Artificial Hydration in Palliative Care - Essay Example

ARTIFICIAL HYDRATION IN PALLIATIVE CARE due: Table of Contents Table of Contents Introduction 2 Artificial hydration 4 Systematic Approach 7 Evaluation 10 The role of the artificial hydration 11 Need for education on palliative care and artificial hydration 12 Moral difficulties 12 The ethical and legal concerns of artificial hydration 13 The ethical concerns 13 The legal concerns 14 The pros and cons of artificial hydration 16 The advantages of artificial hydration 16 The disadvantages of artificial hydration 17 Analyse and evaluate findings and to implement to enhance service delivery 18 Research, protocols and guidelines to develop confidence 18 Palliative care teams in hospitals and hospices 19 Conclusion 19 Bibliography 21 Introduction According to the World Health Organisation, the concept of palliative care applies to the method of enhancing the standard of life of the patients and their caregivers. The patients in most cases experience difficulties connected to diseases that are life threatening. Cancer for instance, is a life-threatening disease, which requires palliative care for the patient during the chronic stage. This medical technique of care, called palliative care is given by avoiding and minimising suffering and pain through early detection and therapy. In addition, palliative care is enabled thorough examination, pain therapy, spiritual, physical and psychological treatment (Kinghorn & Gaines 2007, p. 2). The palliative care in the UK is grounded on three developmental stages that are significant in comprehending the modern palliative care setting. The initial phase of evolution is concerned with the creation of a haven for dying individuals and giving of terminal care. The second level of advancement is the growth of contemporary hospice lobby. The last stage concentrates on the change from hospice to palliative care (Have & Janssens 2001, p. 85-86). As argued by Have & Janssens (2001), in the UK, palliative care is mostly provided to patients suffering from cancer although other patients that have terminal illnesses like Alzheimer’s disease, Acquired Immunodeficiency Syndrome (AIDS), Parkinson’s disease, and advanced heart disease among other conditions that cannot be cured also qualify for the care (p.94). The national umbrella organisation, that facilitates palliative care in the UK, are NCPC (National Council for Palliative Care) and SPPC (Scottish Partnership for Palliative Care). This paper will discuss the artificial hydration in palliative care, its advantages and disadvantages and significance for the patient and end of life care. The discussion revolves around a community setting in the UK. The community palliative care teams provide palliative care in the rural areas. Most of the patients attended to in the community are those that decided to die at home. The services given receive funding from individual charitable bodies and others by the National Health Service (NHS) (Have & Janssens 2001, p. 94). Artificial hydration The artificial hydration in palliative care refers to the administration of fluids into the patient’s body through parenteral routes, nasogastric tube, gastrostomy and nasojejunostomy as a key necessity for nourishment. The truth is that artificial feeding cannot match the natural way of eating through the mouth rather it is a forced method. In most cases, the loss of weight and anorexia are procedures that are normal to dying patients. In addition, at the end of life, people experience bowel obstruction, low consciousness level, nausea and generalised weakness (Bass 2006, p. 14). When a patient is denied artificial hydration, he or she cannot die or become dehydrated. In fact, artificial hydration does not promote or prolong life in terminally ill individuals. In most cases, the terminally ill patients do not require a lot of fluids. Most patients encounter enhanced sedation if well hydrated. On the other hand, some patients face difficulties brought about by retention of fluids. The fluid retention is presented as pulmonary secretions, pleural effusion, incontinence, oedema, ascites and urinary retention (Perrin 2012, p. 99). The NCPC proposes that the utilisation of artificial hydration as a remedy for problems that can be corrected is suitable. For example, in the case of delirium, diarrhoea and hypercalcemia that results in electrolyte imbalance (Bass 2006, p. 14). Analysing various wants of different patients and how it will impact the people, that are close to them, determine the need for artificial hydration. Therefore, palliative care must focus on the family and the patient. According to Perrin (2012), most relatives and caregivers believe that the patients must be supported to eat and take fluids because it is part of the care (p.99). From this perspective, family members of a patient feel that the artificial hydration is a form of nourishment that is entitled to their loved one. This cannot be judges as at this period; the individuals experience emotional torture and fear of the loss of a loved one. Additionally, artificial nutrition and forced feeding is not suitable from the view of religious and ethicists. This is based on the opinion that the religious leaders consider the high level of nuisance the patient may undergo or the weight they put on the individual. From the perspective of the professionals, it is paramount to control the symptom of thirst that the patient is encountering, instead of clinging to a general formula. Byock (1997) promised the dying patients that water and food will always be given (Perrin 2012, p. 100). In the community setting, palliative care is provided by a professional team. The professional team consists of the social and pastoral work, the home care, skilled symptom management, the supportive nursing and the utilisation of community resources to help individuals to stay alive until they die. The community setting provides a suitable place where patients spend their last days with the people they love and have control of the situation. The dying patient’s family is faced with a crisis where they are confronted with good and bad memories, the current demands and the unknown future. The duty of the nurse in palliative care is to assist the family to handle the family disputes and guilt depression. The approach, that is employed, is one that recognises a patient as an entity that is whole, spiritual and physical being (Woods 2007, p.62). The palliative care provided integrates the fundamentals of family-centred and patient-centred care. The palliative care address the fields of legal, ethical, spiritual, social, cultural, physical and psychological (Cho 2013, p. 11). These factors affect the patient’s willingness to reveal the symptoms or the actual severity of the illness. The physical domain is concerned with the distress and other signs, degree of consciousness, wounds, habits, and motor function. While the psychological aspect refers to emotions, worries, independence, personality strengths and self-esteem. The social factors comprise of cultural beliefs, isolation, privacy, financial stability, legal and relationships. The spiritual element is concerned with symbols, practices, values, existential and meaning (CCP 2009, p. 7-8). The holistic approach used in palliative care embraces inter-disciplinary practice in teams consisting of different professionals who are highly qualified. The Palliative care consists of structures that help in managing and analysing the signs with the objective of enhancing the standard of life and alleviate pain. The palliative care integrates the use of non-pharmacological treatments that comprises of directed imagery and relaxation to minimise stress and improve the patient’s life. The cognitive behavioural therapy (CBT) is a non-pharmacological treatment that concentrates on the patient’s behaviour and thoughts. The CBT treatments assist the patient to look at their identity, insights and beliefs and how they dictate their conduct and emotional well-being (Parsons & Preece 2010, p. 179). Acupuncture is utilised in chronic pain therapy that is linked to cancer. Transcutaneous electrical nerve stimulation (TENS) is another effective non-pharmacological treatment. TENS allows a managed electric current of low voltage to pass through the patient’s skin. Reflexology, massage and aromatherapy are used in pain management. The massage is a method that consists of kneading, touching and pressing of soft tissues in therapy. Aromatheraphy utilises oils that are made from plants mainly derived from bark, wood, flowers, leaves, root and seeds. The reflexology is the massage that is performed on particular body areas, for example, the feet (Parsons & Preece 2010, p.180). The restriction of the non-pharmacological therapy is that it does not have evidence-based model that can prove its efficiency and safety (Cho 2013, p. 8). There is use of medications in palliative care. The drug and the amount of concentration used are in line with the point and the degree of pain. An excellent example is the use of muscle relaxants to relieve extreme muscle spas, corticosteroids for nerve and bone root pain and anaesthetic medicines used for uncontrolled and persistent pain (Dickman 2012, p. 21). Systematic Approach The most suitable framework that is applicable in a community setting is the Gold Standards Structure (GSF). The GSF is an evidence-based approach that ensures optimal care for the dying patients that is implemented by general providers. The objective of the approach is to assist individuals to live in a better way before they die. The GSF systematic approach consists of care in the final periods of the individuals suffering from any end-stage diseases in various settings. The GSF is purposed to be a generic enhancement device that is created to be used in primary care for cancer patients. It can also apply to any other patients who are terminally ill from other conditions (Zeppetella 2012, p. 186). The GSF framework has five objectives: - Constant high standard care, - Arranged in line with the preferences of the patient, - Anticipation and planning ahead of the wants, - Enhanced teamwork and staff confidence, and - It is based more on home and less based on hospital. The GSF structure embraces a technique that focuses on the well-being of the patient and their families. In addition, it motivates inter-professional primary care teams to collaborate. The GSF systematic approach is rooted on the best evidence of efficient and principal solutions in the profession. At every stage of the model, an assessment and research are carried out. In palliative care, the primary care teams find the GSF framework consistent with their profession, offer a quality palliative care pursuit and promote equilibrium in care (Zeppetella 2012, p. 186). The seven C’s of the Gold Standards structure of palliative care (Zeppetella 2012, p. 186-187):  Communication Operations have a list of patients that are close to dying that permits the team to give prioritised care. The ‘surprise question’ is one of the devices in the Prognostic Indicator Guidance that recognises patients who qualify for registration.  