patient’s supportive care together with other factors impacting on the quality of care(Watson, 2010). In this respect, therefore, the process is sufficient to offer the required support system that enables the patient to live a life that is as active as possible until death (Meier, 2011). The support system provided during this period is important in helping the family of the patient cope with the moments during which the family member goes through the period of illness (Richfield, Jones andAlty, 2013). In addition, the team-approach process is important in helping address the different needs of the family and the patient, since it incorporates bereavement counseling, and this significantly improves the life quality of both the patient and family. There exist various factors that influence the end-of-life care provided to patients with life-threatening health conditions. Amongst these are economic factors, which determine the patient’s ability to meet the expenses that come with specialized care of the condition (Tibi-Levy, Le and De, 2006). Mrs. Janet was able to access quality care services owing to her financial capabilities. On the contrary, patients from low social classes fail to afford the healthcare insurance cover, hence making it difficult for them to access such specialized health services. Cultural factors are also very important in determining the quality of care the patient is bound to receive (Watson, 2010). For instance, it is very important that the nursing staff understands the different cultural practices and beliefs of the respective patient in order to offer the required care without contravening the beliefs of the society from which the patient comes (Watson, 2010). Mrs. Janet was able to find befitting health care services,with the health care providers within the facility and the society around having sufficient expertise in culture-based health care services. Whereas, her family members, her children, had been taught about the better ways to provide the required care from home; such teaching is of significant importance in ensuring culture-compliant health care services(Tan et al., 2014). The health policies within the local and national healthcare settings are another factor that would significantly influence the course of palliative care of the patient. For instance, the policies of the given locality dictate the manner in which the resources are distributed. Considering that the care for end-of-life diseases demand life supporting machines and other expensive care facilities, the flexibility of the policies would thus determine the quality of care the patient receives(Richfield, Jones and Alty, 2013). Similarly, the cultural attitudes of the society have a significant impact on the care quality to be provided to the patient. In this case, certain cultural practices may not acknowledge certain medical practices, meaning the patient would inevitably decline such care practices when described to her. The quality of care and its effect in alleviating chronic life-threatening health conditions is significantly determined by the availability of the relevant hospice facilities for promoting health. For instance, the availability, accessibility, and effectiveness of hospice facilities determine the quality of care the patient is bound to receive(Watson, 2010). As seen from this case study, the care for patients with end-life diseases is initially in receiving healthcare services from their families, together with social health workers,in their homes. However, as evident in Janet’s case, the care she needed became more complex as the condition advanced, requiring the hospice facility intervention. The availability of proper resources is important in relieving the family of the burden of care provision as well as relieving the patient of the recurrent and unbearable pain and suffering. Additionally, the commitment and agenda of the government and other related authorities towards improved healthcare determines the quality of care to be received by palliative care patients. For instance, the government has the obligation of allocating resources, particularly finances, which should be used for the purchase of necessary equipment for life support as well as hiring qualified personnel to offer palliative care(Watson, 2010). Misallocation of resources by the authority could lead to poor quality of services for patients. In addition, the counseling sessions, as incorporated in palliative care, are an important factor in influencing the illness course, especially when introduced early enough, together with the other forms of therapy meant for prolonging the life of the patient (Thomas et al., 2010). Such