palliative care

Dr Riaz.K.M, Assistant Professor,

Government College of Nursing, Thrissur.

05/01/2023 Palliative care .... Dr. Riaz.K.M 2

Introduction

• Once upon a time, there lived a big mango tree.

• A little boy loved to come and play around it everyday.

• He climbed to the tree top, ate the mangoes, took a nap under the shadow… He loved the tree and the tree loved to play with him.

• Time went by… The little boy grew, and he no longer played around the tree.

Introduction

• One day, the boy came back to the tree with a sad look on his face.

• “Come and play with me,” the tree asked the boy.

• “I am no longer a kid, I don’t play around trees anymore.” The boy replied,

• “I want toys. • I need money to buy them.”

Introduction

• “Sorry, I don’t have money… but you can pick all my mangoes and sell them so you will have money.”

• The boy was so excited. He picked all the mangoes on the tree and left happily. The boy didn’t come back. The tree was sad.

Introduction

• One day, the boy grown into a man returned. The tree was so excited.

• “Come and play with me,” the tree said.• “I don’t have time to play. I have to work for

my family. We need a house for shelter. Can you help me?”

Introduction

• “Sorry, I don’t have a house, but you can chop off my branches to build your house.”

• So the man cut all the branches off the tree and left happily.

• The tree was glad to see him happy but the boy didn’t come back afterward. The tree was again lonely and sad.

Introduction

• One hot summer day, the man returned and the tree was delighted.

• “Come and play with me!” The tree said.• “I am sad and getting old. I want to go sailing to

relax myself. Can you give me a boat?”• “Use my trunk to build your boat. You can sail far

away and be happy.”• So the man cut the tree trunk to make a boat. He

went sailing and didn’t come back for a long time.

Introduction

• Finally, the man returned after he had been gone for so many years.

• “Sorry, my boy, but I don’t have anything for you anymore. No more mangoes to give you.” The tree said.

• “I don’t have teeth to bite,” the man replied.• “No more trunk for you to climb on.”• “I am too old for that now,” the man said.

Introduction

• “I really can’t give you anything… the only thing left is my dying roots, the tree said with sadness.

• “I don’t need much now, just a place to rest. I am tired after all these years,” the man replied.

• “Good! Old tree roots are the best place to lean on and rest. Come sit down with me and rest.”

Purpose of life

1. Who are you ?

2. What you did ?

3. Whom you did it for?

4. What they wanted?

5. What they got ?

Palliative care - facts

1. We all going to die2. Dying is not a medical experience;

it’s a human experience 3. We all act like we are not (most of the time)4. Worst thing in life

1. The thought that I have lived and I am not going to die

2. I haven't lived and I am going to die

Dame Cicely Saunders OM DBE FRCS FRCP FRCN

(22 June 1918 – 14 July 2005) was an English Anglican nurse, social worker, physician and writer

Palliative care

A Different Voice in Health Care to Help Patients Find Their on

Palliative care- Beware

• More you domore you decrease the quality

• Stealing from you what you want to do

• Too much focused on diseasemiss to focus human being

• Dealing with sickest of the sick

Palliate = to make less severeIn health care, to palliate means

to lessen the severity of pain or disease without curing

or removing the underlying cause.

Remember this!

Palliative care

treats, prevents, or relieves

the symptoms of a serious or chronic illness

but does not cure it.

Palliative care + curative care

Remember this too!

Palliative care alone,

when curative care is no longer helpful.

In a nutshellPalliative care

improves the quality of life

for patients who are facing serious illness

as well as for their family and friends.

Quality of life (Calman’s Gap)

QOL=Reality- Expectation

Quality of life

“Whatever the patient says it is”

Quality of life

• Personal values • Meaning in life

Personal values

Altruistic values > Egoistic values

Increased QOL

Meaning in life

It’s not what's next is important … its

what's important to you is important

Palliative care

Hospice care

Pain management

Comfort care

Curative and Palliative ModelWorld Health Model

Curative Model

Palliative model

hospice

Medical Condition over time Death

Palliative care

• Derived from Latin palliare, "to cloak.“ “to conceal” “to hide”

KEY ISSUES• Pain • Awareness needs • Live as a human being• Lack of empowerment• Interruption free care• Autonomy in physical activities • To meet social needs• Intervention for Spiritual needs• Ventilation (Emotional) needs• Ethical needs

Palliative care• Pain • AIDS• Liver Diseases • Leukaemia• Infections • Alzheimer's diseases • Tuberculosis• Intracranial lesions • Ventricular failures • Encephalopathies • Cardiac disorders • Arthritis • Respiratory disorders • Endocrine disorders

Patient

andFamily

Volunteers Physicians

Spiritual Counselo

Social Workers

Pharmacists

Home Health Aides

Therapists

Nurses

Principles 1. Caring attitude2. Consideration of individuality3. Cultural considerations4. Consent5. Choice of site of care6. Communication7. Clinical context: Appropriate treatment8. Comprehensive inter-professional care9. Care excellence10. Consistent medical care11. Coordinated care12. Continuity of care13. Caregiver support14. Continued reassessment

Palliative Care Patient Support Services

1. Pain management – vital for comfort and to reduce patients’

distress. – Health care professionals and families can

collaborate to identify the sources of pain and relieve them

2. Symptom management –Nausea, –Weakness, –Bowel and bladder problems, –Mental confusion, –Fatigue, and –Difficulty breathing

3. Emotional and spiritual support for both the patient and family in dealing with the emotional demands of critical illness.

