Prepared by: AUBREY C.

ROQUE RN, MAN

 It

is designed to give supportive care to people in the final phase of their lives and focus on comfort and quality of life rather than cure.

GOAL: To enable patients to be comfortable and free of pain, so that they live each day as fully as possible. PHILOSOPHY: To provide support for the patient's emotional, social, and spiritual needs as well as medical symptoms as part of treating the whole person.

 Palliative

care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through:

the prevention and relief of suffering by means of :

Identification of pain Impeccable assessment and treatment of pain Identification, assessment and treatment of physiological, psychosocial and spiritual problems

 Affirms

life and regards dying as a normal

process Neither hasten nor postpones death Provides relief from pain and other distressing symptoms Integrates the psychological, ethical, legal and spiritual aspects of care Offers a support system to help patients live as actively as possible until death Offers a support system to help patients families to cope during the patients illness and in their own bereavement.

 Uses

a team approach to address the needs of the patients and their families, including bereavement counselling, if indicated.
enhance quality of life and may also positively influence the course of illness.

Will

Is

applicable even in the early course of the illness in conjunction with other therapies and may also involve studies that may better understand and manage the disease.

 To To

palliate physical symptoms

maintain independence for as long and as comfortably possible isolation, anxiety and fear associated with advancing disease. a dignified death. those who are bereaved.

Alleviate

Provide Support

Palliative care for children is the active total care of the child's body, mind and spirit, and also involves giving support to the family. It begins when illness is diagnosed, and continues regardless of whether or not a child receives treatment directed at the disease. Health providers must evaluate and alleviate a child's physical, psychological, and social distress. Effective palliative care requires a broad multidisciplinary approach that includes the family and makes use of available community resources; it can be successfully implemented even if resources are limited.

 It

can be provided in tertiary care facilities, in community health centers and even in children's homes.

PALLIATIVE CARE- is designed to give support and comfort rather than cure of the illness or problem.
SPECIALIST

PALLIATIVE CARE

Requires a high level of professional skills from trained staff It refers to a service provided by a multiprofessional team led by clinicians led by clinicians with recognised specialist palliative care training.

 Nurses
Doctors Physiotherapists Occupational

therapists Social workers Chaplains and volunteers

Team work is the key to a successful and efficient palliative care.

 Current

licensure in the state of practice Minimum of one year of clinical practice in nursing.

Oncology Psychiatry Home care experience are prepared

Knowledge

of pathophysiology and disease

progression Understanding of pain and symptom management

 Excellent

assessment communication skills Ability to work within and contribute to an interdisciplinary team Ability to assist the patient and family in coping with emotional stress Understanding of an aptitude for organization and communication with patient, family and team members

 Capacity

to manage physical , psychological, social and spiritual problems of dying patients and their families Ability to coordinate the extended and expanded component1s of hospice service Acquisition of counseling, managing, instructing, caring and communicating skills and knowledge. Ability to balance the nurses self-care needs with the complexities and intensities of repeated encounter with death.

 1.)

PALLIATIVE CARE IN HOSPITALS

The most common place to die for people The ways in which staff perform their care for the dying is usually determined by the hospitals policies and routines.

2.)

PALLIATIVE CARE IN THE COMMUNITY

20th century majority of people died at home Current trend a rise of 66% of death in institutions Dying patients usually prefer to die in a home setting

 3.)

DAY CARE

Units based in hospices where patients with advancing disease can attend on a day basis. Care provided includes social and therapeutic benefits for the patient (eg: aromatherapy, wound dressing, bath)

 CARE

HOMES

These nursing homes provide care for elderly patients who require constant medical treatment, but do not require advanced care and specialized doctors in a hospital.

COMMUNICATION- is the essential process by which individual share something of them, whether it is thoughts, feelings, opinions, ideas, values, or goals. (chapter 5)
The first impression of people towards us is determined by 45% of our verbal communication skills and 55% of non verbal skills. The greater part of an individuals personality is developed and maintained through social interaction.

Perception is selective

Only a part of the information sent is perceived. The idea that what is perceived is not precisely what actually is.

It is an interactive and continuous process

The sender is also a receiver of information The receiver is also a sender of information, during the communication process

Its inevitable

It is impossible not to communicate, (it is essential for health providers to be aware that even when words are not used or spoken, communication is occurring.

Culture influences communication pattern

It is critical for health provider to recognize their own cultural conditioning in order to explore the impact it has in their communication with those of another cultural background. Culture involves customs, beliefs, values, and relationship patterns, prescribed behaviors (dress, food preferences and time consciousness).

Importance of good communication at the end of life

Honest communication increases the likelihood that the dying experience will be one through which all the participants can grow emotionally and spiritually Families are better prepared for the final death event and have better bereavement experiences. One of the most important messages that we need to convey to a person with advanced illness is hope.

Barriers to good communication

1. Patients and Families

death is considered a taboo subject

Common reactions are withdrawal from the patient or situation, denial of the reality of a terminal diagnosis, or avoidance of the subject, such as telling jokes or changing the subject.