therapies, as seen in the case study of the patient, include radiation therapiesand chemotherapies, as well as the investigations which are required in order to facilitate comprehensive understanding and management of the clinical complications that are significantly distressing (Steinhause et al., 2000). The professionals involved in the provision of palliative care work in teams, which are constituted by the doctors, nurses, pastoral care workers, social workers, and volunteers. These teams are expected to work together with specialists, GPs, and all the organizations in the community that are tasked with the management of day-to-day support and care of patients (Watson, 2010). The major objective of these groups is to ensure that families and patients receive the most ideal care possible in the facility and in the community. The palliative care is provided within variable settings, which include homes, the facilities for aged care, the acute hospitals, as well as the hospice or units for palliative care (OBrien et al., 2012). The care provided in homes proves to be a big commitment for the carers. Anyone considering becoming a home carer must be ready to discuss with the patient’s doctor, or the community healthcare workers, or the nurses involved in palliative care (Murray, Boyd and Sheikh, 2005). The availability of help for the potential home carers of patients with life-threatening conditions means there is no reason for fear of caring for these patients at home. Though home carers whodo not feel they can effectively manage the provision of the required servicesdo not have to feel guilty about it. Strategies employed to facilitate the delivery of quality palliative care services In order to ensure delivery of quality services in the palliative care unit, the health personnel can employ numerous strategies, among which are the structural elements of the setup (Smith et al., 2014). For instance, the interdisciplinary team among the palliative care providers is key in ensuring the patients receive the best services and better health care to alleviate their conditions. This means that the nurses, physicians, spiritual counselors, social workers, volunteers, aides, and pharmacists have the responsibility of ensuring a close team spirit to ensure that there is no gap between the services provided by each discipline (Gardiner et al., 2012). In reference to the case of Mrs.Janet, for instance, it can be seen that the health personnel demonstrated a very close team spirit, particularly evident in the manner the side effects of the different forms of therapies were managed effectively. In addition, the quality of service offered in palliative care units can be improved through ensuring a sufficient ratio of health care personnel to patients under care (Sigurdardottir et al., 2004). Palliative care must guarantee prompt and effective attention to patients when needed. In Janet’s case, the numerous complications arising from the side effects of the cancer therapies required instant attention to alleviate the painful experience (Reynolds, 2008). Therefore, an increase in the number of staff is important in ensuring that patients do not go through pain without timely attention. Quality health care can also be enhanced through comprehensive determination and documentation of the goals for both the patient and the family concerning the care (Ringdal, Jordhoy and Kaasa, 2002). For instance, there should be an advance care planning in which the physician arranges for treatment for life sustenance as demanded by the family or the patient. In the case of Mrs. Janet, the providers of the palliative care were quick to heed the desires of both the family and patient.The facility withdraws artificial nutrition and other life sustaining services to facilitate a comfortable death, which is an ideal way of alleviating the painful experience of the patient (Johnson and Gadoud, 2011). The health care value is expressed in terms of the quality to cost ratio. This means that improvement of value can be through improvement of quality, reduction of cost, or both (Eyre, 2010). The diffusion of innovations where the program is aimed at targeting the chronically ill population is an ideal way of increasing value through reducing costs and improving the quality of health care for the sickest or most complex patient conditions (Scott, 2001). The quality of care provided in end-of-life patient care can be improved through increasing the access to the hospice and palliative care services for the patients in need (Gott, Ingleton and Gardiner, 2009). For instance, it is evident that patients in this stage of illness experience endless medical problems, including