Coordination It involves recording of key contacts such as a general practitioner and regular district nurse and their contact data. Develop a working relationship to monitor discharges and changes.  Control of symptoms There is a dire concern to ensure the availability of uncomplicated access to specialised palliative care counsel for general practitioners, community matrons, care homes, nurses, pharmacists, ambulance staff and out-of-hours clinicians.  Continuity There are documents that assist the patient and the family to access quality care in any place such as the passport data regardless of the lack of any other information. There should be a structured system that collaborates with other professionals.  Continued learning The GSF structure motivates reflection of independent cases to enhance the care systems. It recognises the local necessities of the primary care and provides suitable solutions.  Carer support The model makes sure the carers are given support upon discharge for a smooth transition and quality care. The model provides the caregiver with the chance to get information on the anticipated events at the end of life and how to manage them.  Care of the dying This concept ensures that a systematic approach employed, for example, GSF protocol is capable of being transferred to different settings. It makes sure that the patient has realistic alternatives of the venue of care; their preferences are implemented and documentation. Three triggers are used to identify the patients suitable the GSF framework and how to prioritise problems. The three are: 1. Will it come as a surprise if the patient died in the next six to twelve months? If the response is negative, what precautions should be carried out to promote a standard of life presently and prepare for the end of life stage? 2. Need/choice: the individual suffering from a terminal illness select the care gives comfort rather than ‘curative’ therapy. Sometimes is in dire need of palliative care for instance, where the patient rejects renal transplant. 3. Clinical indicators: particular indicators of terminal illness for the three dying patient categories that are organ failure, the frail elderly and cancer (Zeppetella 2012, p. 187). Communication is paramount to get accurate data about a patient that aids in an assessment. It is, therefore, crucial for collaborative cooperation that involves sharing of information to enable coordination, decision-making, problem-solving and management of conflict. The team members need to discuss what is considered vital. Doctors communicate with nurses during assessment using the biomedical model of diseases and health. The social workers utilise the bio-psychosocial-spiritual aspect. The nurses give information through description and narration. On the other hand, the doctors share information when necessary or in case of an issue that may be hard to resolve. The SBAR model is used to get the correct patient information. The model assists in the following: - Patient information on the present condition. - An examination of the present problem. - The context for the current situation of the patient. - The recommendations that fulfil the patients want. The manner in which the information is communication influences cooperation. The professional team need to have verbal styles that can promote the health of the patient (Berger, Shuster& Roenn 2006, p.509). From the perspective of the patient, there is need to deliberate about the disorder, artificial hydration, therapy of the illness, about the bad news and medications. It will help the patient and the family to make an informed decision (Dodds, Kumar & Veering 2014, p.233). Evaluation Various tools are used by the palliative care team to monitor and analyse the effectiveness of therapy (Kinghorn & Gaines 2007, p. 12). The devices used in evaluation include: - The palliative care outcome scale that comprises of a 10-point questionnaire that is used by the patients and the staff. - The Palliative Care Assessment tool that is a numerical score system that is quickly filled by the patient. - The Rotterdam symptom checklist that is utilised for measuring the scope of general signs associated to the patient anguish. - The Support Team Assessment Schedule that is a comprehensive, quick device that has various topics and independent score criteria. The symptoms that are measured by these tools are breathlessness, confusion, low mood, pain, and nausea. The role of the artificial hydration The objective of palliative care is to give the best standard of life for dying individuals. The healthcare team responsibility is to analyse situations where the patients is distressed and in need of fluids. The role of a palliative nurse is to help the family or a caregiver to judge if the artificial hydration is suitable to add the life span. An excellent case is where a patient suffers from sub-acute intestinal obstruction with severe vomiting caused by intra-abdominal swelling. In such an event, the patient may feel relieved and comfortable to obtain parenteral hydration. Moreover, it prolongs the life where the obstruction persists and is not fatal (Randall & Downie 2010, p. 90). In most cases, artificial hydration is necessary for the event of sedation. It is used to remove the poison generated by the medicines employed and to stop over-sedation. In particular in the event