Barriers to good communication

2. Poor communication skills of the health care provider

using the dying person's name throughout the conversation making eye contact holding the person's hand placing one's hand on a shoulder or arm smiling gesturing leaning forward caring in what the person is saying (or not saying) and feeling. Asking specific questions such as, "Can you help me understand?" as well as open-ended questions such as, "What is it that you need to do now?" are very important, as is being comfortable with silence.

Barriers to good communication

3. Depth of the physicianpatient relationship: Health Care Providers (HCPs) may develop strong bonds with patient and family, whether they have known them for years or just a short time. These bonds may make breaking bad news or discussing issues around end-of-life care difficult since they may find it difficult to contemplate losing a patient they care for deeply. 4. Personal experiences of illness and death: May affect their ability to care for a person who is at the end of life. 5. Physical, emotional and psychological stress and depletion: May affect ability to communicate caring, empathy and compassion.

Barriers to good communication

6. Fears of confronting own mortality and fears of death: Caring for someone who is dying leads to physicians confronting their own mortality and fears of death. 7. Lack of training and poor role models: A lack of training and role models results in poor communication skills and either a lack of awareness of patients feelings and reactions or inability or fear of discussing these emotions. 8. Fears of emotional outbursts: HCPs are often not taught how to show empathy and caring and may fear emotional outbursts.

9. Fears of appearing weak or unprofessional for displaying emotions: Many HCPs have been taught that displaying emotion is a sign of weakness or unprofessional. These HCPs may have difficulty in discussing end-of-life issues for fear of feeling or displaying emotion.

Barriers to good communication

10. Guilt and self-blame due to introgenic complications resulting in poor quality of life, increased severity of illness and/or death: When illness is due to or has been exacerbated by iatrogenic complications, HCPs may be consumed with self-blame and guilt which may affect their ability to consider the patients situation. 11. Communication Problems: Inconsistent approach to the issues, differences in language can lead to confusion (the perception of mixed messages) and misunderstandings with patients and families.

Barriers to good communication

12. Health Care System

fast pace modern health care system, inadequate time to discuss important matters such as death Unclear who is responsible for initiating and providing follow-up-end-of life conversations?

Practical aspects of communicating at the end of life

Understand oneself and speak honestly (self-awareness) But remember that the key to talking to dying persons is to focus on their needs, rather than ones own. Consider the timing of communication ( ask is this a good time to talk) Provide a setting for open communication arrange the environment and how to adapt their own behavior to facilitate conversation avoid sense of arrogance maintain eye contact

Practical aspects of communicating at the end of life

Allow the patient to guide the communication process; patients personal autonomy and control should be preserved.

Use open ended questions (e.g. what is it that you need to know?)

Practical aspects of communicating at the end of life

Make

no assumptions about what the patient knows; a patient who has not told of their diagnosis might be aware that they are dying. and listen, listen and ask, the most important general rule in the end-of life setting is to listen more and to talk less

ask

yes or no questions are helpful initially to open a difficult subject, (e.g. have you experienced the death of a loved one before.. followed by do you feel like talking about it
attentive listening means no interruption, but listening patiently until there is a pause in the conversation before speaking

Practical aspects of communicating at the end of life

use

understandable terms ask patient what they want use silence liberally support varying emotional response accept denial , usually accept symbolic language encourage patient to tell their life stories tell people what to expect at the very end of life, assume that hearing is still intact

Breaking bad news -- All the communication skills discuss apply to the very difficult task of breaking bad news
Factors that add to the distress of the situation:

Fear of being blamed for the bad news Fear of not knowing all the answers Fear of showing emotions Fear of being reminded of ones own mortality

NOTE: it is often the doctors responsibility to break the bad news but it is helpful to be present when the bad news is initially shared, that is to understand the real situation/condition of the patient.

 AUTHORITATIVE

are practitioner-led strategies wherein the practitioner(nurse) takes responsibility for the client, with the aim of guiding their behavior.

INTERVENTIONS

PRESCRIPTIVE the helper seeks to direct the nehavior of the

client.

INFORMATIVE the helper gives the client information CONFRONTING the helper tries to raise the clients
consciousness about an attitude or behavior.

 FACILITATIVE

aim to help patients be more autonomous through emotional release, self-knowledge and learning, and affirmation of their value and being.

INTERVENTIONS

CATHATRTIC the helper encourages the client to release painful emotions such as fear. CATALYTIC the helper elicits self-discovery and problem solving in the client. SUPPORTIVE the helper affirms the worth of the clients attitudes, qualities and actions.

It is a requisite skills for care providers in the end-of-life care to determine the two important psychological complications of being terminally sick. These skills are:
Assessing

Depression

DEPRESSION is a psychiatric disorder characterized by an inability to concentrate, insomnia, loss of appetite, anhedonia, feelings of extreme sadness, guilt, helplessness and hopelessness, and thoughts of death. The condition is also called clinical depression.

NOTE: Anhedonia: Loss of the capacity to experience pleasure. The inability to gain pleasure from normally pleasurable experiences. Anhedonia is a core clinical feature of depression, schizophrenia, and some other mental illnesses.
Subtypes of Depression:
Major depression severe, lasts for at least 2 weeks (decrease energy, feeling of worthless, guilty) Dysthymic depression less severe (lasts for 2 years or more).