recurrent pain and development of new health conditions, which require prompt attention from service providers (Milligan, 2012). Treatment of distressing symptoms has been proven independently to reduce the complications that arise during illness as well as the hospitalization of patients (Eyre, 2010). The hospice and palliative team often meet with patients together with their families in order to facilitate the establishment of realistic and appropriate goals and objectives for the care given, as well as offering support to families at times of crisis (Rowlands and Noble, 2008). In addition, such meetings and discussions are important in planning for safe transitions from the hospitals to other settings that are more supportive for patients, such as the home hospice, home care, inpatient hospice care, and nursing home care with hospice (Payne, Seymour and Ingleton, 2004). Communication constitutes another important aspect of quality care for patients with end-of-life health conditions. In this, there is the passing of information about the prognosis of the patient, together with the patient’s goals, by a team dedicated with expertise and time, whose sole intention is ensuring decision making which is better-informed (Back, Li and Sales, 2005). In addition, the process ascertains clarity in the planning as well as consistency in the follow-through of the patient. Discussing the matters that concern the patient is important in helping the family lighten the burden of the costs of care as well as in ensuring improved family satisfaction (Radbruch and Payne, 2009). Counseling, as part of the interventions in palliative healthcare provision, is an important aspect that improves the quality of health of the patient. A patient with an end-life health condition undergoes psychological disturbances,hence the need for psychological interventions. Counseling helps in encouraging positive thinking in the patient in regard to the healthcare. The purpose of palliative care is to alleviate physical and psychological problems, and counseling alleviates depression, stress, and hopelessness in the patient(Milligan, 2012). Similarly, counseling for the family members helps relieve them of depression and stress. For instance, they may find the endless care they offer the patient disturbing, hence the need for the counselors to assure them of the importance of their involvement to the wellbeing of the patient. Physical, psychological, and social factors thatimpact the client’s experience in relation to palliative care The patient under palliative care is affected by different factors, which include psychological, physical, and social. It is on the basis of these factors that the provided care is bound to influence the course of health of the patient (Snell, Pennington and Lee, 2009). For instance, the patient in this stage of illness undergoes variable extents of psychological problems, which are variable depending on the disease from which the patient suffers and the side effects arising from the forms of treatments offered (Radbruch and Payne, 2009). Patients under palliative care experience varied levels of physical disturbances in regard to the care provided to them. Patients experience different forms of painful moments, mostly resulting from the side effects of the therapies to which they are subjected (Rabow et al., 2003). Mrs. Janet had a constant pain problem, even with the extensive treatments she underwent. She complained of pain in the lower back and also had radiculopathy in her left leg (Buxton et al., 2010). Additionally, she complained of pain in the nephrostomy tubes, and the pain was so intense at some moments, resulting in sleepless nights. The constant excoriation of the skin caused by leakages from her vesicovaginal fistula caused her extreme pain, and this posed a significant challenge in the treatment (Bruera and Hui, 2013). She had multiple wounds on her skin, together with other cellulitis areas. Pain is a prevalent aspect of patients under palliative care, hence the need for a proactive and aggressive stance in order to achieve comfort. The management of pain may prove significantly challenging, prompting a high level of suffering to the patient (Radbruch and Payne, 2009). Therapeutic interventions, which include chemotherapies and radiotherapies, may result in painful experiences during their administration. In the case of the patient under study, there were numerous forms of infections, among which was the abdominal abscess, together with the many ulcerations of the skin. Other medical complications discovered included deep vein thrombosis, chronic renal insufficiency, depression, and pulmonary embolism (Portenoy et al., 2006). All these complications, for such a long period of time, inevitably subject the patient to psychological disturbances, particularly fear of more complications that may arise during the course of the treatment (Department of Health, 2008). There is no doubt that the course of palliative care resulted in depression and desperate feelings for Mrs. Janet, a factor that must have contributed to her decision to request for the withdrawal of life-supporting services (Gott et al., 2011). Among the prominent psychological symptoms experienced by patients include sadness, depression, nervousness, anxiety, loneliness, guilt, worry, as well as fear. In addition, end-of-life patients also experience loss of independence. For instance, Mrs. Janet did not have absolute autonomy to make decisions regarding the course of the treatment, until the intervention of her children was sought (Ward-Smith, Korphage and Hutto, 2008). Shealso exhibited a sense of lost perspective, phobia for the physical symptoms, as well as fear of death. It is evident that the condition alienated the patient from her family, she only having very limited time during the night hours with her children (Rothen, Stricker and Heyland, 2010). It is thus evident that patients under palliative care suffer from anxiety and depression, particularly when they are forced to lead desperate lives away from their families (Salsberg, 2002). The knowledge that their condition is not bound to heal, and that the care provided is only meant to elongate their lives, makes them feel uneasy and lose self-esteem and desire for life (Milligan, 2011). It is on this basis that Mrs. Janet opted to end her life rather than continue living falsely. In the course of palliative care, the patient also experiences various forms of social disturbances, which include seclusion from peers. For instance, the patient may have to quit the place of work due to the illness or to the demands that come with the therapy. References Back, A.L., Li, Y.F. and Sales, A.E., 2005. Impact of palliative care case management on resource use by patients dying of cancer at a Veterans Affairs medical center.Journal of Palliative Medicine, 8, pp.26-35. Bruera, E. andHui, D.,2013.Palliative care research: lessons learned by our team over the last 25 years. Palliative Medicine, 27(10), pp.939-51. Burt, J., Shipman, C., White, P. and Addington-Hall, J., 2006.Roles, service knowledge and priorities in the provision of palliative care: a postal survey of London GPs. Palliative Medicine, 20(5), pp.487-92. Buxton, K.L., Stone, R.A., Buckingham, R.J., Pursey, N.A. and Roberts, C.M.,2010.Current and planned palliative care service provision for chronic obstructive pulmonary disease patients in 239 UK hospital units: comparison with the gold standards framework. Palliative Medicine, 24(5), pp.480-85. Coupland, V.H., Lee, W., Madden, P., Sykes, N., Møller, H. and Davies, E.A.,2010. Is it possible to determine use of hospice palliative care services by matching hospice and cancer registry data? Palliative Medicine, 24(8), pp.807-11. Department of Health, 2008. End of life care strategy: promoting high quality care for all adults at the end of life. London: HMSO. Eyre, S., 2010.Supporting informal carers of dying patients: the district nurse’s role.Nursing Standard, 24(22), pp.43-8. Gardiner, C., Ingleton, C., Seymour, J., Cobb, M., Noble, B., Bennett, M. and Ryan, T., 2012. Extent of palliative care need in the acute hospital setting: a survey of two acute hospitals in the UK. Palliative Medicine, 27(1),pp.76-83. Gott, M., Ingleton, C., Bennett, M.I. and Gardiner, C., 2011. Transitions to palliative care in acute hospitals in England: a qualitative study. British Medical Journal, 342:d1773 doi:10.1136/bmj.d1773. Gott, M., Ingleton, C. and Gardiner, C., 2009.How to improve end of life care in acute hospitals.Nursing Older People, 21(7), pp.26-9. Johnson, M.J. and Gadoud, A., 2011. Palliative care for people with chronic heart failure: when is it time? Journal of Palliative Care, 27(1), pp.37-42. Kinley, J., Froggatt, K. and Bennett, M.I.,2013. The effect of policy on end-of-life care practice within nursing care homes: a systematic review.Palliative Medicine, 27(3), pp.209-20. Meier, D.E.,2011. Increased access to palliative care and hospice services: opportunities to improve value in health care.Milbank Quarterly, 89(3), pp.343-80. Milligan, S., 2011.Addressing the spiritual care needs of people near the end of life.Nursing Standard, 26(4), pp.47-56. Milligan, S., 2012.Optimising palliative and end of life care in hospital.Nursing Standard, 26(41), pp.48-56. Murray, S.A., Boyd, K. and Sheikh, A., 