PALLIATIVE CARE IN THE TERMINAL STAGE - THE NURSE VIEW
palliative in Medicine
palliative pal·li·a·tive (pāl'ē-ā't?v, -ē-?-t?v)
Relieving or soothing the symptoms of a disease or disorder without effecting a cure.
Taking care of critically ill patients is a challenging task, and it needs proficiency. It’s difficult to handle a family and terminally ill patient without any proper knowledge. To solve the problems and handle the difficult situation during palliative care is proper training and knowledge about palliative care. It also needs proper training and experience for caring terminally ill patient. According to Kaasa & Loge, (2003) in palliative care quality of life is the basic and central concept. The quality of life is has been used in vast concept which includes physical, psychological, spiritual, and social life of a patient.it is an approach to improve the quality of life of patient who come across life threatening illness for example cancer. The main purpose of palliative care is relief from suffering or to early identification of symptoms as early as possible. During my palliative clinical rotation, I have encountered a 60 years old, female patient who was diagnosed with liver cancer stage III. The patient was only in the palliative care she had not received any chemotherapy or radiation. Now she was admitted in hospital for draining ascetic fluid and for pain management. When I was taking the history of patient I came to know that patient was worried about her condition and she was unaware of her diagnosis and prognosis. She was very depressed and anxious about her health. She was unable to do her daily routines due to abdominal distention, pain, and tenderness. Furthermore, she was physically very weak.
While taking care of the patient, I found all four domains of palliative care in my patient which includes physical, psychological, emotional, spiritual and sociocultural. But physical and psychological domains were the most effected domains in my patient. In this paper, I will focus on the physical and psychological domain of palliative care. In literature, it is stated that“Palliative care is aimed at improving the quality of life for patients and their families who are confronted with a life-threatening illness by providing support and care for pain, physical symptoms, psychological and social stress, and spirituality.”(Weiner et al., 2013). While taking care of the patient, I realized that patient was suffering from pain. Some other physical symptoms which are present in a patient are abdominal distention, general weakness, shortness of breath, fatigue, and loss of appetite. According to Skevington & Lofty (2003) pain, fatigue, general weakness, loss of appetite, nausea, vomiting are the common symptoms in cancer patients. Furthermore it is stated in Clinical practice guidelines for quality palliative care (2008) regular, ongoing assessment of pain, no pain symptoms (including but not limited to shortness of breath, nausea, fatigue and weakness, anorexia, insomnia, anxiety, depression, confusion, and constipation), treatment side effects, and functional capacities should be documented through a systematic process.in the case of my patient due to abdominal distention she had pain, feeling fullness and shortness of breath. To relief from pain first I encouraged patient to take deep breathing and staff inserted a drain to drain out ascitic fluid. After draining 1000 ml fluid she felt relief from pain. Also in my patient due to nausea and anorexia, she has low appetite. Due to poor intake, she felt lethargic and unable to do her daily activities. Therefore I encouraged the patient to eat frequently but in a small amount and I also educate her attendant about the importance of proper nutrition.
The second important domain affected in my patient was the psychological domain. Due to physical deterioration mostly, patient become frustrated of their life and do not want to live
They end up with sadness, loneliness, anxiety due to hospitalization and they worried about the prognosis of the disease. My patient was also faced above mentioned problems as she did not know about her prognosis and she was worried about progressive symptoms like abdominal distention, pain, fatigue and general weakness.Furthermore in case of my patient she was worried because she was unaware of her diagnosis.When I was taking history, her attendant said that we did not disclose the diagnosis to the patient because she already worried about disease. As every patient has right to know about their diagnosis and their disease process. According to Jhordy et al (2007), physical weakness and impairment disturb most aspects of life like psychological, social, sexual, spiritual and other daily activities of life. Due to limitations in activities patients at the high risk of psychological problems. Therefore most of the terminal patients think that they are dependent on family and they burden on their children and spouse. In literature, it is stated that mood disorder, anxiety, and depression coexists with advanced illness. Psychological distress with terminal ill patient is very common in palliative care setting. Patient’s response in different ways to show the depression, for example, sadness, fear and grief in different stages of their progressive disease. 35 to 50 % of cancer patient experience psychological problems. The experience of psychological problems effect on an individual coping mechanism with illness, physical symptoms and on their treatment. (Kelly,Chonchinov &McClement, 2006). Therefore it’s very important to assess the psychological problems of patient to give a quality care and is as important as to assess physical condition of the patient. It is also stated in above mention article. That we should educate patient about different psychologist, social groups who support them. To relief from stress I also encourage patient to verbalize her feelings and encouraged her to take deep breathing. We also arrange an activity that we gathered same diagnose patient and encourage them to verbalize their feelings, and I also provide a paper to express her feelings on paper. After the activity, the patient mentioned that she felt better and it effects positively on patients. In addition, I spend most of the time with the patient to encourage her to express her feelings, and I also educate her attendant to support her and spend time with her.
The challenges that I faced during clinical were to communicate the prognosis of the disease. Because the patient was unaware of her diagnosis and their family did not want to tell the patient about her diagnosis. Therefore due to this reason I was unable to communicate the disease process properly and it hinders me to apply the concept of palliative care. Furthermore, due to lack of resources, I was unable to give holistic care.
As a nursing student, I want to recommend that palliative course should be compulsory in the nursing school and medical so that they can provide knowledge about the end of life. There should be proper training for students so they can easily handle the difficulties while taking care of the terminally ill patient. It’s not important to give palliative care to the only terminal patient, but it’s our responsibility that from the diagnosis we have to take care of the patient. On institutional level different seminar should be arranged to give awareness about the palliative care. Also, we can arrange different sessions for patients and families to give awareness about palliative care and disclosure of life-threatening diagnosis.it also important to give proper training to the staff of health care system so they can give comfort and help the patient to end up with a peaceful death. There should be a separate bereavement room for families, so they express and spend last time with their patients. Moreover, there should be a palliative care team so they give proper training to staff ongoing basis to achieve competency in palliative care.According to Ramjan et al (2010), palliative approach can improve comfort and dignity of patient through the early identification and assessment as well as know the patients psychological, emotional, social and spiritual concerns. Furthermore, we can give awareness through social media, that everyone can approach aware about the importance of palliative care. Mostly, patients want to die at the home in the presence and support of family. One of the article it is mention that health care provider needs to support and give education to the family members of symptom management so they can easily continue care at home also (Luckett et al, 2013).
In conclusion, palliative care is very important part of the health profession. The basic theme of palliative care is not the treatment of the disease, but it is all about to decrease the sufferings of the patient. There are different domains in palliative care which are affected due to any of progressive diseases, such as physical, psychological, spiritual, socio-cultural and sexual domains of life. The most important is the physical aspect which disturbs other domains of life. Moreover, when I reflect back, I realized that overall clinical and palliative care is very beneficial and productive. Now I can easily integrate theoretical knowledge in a hospital setting. Furthermore, now we can educate patients, and their family members about palliative care and can assess all domains of health.
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