General appearance of a depressed person

Sadness Resignation Apathy Hopelessness Or may become cheerful when decision come to end suffering

2. Assessing Suicide potential

Requisite skills for end-of-life care is the ability to identify depression and assess for suicidal potential

For assessment of suicide potential, a direct approach is recommended.

Eg. Have things gotten so bad that you are thinking of killing yourself.

Risk factors for SUICIDE:

S Sex (more female attempts suicide but more males commits). U Unsuccessful previous attempt. I Identification with a family member who committed suicide. C Chronic I Illness Ex. Cancer D depression/dependent personality A age (18-25 and 40 above) and alcoholism L Lethality of previous attempts/looses.

Quality and compassionate care at the end of life

Based on its definition, it includes a distinct, comprehensive cluster of services for terminally individual and their families which are provided on a continuum of intensity or LEVEL OF CARE.

1. Routine Home Care

The most common level of care, the heart of hospice of care The full scope of hospice service is provided in the patients personal home/residence Care begins in admission process

Assessment and admission of the patients status and appropriateness for hospice care Also focus on the concerns and issues that troubles the patient and family and how hospice can help them

It is directed towards the relieving of specific problems

Pain Symptoms of disease Anxiety

There is a continuous reevaluation and reappraisal on the specific needs of the patient and family to ensure that support and comfort oriented services are offered in a timely manner There is a significant involvement of the family or primary support person in providing direct hands-on care for the patient With routine home care the patient are able to die as they prefer at home.

 2.

Continuous Home Care

Is an expanded level of care in the home

A skilled nursing of 24 hours is allowed to ease and prevent hospitalization for management of acute symptoms
The chief reason is management of acute physical symptoms, or may also be used when the burden of care giving for families is greater than their resources

 3.

Respite Care
Supports the patients family and the caregiver The family can have rest, vacation or attend events while the patient is cared for in an in-patient setting. Respite care is limited to five day period Care is similar to home care but is rendered in an inpatient setting in a contracted room with basic activities of living assisted by nurses and nursing assistants. Patients are often very ill or have need for assistance with activities of daily living, which is often the precipitating factor for respite care Respite care is expensive due to the intensity of care

 4.

In- patient Care or Acute Symptoms Management

A short term admission to a medicare certified facility for medical problems requiring nursing and medical management Candidate for in-patient care are those: Whose care are so complex or demanding that the family can no longer continue to provide home care

PATIENT Problems for in-patient Palliative Care Admission Imminent death under specific condition Active and potential bleeding Sepsis Seizures Impending delirium tremens Uncontrolled pain Any uncontrolled symptoms Central nervous system dysfunction

Delirium Coma Dementia

Fractures of weight bearing bones Management of complex medications Acute cardiac symptoms

Myocardial infarction Arrhythmias

Complex treatment schedule requiring frequent dressing changes or procedures that require the time, skills and observations of a professional nurse Terminal agitation

 NON-MEDICARE

LEVELS OF CARE

is being provided to expand services to meet identified patient care needs.

A. Residential Care

- is provided in hospice/palliative inpatient settings for patients who require supportive care related to safety needs, weakness or the inability to perform self-care.

-Also provides a way to offer better continuity for patient who are no longer appropriate for in-patient care status

B. Day Care

Designed to provide relief to the caregiver and diverse activities for the patient There are planned activities, meals, and observation and assistance as needed. Patients are transported to the day care site by family or by hospice.

C. Extended Caregiver Services or in-home respite care

The programs offers a shift s of nursing assistants to a patient to supplement or substitute for family caregivers The goal is to keep the patient at home Usually used by working families, frail caregivers, and in situations where the physical demands for care-giving are beyond the strength of the caregiver. Also a way to supplement care when residential care beds are not available.

CHAPTER 3

 It

is a philosophy of care based upon a belief that all aspects of a person must be considered during the treatment of illness and the promotion of quality of life.
is a recent trend when it comes to principles of treatment in the 21ST century.

This

BIOMEDICINE a medical model that says that illness is a dysfunction of the corporeal body wherein the mind is separate from the physical body.
The biomedical approach requires the patient to submit their diseased body to the care of health-care experts for treatment. The view that the mind had no influence upon physical health meant that it was not usually considered by the physicians.

One fascinating area of scientific study that seeks to demonstrate the body-mind link is the PSYCHONEUROIMMUNOLOGY. PNI has conducted studies how life events are evaluated as stressors and investigated how stress alters the effectiveness of the bodys immune system.

 Factors

that may influence health and the course of the disease according to PNI:

Thoughts Feelings Emotions Personality Beliefs

 HOLLISTIC

ASSESSMENT IN PALLIATIVE CARE

Assessment is the key to effective care plan. It must be a comprehensive and sensitive assessment. Holistic assessment may only be done when the nurse gains idea about personhood.

Personhood it is ones identity as a social person.

