The Palliative Care - Essay Example

The Palliative Care Introduction Palliative care is a holistic and multidisciplinary medical care approach that focuses in improving the quality of life of the patients suffering from life limiting conditions as well as their families and loved ones through relief from pain, stress, depression and other related symptoms. In addition, palliative care may also be achieved by offering psychological, physical, and spiritual relief for the patient. In the United Kingdom, palliative care services are not only applied to the end of life patients but are also increasingly widely used in the management of incurable diseases alongside other medical procedures such as diagnosis and treatment. This is particularly attributed to the growing empirical evidence suggesting that the cost –efficacy of palliative care significantly outweighs attempts at disease cure, with regard to quality of life for both the patient and the family. The provision of palliative care is often affected by a number of external influences such as pathways, government policies and agendas and hospice availability as well as internal influences some of which may include psychological and physical aspects of the patients or their families. Other internal factors may also include the knowledge of the care givers regarding the principles and practices of palliative care, attitudes of the caregiver on life and death and support from relatives and family members. This paper is based on a case study of Mrs. Janet, an end of life cancer patient who was admitted in a hospital in the United Kingdom 28 years after her initial diagnosis of cervical cancer (see Appendix A). The case study analysis attempts to highlight some of the potential external influences that may have directly influenced her end-of-life care, as well as the strategies applied by concerned practitioners in facilitating the delivery of palliative care services of the required quality. In addition, the present case analysis also seeks to critically 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. External influences which have a direct effect on end-of-life care There exist a diverse number of factors that influence the end-of-life palliative care provided to patients with life-limiting health conditions. In the case study, Mrs. Janet’s end of life care is likely to be directly influenced by external factors such as such as cultural factors, care pathways, government policies and agendas and hospice availability. Cultural influences During the provision of end-of-life care palliative care, culture is one of the critical aspects that may determine the success of the care provided to the patient. Although the role of culture in palliative care is rarely acknowledged, the attitudes of individuals including the care givers and the patients towards the end of life care are highly influenced by their cultural perspectives. For example, in the case study, an effective communication between Mrs. Janet, the patient and her caregivers may have been significantly hindered by the different cultural background between her and her caregivers. This is because culture is often a strong determinant of the people’s views regarding death and illnesses as well as how the information regarding end of life issues can be communicated. On the other hand, cultural factors are also very important in determining the quality of care the patient is bound to receive (Watson, 2010). For instance, in some cultures, the patient may need to participate in the planning of the rituals to be performed in their funerals while in other cultures, discussing death may be considered to be a taboo or inappropriate. 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. In this regard, it may be 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). In the case study, 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). Government Health Policies and Agenda Government health policies and agenda is also an important external influence that plays a critical role in the provision end-of- life care both in the local as well as the national healthcare settings. For example, with regard to the local healthcare settings, the UK government recommends that each local community must have carers and other related support networks to assist in the delivery of palliative care services. The implementation of this policy is likely to enhance the effectiveness of palliative services currently available in the local healthcare settings. On the other hand, an important government policy related to the provision of palliative care that has been in existence for some time is the development of standards and quality assurance measures for palliative care based on the 1995 Carers recognition and services act. The recommended development of national accreditation system is likely to help guide and regulate the quality of palliative care services offered in the National Health care settings across the United Kingdom (Firth, 2004, p. 151). Hospice Care Availability The availability of Hospice services is another influential external factor that may directly impact on end of life care. According to the National Health Services (2014), hospices care services are particularly meant to provide care for individuals from the point of their diagnosis with terminal illnesses up to the end of their lives. Although hospices do not normally provide care from diagnosis but rather from the time when an individuals condition has become terminal, 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. With the rapidly ageing population in the UK as well as the increasing number of individuals with long term health conditions, there is an urgent need to improve the availability of Hospice case services. This is particularly because the availability, accessibility, and effectiveness of hospice facilities determine the quality of care that a 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. Additionally, the availability of proper care facilities is critically 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. 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 (O'Brien et al., 2012). The care provided in homes proves to be a big commitment for the careers. According to Murray, Boyd and Sheikh (2005), anyone considering becoming a home career must be ready to discuss with the patient’s doctor, or the nurses involved in palliative care. The availability of help for the potential home careers of patients with life-threatening conditions means there is no reason for fear of caring for these patients at home. Though home careers who do not feel they can effectively manage the provision of the required services do not have to feel guilty about it. Care Pathways Care pathways refer to the integrated methodologies for decision making and coordination of care services. According to Firth (2004), the availability of care services may directly impact on the success of palliative care services. In the UK, some of the care pathways available include Liverpool care pathway among others. Economic Influences Economic influences may have also had a direct impact on the patient’s end of life care. For example, despite the fact that that the UK government offers free palliative care at the point of access, end of life care often come with a number of financial challenges some of which may include the cost of transport costs, loss of earnings during the period as well as other associated expenses. In this regard, a patient’s ability or inability to meet the expenses that come with specialized care may directly impacts on the success of their end-of-life care (Tibi-Levy, Le and De, 2006). For example, Mrs. Janet was able to access quality care services owing to her financial capabilities which enabled her to meet all the potential expenses such as transport costs and related financial requirements associated with palliative care. 