Palliative Care for Chronic Obstructive Pulmonary Disease - Assignment Example

? Case Study on Palliative Care for Chronic Obstructive Pulmonary Disease-2 Module Non-Malignant Palliative Care Module NURS09022 Stuart Milligan Assignment : Non-Malignant Palliative Care Portfolio Banner number : B00199070 Submission date : 8th Aug-2011 Words Count : 2356 “Using a case study approach, describe how the palliative care needs of someone with a specific non-malignant disease can be met. You should quote relevant literature to support your arguments, and to demonstrate a thorough understanding of the evidence base for practice and the roles of different professionals and care providers. Contents Page Introduction-----3 Palliative care needs of patients with COPD-----3 Critical analysis of current approaches to symptom management, psychosocial and spiritual support and communication for this patient group-----5 Critical overview of the roles of different professionals and care providers in the care and support of this patient group-----8 Summary and conclusions-----10 Case Study on Palliative Care for Chronic Obstructive Pulmonary Disease Introduction There are several non-malignant conditions which need palliative care because of the degree of suffering in the end-stage. One such disease is chronic obstructive pulmonary disease (Croft, 2005). Patients with this condition develop many symptoms which cause great discomfort and despair not only to the patient but also their dear ones. According to Deane (2008), "patients with chronic obstructive pulmonary disease follow a slowly-declining disease trajectory, punctuated by acute episodes of ill health, until the acute episode that proves to be the fatal one." “More often than not, death is sudden and unexpected” (Deane, 2008). The only solace to such patients would be to provide a comprehensive care which takes care of the physical, psychological, emotional, spiritual and religious needs of the patients so that they lead a peaceful life until their death (Croft, 2005). Such a care is known as palliative care. In this project various aspects of palliative care will be discussed which are individualized and tailor-made to a 85 year old patient by name James with chronic obstructive pulmonary disease in end-of-life situation. Palliative care needs of patients with COPD James is a known patient of chronic obstructive pulmonary disease and suffers from severe breathlessness, distress, despair and discomfort. Chronic obstructive pulmonary disease or COPD is a devastating medical illness which causes a great degree of human suffering (GOLD, 2008). It characterized by non-reversible airway obstruction due to either emphysema or chronic bronchitis or both. It is not only a major health issue but also a significant source of economic and social burden (Fromer and Cooper, 2008). One of the most frightening and debilitating symptom of COPD is breathlessness which is progressive. The most common cause of COPD is cigarette smoking (Silvermann and Speizer, 1996). This condition affects about 15% of cigarette smokers (NICE, 2004). Many patients with COPD do not receive appropriate end-of0life care because of the unpredictable course of their disease (Deane, 2008). Along with these symptoms, patients with COPD have other co morbidities which need to be managed too (Deane, 2008). Though the clinical course of COPD is not predicable, end-of-life care is yet possible. In the last year of life, patients like James with COPD are likely to suffer from chronic dyspnea, low mood, weakness, easy fatiguibility and pain (Deane, 2008). COPD most commonly presents as acute infection of the lungs or cough that is productive. The disease is progressive and eventually, the patient develops breathlessness which, over the course of the disease because the most predominant and distressing syndrome. The patient also begins to suffer from exercise intolerance and also easy fatiguibility. All these symptoms make the life of the patient miserable and helpless. The main reason for breathlessness is poor oxygenation of the lungs and ventilation perfusion defects. Breathlessness can be of different grades and the best scale to measure it is the Medical Research Council (MRC) Dyspnea scale (NICE, 2004). Progression of the disease manifests as increased exacerbation frequency, cyanosis and ultimately right heart failure (Sharma, 2006). One of the challenges in palliative care in these patients is to determine the right timing for discussion of various topics related to palliative care. According to a systematic review by Conventery et al (2005), in COPD cases, terminal care issues must be initiated when poor prognosis indicators like FEV1 of less than 30 percent, corpulmonale and abnormal blood gases ensue. According to Steinhauser et al (2000; cited in Deane, 2008), "for any patient and their family to experience good death, six conditions are required: freedom from distressing symptoms, participation in treatment decisions, planning and preparation for death, completion of life with faith and spiritual experiences; resolution of conflicts; and affirmation as a whole person by caregivers." Critical analysis of current approaches to symptom management, psychosocial and spiritual support and communication for this patient group. The aim of palliative care must be to relieve the patient of suffering, promote function of the patient, deliver help to meet the daily living needs of the patient, provide psychosocial support to the patient and also the family of the patient and clarify goals of care and associated treatments. The objective of palliative care in James must be to support him to live as actively as possible until he is alive, help the family members cope with their