 CULTURAL

COMPETENCE

refers to an ability to interact effectively with people of different cultures. Cultural competence comprises four components:

Awareness of one's own cultural worldview Attitude towards cultural differences Knowledge of different cultural practices and worldviews Cross-cultural skills

 Is

a patterned behavioral response that develops overtime and is shaped by the values, beliefs, norms, and practices that are shared by members of the same cultural group.
the twentieth century, "culture" emerged as a concept central to anthropology, encompassing all human phenomena that are not purely results of human genetics

In

 Dimensions

Of Culture

Gender Age Differing abilities Sexual orientation Religion Financial status Residency Employment and Educational level

 Refers

to a dynamic, continuous process of awareness, knowledge, skills, interaction and sensitivity. implies not only awareness of cultural differences but also the ability to intervene appropriately and effectively become more culturally competent, nurses are required to learn in the

It

To

Affective (attitudes, feelings, and beliefs) Cognitive or intellectual or psychomotor or behavioral domains and assumes skills in critical thinking

 Cultural

competence is demonstrated when the nurse:

Shows respect for the inherent dignity of every human being irrespective of their age, gender, religion, socioeconomic class, sexual orientation and ethnic or cultural group Accepts the rights of individuals to choose their care provider, participate in care or refuse care Acknowledges personal biases and prevents these from interfering with the delivery of quality care to persons of other cultures Recognizes cultural issues and interacts with persons from other cultures in a culturally sensitive way Incorporates cultural preferences, health beliefs and behaviors, and traditional practices into the care management plan.

 1.)

Cultural awareness- examination of ones own heritage, familys practices, experiences, religious or spiritual beliefs.

Cultural awareness encourages us to examine the influence of cultural stereotypes ( stereotyping occurs when one makes an assumption about an individual based solely on the individuals groups membership) have on our beliefs, values and clinical practice To avoid prejudice, discrimination and interference with holistic care To find similarities rather than differences

 An

essential skill in the provision of culturally appropriate services, cultural awareness entails an understanding of how a person's culture may inform their values, behaviour, beliefs and basic assumptions.

Cultural

awareness recognises that we are all shaped by our cultural background, which influences how we interpret the world around us, perceive ourselves and relate to other people.

 2.

Cultural Knowledge- serves as a guide to assist the hospice and palliative care team to gain a better understanding of the individual and family.

It is to recognize the uniqueness of an individual or the differences that exist even within the group. Differences must be identified to provide culturally appropriate care to the patient and to the family

 3.

Cultural Skill- is important to assess cultural behavior and beliefs.

such as skills in , cultural assessment, crosscultural communication, cultural interpretation and appropriate intervention Working appropriately and productively with others

 4.

Cultural encounter the actual experience or immersion to a culture.

When we meet people from other cultures there is the potential for development and change. How we handle this meeting- or a possible conflict- will often be the determining factor for the outcome of the cultural encounter.

1.)Communication-person may cause to return to their most familiar or native language when they are sick. Recognize the ways in which people of different backgrounds communicate with each other, which includes

Identify the language spoken in the home How the patient prefers to communicate Patients speaking or reading ability

Interpreter must be necessary for language barrier Important to recognize the overall characteristics of language and the communication process:

Respect the way a person wishes to be addressed Be aware of the rules of communication within the culture

Listen to the quality of voice to help understand the message

It is necessary to vary the techniques of communication depending on the individual (communicate in a non hurried manner, listen carefully, and speak slowly and distinctly) Be aware of acceptable practices; the use of touch, eye contact etc.

Types of touch: Functional professional- exam and procedures Social polite greeting, handshake Friendship Warmth hug, arm in shoulder Love intimacy tight hugs and kisses Sexual arousal by lovers

 2.)

Space the dimension of comfort zone

The intimate zone 0-18 inches (whispering) The personal zone 18-36 inches (family and friends) Social zone 4-12 feet
Public zone 12-25 ft.

Proxemics study of distance zones between people during communication.

 3.)

Social organization - the different structures in various groups such as: family, religious groups, ethnic and racial groups.
4.) Time- implications of how cultural group views the concept of time, is important to understand the patients response to prognosis and duration of illness.

Future oriented-defer gratification of personal pleasure until future obligations have been met Present-oriented group focus on living on the present and are not overly concerned with the future; time is flexible

5.) Environmental control- is the ability of individuals to plan activities that control nature. 6.) Biological variations- physical differences affects assessment findings of individuals with varying skin color.

 Nutrition-

dietary pattern of cultural group, food is used to assess, treat and prevent illness Decision making- with the Patient Selfdetermination Act (PSDA) of 1991 decision making shifted from the physician to the patient Pain management Death rituals in mourning practices

MIDTERM TOPICS

 Clinical

encounter is influenced by ;

the personal and cultural values of both the patient and the provider moral traditions of the health professions social and political context of the health care system

 Ethical

issues that arise in the care of the

dying:

truthfulness and confidentiality decision-making authority in the professional patient relationship appropriate use and allocation of technology and other health care resources decision to withdraw life-sustaining treatment decision making for patient who have lost their own decision making capacity request for assistance in suicide active euthanasia

 Expectation

of patients, family and team

The conflicting expectations of patient, family and team is an ethical issue that needs to be addressed It is important to assess and clarify the goals and expectations from the beginning of the relationship between the patient, family and hospice team Palliative care is appropriate when a patients disease is no longer amenable to cure, when the burden of life-prolonging treatment outweigh the benefits.