where sedation is used to make the patient unconscious, the artificial hydration should be done to prevent death caused by dehydration. Artificial hydration is also crucial in patients suffering from delirium that is as a result of abnormal levels of electrolyte. In such a case, it aids in raising the removal of opioid metabolites. Need for education on palliative care and artificial hydration The information that an individual expects is different in various people. When deliberating about ways and means of prolonging life, it may involve revelation of information on prediction. It may include interventions that are under discussion or not. It is the role of the nurse professional to decide the amount of information that will be presented to the patient and the technique that is most appropriate (Randall & Downie, p. 90). Many patients suffering from irreversible intestinal obstruction wish for a long life. In a situation where they receive the correct information about symptom control procedures, they put them into consideration when making decisions (Randall & Downie 2010, p. 90). The artificial hydration is administered in the consent of the family or caregivers. The family members or the care providers are entitled to know that the artificial hydration is not helpful in all patients. The need for the artificial hydration is determined by the patient’s illness. In most situations, if correct oral care is provided, there is no need for artificial hydration. As stated by Bass (2006), a condition known as third spacing may be caused by artificial hydration (p.14). The condition may in turn cause pulmonary and peripheral oedema resulting from minimum oncotic pressures. In other instances, the artificial hydration may cause much discomfort to the patient, increase pulmonary and gastrointestinal secretions. Thus, there may be a need to stop the fluids and the patient’s family, and caregivers are helped to make the right decision. Moral difficulties The health care team should identify the person who is dying immediately to provide suitable medications and care. In the UK, a guidance known as (LCP) Liverpool Care Pathway created specifically for the care of the dying is used to maximise the care given to the patient. LCP enhances suitable comprehension, support among the close people and the patient. The obligation of care is to provide relief of psychological anguish and physical comfort for the patients who are dying. It is critical to provide the best symptom control method and stop burdensome and inefficient therapy (Randall & Downie 2010, p. 91). The method of artificial hydration is highly contentious at the end of life care. The only way, to justify the utilisation of the techniques, is that it is capable of quenching thirst. Considering the adverse consequences, the artificial hydration has to the individual; it is proper to withhold therapy in a dying patient. Nevertheless, where the patient was receiving hydration through tubes, it is in order to continue with the process until the end of life (Randall & Downie 2010, p. 92). The ethical and legal concerns of artificial hydration When the patient is incapacitated and, therefore, cannot make judgements whether start or stop artificial hydration, the health professionals make the decision on his/her behalf. The health professional hence weighs the risks and benefits when making such decisions in accordance with the known priorities and preferences of the patient. The overall goal is to make the last days as comfortable and less pain as possible (Randall & Downie 2010: 92-97). The ethical concerns The artificial hydration encounters unknown considerable risks and benefits. The decisions on the utilisation of artificial hydration must be constant with the medical state of the patient, objectives of care and prognosis. The decisions are influenced by religious and cultural norms. The doctors, families and patients are at liberty to be directed by their norms. Nevertheless, the health professional uses three key principles to explain the significance of the artificial hydration. To start with the health professional are supposed to offer education to the patient and family and acknowledge that the procedure is not fundamental and cannot be provided by anyone. The artificial hydration is a medical procedure that is carried out for medical symptom. In addition, it uses tools that are set up by knowledgeable personnel that use technical process. Therefore, the health professional should let the patient and the family realise that artificial hydration has similar procedures as other medical and surgical procedures (Casarett, Kapo & Caplan 2005, p. 2608). Secondly, the health professional must describe the process of artificial hydration in the sense that it creates pain that is related to risks and benefits that are not known. Lastly, the health professional should enlighten the patient and the family on the fact that the objective of the artificial hydration is not to make the patient comfortable. It is clear that the in the giving of palliative care, signs of thirst can be controlled using for instance, wet swabs or ice chips to satisfy the feeling without using artificial hydration. The health profession is required by moral statutes to notify the patient and the family about the possible risks and benefits of artificial hydration during the comprehensive informed-consent process. Sometimes the family or the patient may reject the artificial hydration on the basis of their beliefs on foods. A health