illness of their loved one and prepare them for death of James. The four cardinal principles of palliative care are non-malificence, beneficence, patient autonomy and justice. These principles need to be applied in the perspective of respect for life, acceptance of the fact that death is inevitable, provision of treatments which take care of the ongoing suffering, striving to preserve life only as long as life is not a burden and beyond that only asserting life, and also individual needs and that of the society (National Cancer Control Programme, 2005). Breathlessness is a distressing feature in COPD patients like James and this symptom can be managed using both physiotherapy and pharmacotherapy strategies. According to a study by Cambach et al (1997), a combination of both pharmacotherapy and physiotherapy strategies are more effective than pharmacotherapy alone. Pharmacotherapy involves use of steroids, bronchodilators and other drugs. Useful bronchodilators in COPD scenario are methylxanthines, anticholinergics and beta-2 adrenergic receptors (Fromer and Cooper, 2008). Deane (2008) recommends opioids and even midazolam for those who are severely dysnoeic and are on maximum medication. Midazolam however, is recommended only in hospitalized patients. Oxygen must be used judiciously because unnecessary oxygen administration can diminish oxygen drive which is the survival aspect for many patients. Non-pharmacologic method of relief of breathlessness includes positioning (Yohannes, 2007). Certain postures and positions of the body are useful in decreasing breathlessness. These positions decrease consumption of the oxygen of the body and increase the lungs' ventilation-perfusion ration, thus helping relieve breathlessness. Patients must be taught and helped to choose a position that is comfortable for them. There is some evidence that breathing control techniques help the patient cope with breathlessness. In these techniques, the patient must be advised to listen to the breathing noise during expiration and the patient must make every effort to reduce this noise during breathing out. No deep breaths must be taken even if the patient gets tempted. While performing this exercise, the patient must rest in comfortable position. Repeated practice helps the patient rest in a position that is comfortable and perform this exercise. At the same time, it is very important to pay importance to clear sputum because accumulation of sputum can lead to infection and further accumulation of sputum. Sputum clearance from the chest can be done through active breathing cycles (ARS, 2004). Those with severe non-responsive breathlessness will need sedation at regular intervals. Midazolam, levomepromazine and phenobarbital are excellent sedating drugs. Opioids are not recommended for sedation, they are instead recommended for pain relief (Deane, 2008). Pain management in James must be guided by 'analgesic ladder' by the World Health Organization (WHO, 2009). The basic drugs for pain relief would be paracetamol and non-steroidal anti-inflammatory drugs. When these fail, opioids and higher end- opioid must be used. Common side effects to these drugs are tolerance, nausea, constipation, drowsiness, sleep disturbances and confusion. Intolerance to side effects or ineffectiveness in pain relief is an indication to either change the type of analgesic used, or use a combination of analgesic or step up the analgesic in the analgesic ladder. The most powerful analgesic in the third and last step of the analgesic ladder of WHO is the 'high opioid analgesics' like hydromorphone, morphine and fentanyl (WHO, 2009). Pain Assessment Checklist for Seniors with Limited Ability to Communicate is an useful tool for pain evaluation (SIGN, 2008). Addressing spirituality is an essential part of treatment of end-of-life patients like James (Deane, 2008). This is because, spirituality is the basic needed of each and every individual through whom the individual looks for meaning of his or her life. The religious aspect of the patient may be taken care of by taking him to church as much as possible or by asking some one to read bible for him or by asking a priest to meet him. Spiritual care is possible by gauging the depth of despair, distress and anger, supporting all him decisions, offering him to discuss him problems without inhibitions and by showing concern to all his interests like ceremony after death and preparing wills (National Cancer Control Programme, 2005). Good quality of life and sense of dignity can be maintained by allowing James to lead as much normal life as possible, by facilitating him to indulge in enjoyable activities, by making him feel that he is still wanted and by providing him opportunity, space and time to spend time with his partner, children and grand children (Hall et al, 2009) According to Mok and Chiu (2004), "involvement represents encounters that emphasize the importance of being concerned, interested and giving." Actions of care, appropriate attitudes and trustworthiness not only establish a connectedness with patient, but also help in the improvement of physical and emotional state and help them go through the journey of death with peace. The family members must be therapied to come to terms with the fact that their loved one will be leaving soon. They should be allowed to see and talk to them as much as possible. The family members must not be allowed to see distressing things like restlessness of patient, intravenous lines and changes in the color of the skin (National Cancer Control Programme, 2005). Critical overview of the roles of different professionals and care providers in the care and support of this patient group The main caregiver in James is the nursing staff because