Ideally it is the decision of the patient or family to enter hospice

The hospice team needs to know about the previous clinical course, and what the patient and family have been told and the understanding about the course.

 Communication

of information (about diagnosis and prognosis)

families who insist that the information be withheld from the patient or the patient insisting that the information be withheld from the family it is important to remember individuality of patient and families

each request should be treated sympathetically and with respect : that is to find the concern for withholding the information, asked in sympathetic and understanding manner to elicit information.
Communication of information about illness and prognosis is a process, conversation will have to be repeated several times.

 Pain

management the patient and the familys attitude towards the use of narcotic analgesics can be a source of frustrations and ethical concerns for the hospice team: such as
a. patient stoicism b. fear of addiction c. fear that admitting to pain means admitting that the disease has progressed d. reluctance

 Advance

care directives allow patients to provide instructions about their preferences regarding the care they would like to receive if they develop an illness or a lifethreatening injury and are unable to express their preferences. care directives can also designate someone the patient trusts to make decisions about medical care if the patient becomes unable to make (or communicate) these decisions. This is called designating power of attorney (for health care).

Advance

 Federal

law requires hospitals, nursing homes to provide written information regarding advance care directives to all patients upon admission.

Advance care directives can reduce: Personal worry Feelings of helplessness and guilt by family members Futile, costly, specialized interventions that a patient may not want Overall health care costs Legal concerns for everyone involved

 Verbal

instructions. These are any decisions regarding care that are communicated verbally by an individual to health care providers or family members. donation. This may be accomplished by completing an organ donation card and carrying it in your wallet. A second card may be placed with important papers (such as a living will, insurance papers, and so on). Most hospitals or other major health care centers have organ donor information available.

Organ

 Living

will. This is a written, legal document that conveys the wishes of a person in the event of serious illness. This document can speak for a patient who is unable to communicate. A living will may indicate specific care or treatment the person does or does not want performed under specific circumstances.

This may include specific procedures, care, or treatments such as the following: CPR (if cardiac or respiratory arrest occurs) Artificial nutrition through intravenous or tube feedings Prolonged maintenance on a respirator (if unable to breathe adequately alone) Blood cultures, spinal fluid evaluations, and other diagnostic tests Blood transfusions

 Special

medical power of attorney. A legal document that allows an individual to appoint someone else (proxy) to make medical or health care decisions, in the event the individual becomes unable to make or communicate such decisions personally.

NOTE: This document provides for power to make medically related decisions only and does not give any individual power to make legal or financial decisions.

 DNR

(do not resuscitate) order. This states that CPR (cardiopulmonary resuscitation) is not to be performed if your breathing stops or your heart stops beating. The order may be written by the person's doctor after discussing the issue with the person (if possible), the proxy, or family.

 Assisted

suicide is the common term for actions by which an individual helps another person voluntarily bring about his or her own death.

"Assistance" may mean providing one with the means (drugs or equipment) to end one's own life, but may extend to other actions. It differs to euthanasia where another person ends the life. The current waves of global public debate have been ongoing for decades, centering on legal, religious, and moral conceptions of "suicide" and a personal "right to death". Legally speaking, the practice may be legal, illegal, or undecided depending on the culture or jurisdiction.

 Euthanasia:

the intentional killing by act or omission of a dependent human being for his or her alleged benefit. (The key word here is "intentional". If death is not intended, it is not an act of euthanasia) Voluntary euthanasia: When the person who is killed has requested to be killed. Non-voluntary: When the person who is killed made no request and gave no consent. Involuntary euthanasia: When the person who is killed made an expressed wish to the contrary.

 Assisted

suicide: Someone provides an individual with the information, guidance, and means to take his or her own life with the intention that they will be used for this purpose. When it is a doctor who helps another person to kill themselves it is called "physician assisted suicide." By Action: Intentionally causing a person's death by performing an action such as by giving a lethal injection.

Euthanasia

 Euthanasia

By Omission:Intentionally causing death by not providing necessary and ordinary (usual and customary) care or food and water

A protection for everyone concerned

The law that affects the entire community

It is a strict, principle-based reasoning that uses the circumstances of a case to evaluate the laws that are applicable. Also known as civil law, was used to compensate people who suffered wrongful acts known as TORTS. Rules of conduct shared by the community

 It

creates categories that distinguished one person from another and one situation from another situation. It solidifies the lines that draw these distinctions into fences, trying to assure that everyone understands the either/ or nature of their choices how to behave. science it is a result of research and investigations

in

court rules only upon issues that ripened into full conflict and only when the parties whose actual interests are at stake stand before it.
grounded in underlying, discoverable realities from which facts can be established by experimentation, issues can be discussed and debated in abstract terms , problems can be anticipated and disputes can be avoided

Are

 Legal

thinking uses inductive reasoning to sort issues by similarities and differences to bring the right result for the case at hand.
relies on logic

Science

 Rights

are boundaries that others are forbidden to cross Trespass against property or person
The

current laws that govern the health care practice relies on precedents to the medieval concept of trespass against a person, a common law tort.