2005. Palliative care in chronic illness: we need to move from prognostic paralysis to active total care. British Medical Journal, 330, pp.611-12. OBrien, M.R., Whitehead, B., Murphy, P.N., Mitchell, J.D. and Jack, B.A.,2012. Social services homecare for people with motor neurone disease/amyotrophic lateral sclerosis: why are such services used or refused? Palliative Medicine, 26(2), pp.123-31. Payne, S., Seymour, J. and Ingleton, C., 2004.Palliative care nursing principles and evidence for practice.1st ed.Maidenhead: Open University Press. Penrod, J.D., Dellenbaugh,C.W., Hochman, M.L., Maciejewski, E. and Morrison, R.S., 2006. Cost and utilization outcomes of patients receiving hospital-based palliative care consultation.Journal of Palliative Medicine, 9, pp.855–60. Portenoy, R.K., Lupu, D.E., Arnold, R.M. and Storey, P., 2006.Formal ABMS and ACGME recognition of hospice and palliative medicine expected in 2006.Journal of Palliative Medicine,9, pp.21-3. Pyenson, B., Connor, S., Fitch, K. and Kinzbrunner, B., 2004.Medicare cost in matched hospice and non-hospice cohorts.Journal of Pain Symptom Management, 28, pp.200-210. Rabow, M.W., Petersen, J., Schanche, K., Dibble, S.L. and McPhee, S.J., 2003.The comprehensive care team: a descriptionofa controlled trial of care at the beginning of the end of life. Journal of Palliative Medicine, 6, pp.489-99. Radbruch, L. and Payne, S.A., 2009. White paper on standards and norms for hospice and palliative care in Europe: Part 1. European Journalof Palliative Care, 16, pp.278-89. Reynolds, P., 2008. Title VII innovations in American medical and dental education: responding to 21st century priorities for the health of the American public. Academic Medicine,83, pp.1015-20. Richfield, E.W., Jones, E.J.S. and Alty, J.E., 2013. Palliative care for Parkinson’s disease: a summary of the evidence and future directions. Palliative Medicine, 27(9), pp.805-10. Ringdal, G.I., Jordhoy, M.S. and Kaasa, S., 2002. Family satisfaction with end-of-life care for cancer patients in a cluster randomized trial. Journal of Pain Symptom Management, 24, pp.53-63. Rothen, H., Stricker, K. and Heyland, D., 2010. Family satisfaction with critical care: measurements and messages. Current Opinion in Critical Care, 16, pp.623-31. Rowlands, J. and Noble, S., 2008. How does the environment impact on the quality of life of advanced cancer patients? A qualitative study with implications for ward design.Palliative Medicine, 22, pp.768-74. Salsberg, E., 2002. The supply, demandand use of palliative care physicians in the U.S.: areport prepared for the Bureau of HIV/AIDS, HRSA.Albany, NY: Center for Health Workforce Studies. Scott, G., 2001. A study of family of carers of people with a life threatening illness:implications of the needs assessment.International Journal of Palliative Nursing, 7(7), pp.323-30. Sigurdardottir, K.R., Kaasa, S., Rosland, J.H., Bausewein, C. and Haugen, D.F.,2004.The European Association for Palliative Care basic dataset to describe a palliative care cancer population: results from an international Delphi process.Palliative Medicine, 28(6), pp.463-73. Smith, S., Brick, A., O’Hara, S. and Normand, C.,2014.Evidence on the cost and cost-effectiveness of palliative care: a literature review. Palliative Medicine, 28(2), pp.130-50. Snell, K., Pennington, S. and Lee, M., 2009.The place of death in Parkinson’s disease.Age Ageing,38(5), pp.617-19. Steinhauser, K.E., Christakis, N.A., Clipp, E.C. McIntyre, L. and Tulsky, J.A., 2000. Factors considered important at the end of life by patients, family, physicians, and other care providers. Journal of the American Medical Association, 284(19), pp.2476-82. Tan, A., Seah, A., Chua, G., Lim, T. and Phua, J.,2014.Impact of a palliative care initiative on end-of-life care in the general wards: a before-and-after study.Palliative Medicine, 28(1), pp.34-41. Thomas, K., Hudson, P., Oldham, L., Kelly, B. and Trauer, T.,2010.Meeting the needs of family carers: an evaluation of three home-based palliative care services in Australia.Palliative Medicine, 24(2), pp.183-91. Tibi-Levy, Y., Le, V.M. and De, P.G., 2006. Determinants of resource utilization in four palliative care units.Palliative Medicine, 20, pp.95-106. Twycross, R., 2003. Introducing palliative care.4th ed. London: Radcliffe Medical Press. Ward-Smith, P., Korphage, R.M. and Hutto, C.J., 2008.Where health care dollars are spent when pediatric palliative care is provided.Nursing Economics, 26, pp.175-8. Watson, M., 2010.Changing emphasis in end-of-life care.British Journalof Hospital Medicine, 71(1), pp.6-7. World Health Organization, 2009. Palliative care. [online] Available at: [Accessed 13 June 2014]. Read More