professional, that has beliefs that do not support the artificial hydration, should not be trusted, and the family, or the patient has the right to move to another doctor. The health institutions are supposed to encourage the doctors in performing artificial hydration (Casarett, Kapo & Caplan 2005, p. 2608). The legal concerns The legal concerns are directed by the Mental Capacity Act (2005) which became legally binding in 2007 (The National Council for Palliative Care (n.d.), p. 1). Considering the Mental Capacity Act, patients with the ability to agree or reject artificial hydration are assisted to engage in the discourse about the procedure. Where the patient is not mentally stable to make decisions, there is need to check if there was an advance decision that rejected artificial hydration. It is because if such an advance decision exist, then it is legally binding as long as it fulfils the terms and conditions of the Mental Capacity Act. There are times when patients appoint a representative who makes a decision on their behalf according to their wishes. In some instances, a Court Appointed Deputy is elected by the Court of Protection to act as a decision maker for the patient. The limitation is that the Court Appointed Deputy cannot make decisions concerning life-sustaining therapies. Their responsibility is to ensure that the patient’s best interests are honoured. In situations where the patients lack family or representative to make decisions, and then, an Independent Mental Capacity Advocate is consulted. The advocate function is to see to it that the patient’s best interests are satisfied. The advocate only contributes in decision-making but is not qualified to make the final judgement. In a scenario where the patient is not able to make personal judgements, and does not have a Lasting Power of Attorney, the person who may decide to initiate or stop the artificial hydration is the general practitioner or the consultant (The National Council for Palliative Care n.d, p. 3). According to the Mental Capacity Act, the best interests of a patient incapable of making decisions are outlined in a particular procedure that is applicable when examining the patient. The Act states that: - Put into considerations all the significant situations. - No one should discriminate the patient. - Try as much as possible to motivate and allow the patient to engage, or promote his/her potential to take part in artificial hydration decision-making. - The patient’s views are confirmed to establish his/her best interests. It may include an Advance Statement that might not meet the standard of a legal binding advance decision. It is significant in establishing the patient’s beliefs, values and wishes concerning artificial hydration. - The views of the patient’s close relatives or friends are taken into account to determine the patient’s best interests. It may include people that care for the patient, individuals interested in the patient’s health. In addition, anyone appointed by the patient for consultation purposes (The National Council for Palliative Care n.d, p. 3). The pros and cons of artificial hydration In reference to a review by the UK Association for Palliative Medicine, printed by the National Council for Palliative care, there is not enough proof that artificial hydration was a significant process at the end of life. However, the report indicated that continued artificial hydration deteriorated the pleural effusions and peripheral oedema. The advantages of artificial hydration In a situation where there is the addition of nutrients and energy, the artificial hydration prolongs life and gives the family and the patient enough time to: - Give emotional support through minimising fear of being left alone. - Promote patient and family bonding. - Give confidence that all the best is done to ensure the patient live as long as possible. - Permit denial to act as a natural mechanism that safeguards the patient from the fear of death that is inevitable. The artificial hydration prevents recognised anguish because of worry that dehydration is a painful way of dying. Likewise, it satisfies the moral norm that all individuals are supposed to feed. In addition, fluid is an obligation as it stops the discomfort generated by thirst. It also enhances the patient holistic feeling of self-esteem and health. On the other hand, artificial hydration helps to boost the potential to recover from the impact of other medical treatments (Niedert & Dorner 2004, p. 256). The disadvantages of artificial hydration The artificial dehydration makes the patient encounter physical suffering and pain during: - Line or tube usage and insertion - Limited movements because of attachment to the infusion equipments. - Moral and spiritual conflict. - The patient is isolated from other people. - Financial difficulties. - Increased intake of fluids and much pharyngeal secretion that end up to a death rattle. - Psychological torment that is caused by the feeling of sadness due to hardships put on shoulders of friends and families by the patient. - More pulmonary and nasogastric secretions that may necessitate suctioning. - Utilisation of restraints. - Increased necessity for catheterisation in patients who are too weak to assimilate large quantities of fluids. - Overload of fluid, thrombosis, sepsis with complete parenteral nutrition, pulmonary and peripheral oedema. In addition, there is a likelihood of lung puncture and ascites. - Vomiting, diarrhoea, painful distention, nausea, a lot of a stomal