Free from being touched without consent The law of negligence was born as a partner concept implying the duty of care for those to whom consent to touch is given It is only through the trial of actual cases, decisions made after actual harm has been done, that the common law grows and changes. In the spirit of the modern age, right is now what we called as powers, dignities or privileges.

Right to live Right of choice Right to die

Governed by the law of professional negligence, sometimes called MALPRACTICE.

Negligence-refers to the commission or omission of an act, pursuant to a duty, that a reasonably prudent person in the same or similar circumstance would or would not do, and acting or the non-acting of which is the proximate cause of injury to another person or his property.

The law of professional negligence is all about the right of a patient to receive care that meets the objective standards established within the professional community

Four elements of professional negligence

What was the duty of care Was the duty breached Was the harm to the patient actually caused by the breach of duty What is the loss or harm

NOTE: the first two questions establish liability for negligence and the final two establish damages and the share attributable to the negligence of the tortfeasor Punitive damages-extra measure of damages, depending on the facts of the case, the skills of the lawyers, and the influential voices of the jury. This amount could be very extravagant
Compensatory damages- the amount is victim specific, meaning that the monetary recovery depends on financial values associated with the loss to the actual victim and the victims family, including loss of earnings. E.g. the younger the victim with promising future is higher in compensation than a poor old person.

A patient communication with the physician is privileged, (privilege communication)

The doctor could not disclose the information learned in the course of treatment to anyone outside of the medical team without the consent of the patient The issue in breach of confidentiality only arises if there is financial harm to the patient as the result of breach. Judges can do allow queries of the medical team when a medical facts is in controversy In Hospice-it is important to recognize that only members of the team should have access to privileged information unless the patient has given permission for information to be shared with family and friends

The privilege and the right to release it, passes to an appointed surrogate in the event of a patients incapacity

A right to consent or to refuse consent to being touched Touching someone without consent constitutes tort of battery Consent may be implied from circumstances, however when touching can be invasive and cause pain or harm, the issue of consent come into play The tort of battery arises most often in contemporary medical case law in instances of mistaken identity where a patient is subjected to surgery intended for another person. The tort of battery arises most often in a medical case law in instances of mistaken identity where a patient is subjected to surgery intended for another person.

The more common issue in hospice is the Doctrine of Informed Consent, this doctrine has found ground in malpractice where patients experienced unexpected outcomes that in hindsight, they learned foreseeable risk of treatment.
Courts have ruled that patients must be afforded the choice of alternatives to recommend treatments and a prospective of the risks.

Dying patient often lose their mental capacity to make rational choice Durable power of attorney for health care in anticipation of fate- patient appoints surrogate or proxy decision makers.

The legal document serves to delegate the right of consent to the surrogate or proxy decision makers

Not only at the end of life but with all the proposed medical treatment to refuse or to withdraw their consent once given The right is extended to their surrogate decision maker and was the basis for allowing the discontinuance of artificial ventilation in the case of Nancy Cruzan also called Right to Die Not only logically connected to treatment that prolong life but also with regards to patient s with religious or philosophical beliefs that bring moral and ethical criteria to aspect of medical care

The common law recognizes NO RIGHT to choose to die and no power to seek the assistance of a physician to carry out the suicide The law requires medical service providers to supply more and better information about proposed treatments so the patient can exercise judgment and choice.

Contracts and agreements Advance directives Releases and consents

 Agreements

that are executed follow a legal standards of mental competence , a spouse may enter agreement to act for the benefit of a spouse but circumstances of intimacy and specialized knowledge between patient and her/his health care providers will require special caution in matters where legal or financial interest of the patient may involved

a.DNR / DNI- part of the treatment plan and are placed prominently in the medical records. The patients consent to these papers is a refusal of medical treatment in advanced of its proposed intervention.

b.Right to die statement- a patient may refuse to give consent to the treatment, which remains in effect even after the patient loses consciousness or capacity and is self-executing.
c. Instructions regarding cremation and embalming-

the statement have legal effect over the rights of survivors to dispose of the body
d.Power of attorney for health care- a power of

attorney for health care appoints a surrogate or proxy to consent to treatment in the event of the lack of capacity of the principal

 the

primary purpose for obtaining consent to palliative care treatment plans is to document the existence of INFORMED CONSENT.

A releases of legal document / medical information, where patient Releases should always be in writing

 The

duty of care of health care providers is to the patient, the consent to treatment or refusal to treatment is legally considered to be the action of the patient.

Whether the proxy actually carries the wishes of the incompetent patients is not a cause that a court will entertain, however as long as the decision is made by the person with the legal authority to make. The court will hear and decide cases when the authority of the proxy is challenged ( rather than the proxys decision)

CHAPTER FOUR

 Careful
Careful

history taking

review of symptoms and thorough physical examination realistic goals as you plan the care for the client

Set

 the

absence or loss of energy or strength fatigue

The general causes of fatigue are:

Infection Anemia Chronic hypoxia Metabolic and electrolyte disorder Psychogenic Pharmacologic Malnutrition

 Treatment

= improve the clients sense of well being (address each cause of fatigue individually)
measures = goal setting

General

MEDICATIONS:
Corticosteroid-

used to produce a feeling of well being and increased energy in patient with terminal cancer (improvement usually seen
after 10 to 14 Days of therapy)

dexamethasone and prednisone

 Psychostimulants

fatigue associated with depression or opiod-induced sedation may respond to psychostimulants.