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. Strategies employed to facilitate the delivery of quality palliative care services There are a number of strategies that have been employed by the practitioner to ensure the successful delivery of quality palliative care services to the patients at the facility. Firstly, in order to facilitate the delivery of quality palliative care services, the management of the practitioner has developed an education and awareness strategy that seeks to promote the development of palliative care skills among the staff and health care workers working in the facility (Watson, 2010). This is intended staff and health care workers in the facility more knowledgeable and well informed on matters related to palliative care provision. Another important strategy used by the facility is the development of closer collaboration between its various departments. Generally, the palliative care facility has always strived to encourage team work and cooperation among its doctors, nurses, physicians, spiritual counselors, social workers, volunteers, aides, and pharmacists in order 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. Lastly, based on the facility’s current problem of inadequate staff, the practitioner is currently seeking to employ more workers. This is an important strategy since 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 or 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. For instance, 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. Internal Influences on the client’s palliative care Experience Based on the case study, a number of internal influences including the physical, psychological, and social factors that impact the client’s experience in relation to palliative care can be identified. For instance, with regard to the psychological factors, patients in their end of life phase of illnesses such as Mrs. Janet often undergo diverse psychological problems, which are normally 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). As a result, the World Health Organization (2009), recommends that patient in their end of life palliative care should be subjected to numerous psychiatric examinations during the process of care in order to ascertain her competence in making decisions that directly affected her medical condition. On the other hand, patients under palliative care may also 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 her lower back and also had radiculopathy in her left leg. 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). In most cases, terminal illnesses such as cervical cancer often result in depression and desperate feelings for patients such as 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). She also 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). In most cases, 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 improve their lives as opposed to curing their conditions may make them feel uneasy and lose self-esteem and desire for life (Milligan, 2011). 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. Management of Pain and other Distressing Symptoms Provision of relief from pain and other distressing symptoms of the patient’s condition is one of the critical roles of palliative care. Apart from pain some of the depressing symptoms include breathing difficulties, fatigue, constipation, lack of appetite and hopelessness. Effective pain and symptom management is critically important during palliative care particularly for terminally ill patients in their near end life such as Mrs. Janet. In the case study, managing pain is one of the most challenging aspects of palliative care provision for Jane. This is because as a late stage cervical cancer patient Jane was bound to experience severe pain as cancer slowly spread into her nerve endings, muscles and bones. One of the effective ways through which the caregivers were able to assist Jane in the management of pain resulting from her condition was the administration of painkilling medications such as paracetamol and ordinary non steroidal anti-inflammatory drugs like ibuprofen. However, cases of extreme pain required the administration of powerful painkillers such as morphine and codeine. According to Emanuel and Librach (2011), medications for pain can be categorized into two broad classes namely opioids and adjuvant analgesics. The former dulls pain systematically throughout a patient’s body through the use of opioid analgesics that are prescribed by palliative care physician while the latter focuses on use of given helper medications like steroids and Anticonvulsant medications to curb nerve or bone pains. Another treatment option is family-oriented care that was also applied in Mrs. Janet’s case. Generally, patients in need of palliative care often require people who can sooth their fear and pain with equal skill. In addition, the program could be tailored to encompass care that targets the extended family members of the patient who need to be nurtured and reassured given that they (family members) could also be worried of the status of the victims. Delivery of such care through hugs and listening ears will go a long way providing the family members with the assurance that there is going to be some light at the end of the tunnel. Lastly, the other depressing symptoms were treated and managed using a wide range of options depending on the nature of the complications. For example, after the Mrs. Janet had developed an obstruction on her bowel, there was need for her to undergo exploratory laparotomy. She was also subjected to extensive restriction of the bowel, followed by replacement of the gastrostomy. Conclusions and Recommendations In conclusion, the case study as revealed a number of aspects involved in the provision of end of life palliative care. For example, apart from highlighting the importance of the external influences such as care pathways, government policies and agendas and hospice availability, Mrs. Janet’s case also reveals the critical role played that various internal influences like psychological, physical aspects and psychosocial factors as well as some of the ways of managing pain and other distressing symptoms during the provision of palliative care to terminally ill patients. Recommendations for Future Practices The provision of quality palliative care services for all citizens in the future involve setting and reaching a number of targets key among them building capacity of related facilities, integration of palliative care services and change of eligibility criteria used to admit individuals into palliative care to include all patients who been diagnosed with a life limiting condition (Bruera and Hui, 2013). This paper presents a number of recommendations based on the experiences of Mrs. Janet during her palliative care. Firstly, in the future practices, palliative care practitioners and other facilities offering palliative care services should develop comprehensive educational programs for their staff to enhance their palliative care skills. This will also improve their ability to effectively meet the challenges associated with the provision of palliative care at all stages of a patient’s disease condition. For example, in my current environment, training on the provision of palliative care services could be included by incorporating the palliative education into the curriculum for the in-service education. Another important recommendation is that palliative care should be commenced as early as possible immediately a patient has been diagnosed with a life limiting condition. This may help alleviate some of the challenges associated with delayed provision of palliative care. Lastly, there is need to develop a holistic and integrated approach involving a closer collaboration between the doctors, nurses, healthcare givers and all the other persons involved in the provision of palliative care services. Lastly, there is need to increase funding of palliative care facilities in order to allow them cater for associated expenses such as transport costs particularly for economically disadvantaged patients. 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[online] Available at: [Accessed 13 June 2014]. APPENDIX A: PALLIATIVE CARE CASE STUDY Patient’s case study The palliative health care focused on herein concerns 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 her struggle with cervical cancer illness. 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. It was discovered that her bowel had difficulty absorbing 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. The team sought psychiatry opinion, and the result of the examination proved that the patient was effectively competent. On the other hand, Mrs. Janet’s children, who constituted her immediate family, held a meeting and agreed to offer support 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. Read More