leakage, wound dehiscence in tube feeding and a possibility of pneumonia and aspiration (Niedert & Dorner 2004, p. 256). Analyse and evaluate findings and to implement to enhance service delivery The palliative care goals and objectives are to provide care for dying people in order to reduce the pain they undergo. This service is required after the patient is discharged from the hospice and receives the care at the comfort of their homes. In order to provide quality palliative care, there is a multidisciplinary team working together that include a bereavement service, training and education programme and a community palliative care service. The palliative care embraces any model that is convenient for the situation (Scott & Howlett, 2009, p.4). From the research carried out in New Zealand and Australia where there is a high level of service delivery standards, indicate that the palliative care is delivered through hospital support teams, inpatient and home care. It is evident from New Zealand where there is more use of day-care services. According to the research, it is clear that the model of care relies on the historical aspects of an individual country. The model is also influenced by the population density, local community surrounding and financial support (Ferrell & Coyle 2010, p. 1256). Research, protocols and guidelines to develop confidence The utilisation of clinical protocols involves a lot of international studies. The three objectives the guidelines include the standardisation of profession to give an efficient and cost-effective health care system, risk management and rapid incorporation of research into practice. The integrated pathways are the devices used to execute clinical governance that focus on improving the standard of care in the UK. In addition, they bring the latest research evidence into the clinical care. Moreover, they are used to audit compliance by assessing the reported differences in the care plan (Payne, Seymour & Ingleton 2008, p.544). Therefore, the clinical protocols build confidence in the palliative care because they are evidence-based. Palliative care teams in hospitals and hospices The palliative care teams in hospitals attend to the needs of dying patients in the community hospitals. In the UK, a community hospital population is less compared to the general hospitals. Unlike in the general hospital, the managers are of the view that the staffs possess the necessary expertise to manage the end of life of the patients. Moreover, in the community setting there is the necessary facilities, resources and equipments. However, there is the lack of adequate skills in psychological elements of care (Payne, Seymour & Ingleton 2008, p. 389). The community hospitals provide the rural population with continuous medical care that results to uncomplicated deaths. This is an indication of a well-organised staff that manages patients well in those hospitals. The community hospital is a paramount resource package for the old in the UK. The palliative care teams in the hospice give care to dying people residing in nursing homes. I nursing homes, the continuous care comprises of all the time presence of a nurse that help with the necessities of the intensive service. The palliative care is offered by inpatient consultation teams that focus on inpatient units. In the hospice, the palliative care is provided when instructed by the primary care doctor (Berger, Shuster & Roenn 2006, p. 495). Conclusion All in all, artificial hydration is an essential procedure that may be used to prolong the life of the patient. It is morally upright to withdraw and withhold if it brings the best outcomes in a patient. It is proved by the case of Airedale NHS Trust V. Bland (1993), where Anthony Bland survived through artificial hydration and nutrition (Kinghorn & Gaines 2007, p. 187). The case clearly demonstrated the importance of the process for a particular patient. The patient survived in the vegetative state for more than three years, and this maintained the sanctity of life. Artificial hydration poses a challenge to caregivers especially when a patient is sick and unable to feed, and they are not sure whether to initiate the process. The patient and the families are grounded on their beliefs, values and faith. The fact that it does not influence the management of symptoms and the survival of the patients makes it lose value. The side effects, which arise because of the artificial hydration, are worse than the current state of the patient. However, if the process is initiated to correct a flexible situation then it is worth all the risk for the sake of life of the patient. The multidisciplinary medical team should review the decisions made in regard to a patient daily according to the patient’s conditions. In some cases, the families may be worried by the insufficient nutrition or hydration of the patient. The health professional should offer guidance on how to manage the anxieties. The artificial hydration is initiated as the last resort where other means of hydration have failed. Moreover, it is not a permanent process and can be stopped if there is a need to do so. The patient continues to receive quality palliative care and if it is necessary artificial hydration is provided, and other symptoms are handled. Bibliography BASS, M. (2006). Palliative care resuscitation. Chichester, England, Wiley. http://www.123library.org/book_details/?id=4249. BERGER, A., SHUSTER, J. L., & ROENN, J. H. V. 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