he is in a residential facility. The activities of the team are coordinated by the primary care physician. Other team members include hospice physician, nurses, home health aides, social workers, clergy, trained volunteers, and other therapists like speech, physical and occupational therapists. The team outlines individualized medical and support services which includes nursing care, personal care like bathing, dressing and taking to toilet; physician visits, social services and counseling (NHPCO, 2008). The team also decides on the tests and procedures to be done on the patient, the medicines and other treatments to be given and the required medical equipment that should be around the patient (NHPCO, 2008). The ultimate aim of the team is high-quality comfort care (NHPCO, 2008). The staff of palliative care is specially trained to assess, anticipate, treat and prevent certain physical symptoms which are the root cause for distress and discomfort. Pain and dyspnea management is the most important aspect of palliative care in COPD patients like James. The staff of the palliative care team coordinates with the treating physician and makes sure that all medicines, treatments and procedures aim to keep the patient comfortable and pain-free. The staff continuously evaluates and monitors the effects of these therapies (NHPCO, 2008). Palliative care team also provides bereavement care for surviving family members. This care is provided by trained volunteers, clergy members or professional counselors (American Cancer Society, 2008). The nursing plan is mainly based on the physical and mental needs of the patient and this will be developed after discussion with various members of the team, with the main coordinator being physician. The family members also need to be involved in drawing up the nursing care plan. Nurses play an important role in palliative care of James. Since they closely work with him, nurses are able to provide holistic support, emotionally, personally and spiritually. Nurses also have an important role in the monitoring and assessment of pain, breathlessness and other symptoms. Infact, often, they are the first persons to report about the pain suffering to the physician and also provide advice to the treating physician about response to pain management. It is very important for the nurses providing pain care to James to be aware of the WHO analgesic ladder, various side effects of the pain drugs that are prescribed, drug-drug interactions and also various drug-diet interactions (Shaw, 2006).The nurses must record, report, evaluate and inform the physician about the drugs administered, their side effects and response to treatment (Delphi Study, 2007). Coordinators of different specialties must educate James about the dosing and type of drugs necessary for pain control. The real fact with regard to palliative care in patients with COPD is that communication pertaining to advanced care planning is limited. Infact, only a minority of patients suffering from advanced COPD discuss about palliative care needs in end-stage. Many patients do not even receive information pertaining to prognosis of progress of the disease and also the various palliative care services available in the local area or elsewhere. Infact, research has shown that even after home care therapy has been initiated, patients are unaware of their life-limiting status and the exact cause of their illness (Heffner, 2011). Multiple barriers can arise in palliative care of patients with COPD and the barriers can be categorized into physician-centered barriers and patient-centered barriers. Physician centered barriers include delay in the diagnosis of COPD, no unique trajectory of the disease, difficulty in establishing the prognosis and course, increased comorbidities, limited physician skills, reluctance of the physician in initiating advanced plan discussions, limitation in the environment of practice and other such aspects. Patient centered barriers include no communication from the patient side about acute exacerbations, poor understanding of the nature of the disease, misperceptions about the limitation nature of the disease and comorbid conditions like anxiety, depression cognitive impairment, helplessness and social isolation (Heffner, 2011). Summary and conclusions Patients with chronic obstructive pulmonary disease have an unpredictable course with characteristic exacerbations. In the end-of-life situation, they suffer from breathlessness, pain, easy fatigability and weakness. These patients need palliative care in terminal stages; however, because of unpredictability of the course of the disease, it is not possible to address all issues pertaining to terminal care in all patients and unexpected death much as possible can occur in many patients leaving their family members shocked. As much as possible, palliative care must be initiated when lung function decreases and corpulmonale develops and the palliative care must address cultural, spiritual and economic aspects including addressing needs related to various distressing symptoms. Advanced management and palliative care of those with COPD is a much recognized aspect. However, several physician related and patient centered barriers prevent those in terminal stages receive appropriate care and management. These barriers must be identified for holistic patient management. References American Cancer Society. (2008). What is Hospice Care? Retrieved on 14th July, 2011 from http://www.cancer.org/docroot/ETO/content/Eto_2_5x_What_Is_Hospice_Care.asp American Thoracic Society/European Respiratory Society Task Force or ATS. (2004). Standards for the Diagnosis and Management of Patients with COPD. 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