Methylphenidate may be initiated at 5 mg in the morning and at noon, avoiding doses later in the day to prevent interference with sleep and titrated to 40 mg per day

 Erythropoietin

( the growth factor) to increase hemoglobin, hoping to reverse the fatigue associated by anemia
to all episodes of infection for it does not only causes fatigue but they are also often life threatening

Antibiotics

 Associated

with clinical conditions where Respiratory system is subject to an increased mechanical workload Ventilation needs to be increased There is respiratory muscle weakness due to fatigue, paralysis or lung volume increase

Treatment = treat the underlying causes of dyspnea

 the

infrequent, difficult passage of small hard stool. Causes of Constipation: Decreased fluid and fiber intake in the diet Poor blood circulation in the GIT Decreased physical mobility Medication (eg. Calcium supplements) Any condition that increases colonic absorption

Probable

What are the principles in using Laxative Therapy

It is better to prevent constipation than wait to treat it. If there is fecal impaction, evacuation will not occur until manual rectal disimpaction is performed Intestinal obstruction must be ruled out Combining agents with different mechanism of action often will improve results

 Bulk

forming laxative

-Contains polysaccharide or cellulose derivatives resistant

to bacterial breakdown, more than 24 hours to effect and often Ineffective in the terminally ill patient. - Inappropriate for use in opiod-induced constipation
Emollient

laxative (eg. Mineral oil)

-this lubricate the stool surface and penetrate the feces to soften and promote easier passage. -Also acts to decrease colonic absorption of water. -15 to 30 cc daily is given which takes effect in 8 to 48 hours, given at bedtime but caution should be observed for aspiration is a common problem in the elderly that might cause acute or chronic lipid pneumonitis.

Fecal softeners -composed of surfactant agent not absorbed by the gut. -Act as detergent to increase water penetration in the stool bolus, making it softer and easier to expel. -Also promote water and electrolyte secretion, with an effect from 24 to 72 hours - Docusate, Poloxamer

Stimulant or irritant laxative -stimulate the myenteric plexus to induce peristalsis, commonly used preparations to stimulate bowel movement. -Include senna, bisacodyl (brown discoloration of acidic urine may occur in senna or cascara sagrada.) - All stimulant may cause severe cramping and abdominal discomfort, but may be avoided by careful dosage titration and by using in combination with stool softeners

Osmotic laxative - exert osmotic effect by increasing the intraluminal volume by retaining water, increase water secretion and stimulate increase peristalsis. -Lactulose and sorbitol -15 to 30 cc one to two times daily. - Flatulence is the undesirable effect. -Glycerin is the rectal preparation

Saline laxative - sulfate and citrate salts of magnesium -Continuous use may lead to electrolyte imbalance for patient with hypertension, CHF or significant renal dysfunction

Enemas -enemas may be available formulated with sodium phosphate, bisacodyl or mineral oil. -Oil retention enemas are especially useful in the setting of very hard impacted stool -should be used as an adjunct to a prophylactic oral regimen Uses of enema includes: for surgical preparation and diagnostic purpose

 To

recognized patients rights to pain assessment and management Assess the nature and intensity of pain Record results of assessment to aid in followup Ensure competency in pain assessment and management Support appropriate prescribing of pain medications Address the need for pain management in discharge planning

Unrelieved pain is associated with considerable detrimental physiologic and psychosocial consequences Pain can affect every aspect of a persons quality of life Unremitting pain can consume every aspect of life Pain may lead to feelings of isolation Emotionally: pain can be an expression of

hopelessness, helplessness, anger, anxiety, depression, and frustration

 Whatever

the person says it is, and existing whenever the person says it does
definition of pain designates the patient as the authority about pain is inherently subjective phenomenon

This

Pain It

is a sensation that is influenced by physical, psychosocial and spiritual circumstances.

 Examples:

the experience of pain can be impacted by knowledge and beliefs about pain; Previous pain experiences Particular styles of coping Educational level Age . gender Availability and type of social support systems Role models and family members Cultural, religious and social influences

 ACUTE-

pain typically has a well-defined onset, lasts a relatively short period of time, and responds well to treatment

Often signals an injury and when the injury heals, the pain disappears

CHRONIC-

or persistent pain may have a defined onset, can be mild or severe, and is present for an extended period of time.

Often responds unpredictably to treatment In the dying, this pain can be unrelenting and is often progressive

A person in painbody attempts to respondbrain (pituitary gland) produces protective natural opioids (endorphins and enkephalins) to lessen the perception of painful nerve signalsthis chemicals help to stop neuron from sending a pain message

Somatization disorder

Characterized by multiple physical symptoms

Pain disorder

Has primarily physical symptom of pain, unrelieved by analgesic

 Palliation

- easing the severity of a pain or a disease without removing the cause.

To

palliate a disease is to treat it partially and insofar as possible, but not cure it completely.

 In

hospice enrollees should be terminal or having a prognosis of six months or less In palliation of non-cancer it is unpredictable for they tend to become stable until exacerbation occurs.
Cancer patient responds to definitive therapy e.g. surgery. Radiation, chemotherapy for only a period of time, it can be discontinued. In non-cancer disease active treatment is effective until very near death Example of active treatment is the use of diuretics for CHF to relieve pulmonary edema, Intubation and mechanical ventilation for COPD

 Prognostic

uncertainty makes it difficult to determine when non-cancer patients are actually dying

It reduces the length of stay in hospice programs, almost one third of the patient die before the end of their first week in hospice. It is important to remember that symptom management, advance care planning and psychosocial/spiritual support are appropriate regardless of apparent stage of disease.

 This

will determine which patients have endstage illness. It will also help with the cost/benefit analysis of palliative intervention Criteria as adapted from the National Hospice Organization:

1. End-stage heart disease

Usually manifested by heart failure For those with systolic failure- left ventricle has become weakened and dilated For those with preserve systolic function who have a small poorly compliant(stiff) left ventricle that cannot tolerate pressure or volume stress and cause multiple episodes of flash pulmonary edema, without ventricular enlargement

 Treatment

for end-stage heart disease

Diuretics and angiotensin converting enzymes (ACE) inhibitors -- (ACE inhibitors are medications that slow (inhibit) the activity of the enzyme ACE, which decreases the production of angiotensin II. As a result, the blood vessels enlarge or dilate, and blood pressure is reduced. This lowers blood pressure and makes it easier for the heart to pump blood and can improve the function of a failing heart.

angiotensin receptor blockers (ARBs)- The angiotensin receptor blockers (ARBs), also called angiotensin (AT1) receptor antagonists or sartans, are a group of anti-hypertensive drugs that act by blocking the effects of the hormone angiotensin II (Ang II) in the body, thereby lowering blood pressure.

2. Heart failure is advance if patients continue to decline after hospitalization that involved invasive monitoring with Swan-Ganz catheter.

Any patient failing an inotropic infusion of dobutamine ( stimulates the B- receptors of the heart, increasing myocardial contractility thereby increasing cardiac output) should be considered for hospice evaluation or a primarily palliative approach

3. Lung disease- considered advance when patient have disabling dyspnea, with blood gas deficit, arterial pO2 below 60 on room air and pCO2 above 50.
Intubation and mechanical ventilation are necessary because the patient is already resistant to bronchodilators.

4.

Dementia including Alzheimer - is difficult to determine the prognosis.

The dementing process is not fatal but medical complications are. ,that the patient is said to be nearing death. Indicators of severe dementia increased incidence of complication, they become bed ridden prone to pneumonia, lung atelectasis, sepsis etc.) Loss of the ability to ambulate independently and loss of the ability to carry on meaningful conversation.

5. End-stage liver disease Bleeding from esophageal varices particularly for advanced liver disease Elevation of prothrombin time due to shortage of liver-dependent clotting factors 6. End-stage renal disease (ESRD) Treated with dialysis For severe renal function abnormalities without dialysis, and to those whose serum creatinine is over 6.0 or creatinine clearance under 10 ml/min (15 ml/min for diabetics) short term mortality

Grief

Refers to the subjective emotions and affect that are a normal response to the experience of loss.

Grieving/Bereavement

Refers to the process by which a person experiences the grief.

Anticipatory grieving

Is when people facing an imminent loss begin to grapple with the very real possible loss or death in the near future.

Mourning

Is the outward expression of grief.

Kubler-Ross stages of grieving 1.Denialis shock and disbelief regarding the loss NO NOT ME. 2. Angermay be expressed toward God, relatives, friends or health care providers. WHY ME 3. Bargainingperson asks God or fate for more time to delay inevitable loss. WHY ME. 4. Depressionresults when awareness of loss becomes acute. STAGE OF SILENCE 5. Acceptanceshows evidence of coming to terms with death. YES, ITS ME.

 NOTE:

it is important that grief and bereavement is a normal transition or opportunity to grow rather than a problem
provide care in the end of life it is important to recognize suffering (grief and bereavement) and what are the growth opportunities it may afford the patient

To

 Byock

s areas for patient to grow and find meaning:

Sense of completion with wordly affairs Sense of completion in relationships with community Sense of meaning about ones individual life Experienced love of self Experienced love of others Sense of completion in relationship with family and friends Acceptance of the finality of life- of ones existence as an individual Sense of a new self beyond personal loss Sense of meaning about life in general Surrender to the transcendent, to the unknownletting go

It is not necessary for patients to examine each of these areas. The goal is to develop sense of closure or resolution, the patient may find meaning and identity at a time when his or her connection to the world is slipping away.

Techniques to develop the sense of closure:

Storytelling Life review Reframing problems

In hospice we aim for our patient to die wellwhich suggest that some preparation and work may be necessary in order to realize the ending state.

The process of dying well is living life fully while dying.

Be physically present.
Be non-judgmental. Encourage verbalization of feelings. Allow the patient to cry. Recognize your own thought about death and dying.