Symptom Management• Agitation/Delirium• Anxiety/Depression• Anorexia/Cachexia• Constipation• Dyspnea/Shortness of

Breath• Control of Secretions• Fatigue• Pain

Symptom Management

Delirium• Occurs in up to 85% of terminally ill pts• Common in last 24-48hours of life• Disturbance in consciousness and cognition: develops in

SHORT PERIOD OF TIME• Poor attention, psychomotor agitation or psychomotor

retardation, perceptual disturbances, disordered sleep-wake cycle

• Related to medical condition

Symptom ManagementDelirium

Causes:• Medications • Brain Tumor• Metabolic abnormalities• Organ failure• Dehydration• Infection

• Hypoxemia• Fecal Impaction• Urinary Retention• Unfamiliar environment

Symptom Management

Delirium Assessment:• Know your resident• History: important to know onset of change in

condition• Medication Review• Physical Exam• Identify Reversible Causes….(what can we

change…)

Symptom Management

Delirium Treatment• Treat underlying cause: correct what can be

reversed.• Symptom control: may need medications• Medications: – Neuroleptics: mainstay of treatment…use with

caution– Benzodiazepines: cautious use indicated

Symptom Management

Delirium Treatment: Non-Pharmacologic• Avoid over-stimulation• Quiet room with familiar objects• Proper lighting• Orientation: visible clock, calendar• Family member at bedside• Fall Risk

Falls Prevention

• Team approach to determine interventions• Safety alarm• Low beds, mats• Move resident closer to nurses station• Toileting Program

Symptom Management

Anorexia/Cachexia• Prevalence: 24 to 80% in geriatric population• Definition: Progressive weight loss, lipolysis,

loss of organ and skeletal protein and profound loss of appetite.

Symptom ManagementAnorexia/CachexiaCauses• Immune mediators• Tumor products• Change in taste, dry

mouth, mouth sores• Nausea, constipation• Gastritis, Peptic ulcer

disease

• Candidiasis of GI tract• Radiation/Chemo TX• Drugs/Medications• Metabolic changes:

dehydration• Depression• Pain

Symptom ManagementAnorexia/CachexiaIdentify and treat reversible causes:• Reversible causes:• Dry mouth• Oral yeast/Candida infection• Acid Reflux, affecting the esophagus• Nausea/vomiting, constipation• Pain • Depression

Symptom Management

Anorexia/CachexiaDietary Changes• Involve resident in menu planning• Offer small portions of resident’s favorite

foods• Avoid foods with strong odors• Offer easy-to-swallow food: semi-liquids,

puddings, ice cream, soft or pureed foods.

Symptom ManagementAnorexia/Cachexia Medication Management:Caveat: Nothing works for very long, all medications have side

effects, and short durations of action.Appetite Stimulants• Corticosteroids• Progestational drugs• Cannabioids• Thalidomide

Symptom ManagementAnorexia/Cachexia Education• Part of the disease process• Not starving• Forced feeding can cause discomfort• Artificial feeding usually not beneficial• Human body can survive comfortably on very

little food

Symptom Management

Pain• Prevalence– 72% non-cancer patients experience pain in their

last 6 months– 87% cancer patients experience pain in their last 6

months

Retrospective survey of 1472 non-cancer deaths and 202 cancer deaths in the UK. Addington-Hall and Karlsen, 1999

Symptom Management

Pain: Common Causes in Elderly• Arthritis (approx. 70%)• Old fractures/prosthetic joints(approx 13%)• Neuropathy (approx. 10%)• Cancer related (approx. 4%)• Other (approx. 2%)325 Randomly selected subjects from 10 community based nursing homes. Adapted

from Ferrell, et al 1995

Symptom Management

Pain• Multi-dimensional, – “what the resident says it is”,– affects all aspects of the persons life.

• Consistent evidence that pain is under-assessed and under-treated

• Systems Barriers– Resident, family, staff, physician

Symptom Management

Guidelines for Pain• Assessment• Regularly scheduled pain medications (not prn

only)• Increased use of opioids• Non-pharmacologic analgesia

Symptom Management

Pain Assessment– Resident self-report, if cognitively able• Numeric• Color/ Visual Analog • Faces

– Behavioral tools• Observe breathing, behavior, body language,

vocalization, consolable– Interview

Symptom Management

Pain Treatment• World Health Organization Step Model– Mild (1-3)– Moderate (4-6)– Severe (7-10)

• Use opioids when indicated: moderate to severe pain.

Symptom Management

Pain Treatment- Barriers• Fear of addiction• Fear of stigma• Fear of opioids • Related to resident, family, staff, physician• Under report

Symptom Management

Pain Treatment Non-Pharmacologic • “ a hand to hold, a heart to touch…”• Sensory stimulation: Presence– Visual: picture books– Auditory: music– Smell: aromatherapy– Touch: Tactile objects, massage– Taste: sweet

Symptom Management

Pain Treatment Non-Pharmacologic • Exercise programs• Acupuncture• Transcutaneous nerve stimulation (TENS)• Relaxation therapy, guided imagery

Overall Goals of Palliative Care

• To eliminate or reduce discomfort• To improve quality of life• To improve mood• To decrease fatigue• To decrease pain

Communication

• Essential to palliative medicine• Includes:– Honesty– Willingness to talk about dying– Sensitive delivery of bad news– Encourages questions

• Identifies choices with benefits and burdens• Assists patient/family make decisions in keeping

with their goals

Goals of Care

• Patient/Resident specific • Realistic• Related to life expectancy • Determined by care setting• Patient/Resident driven

What does Palliative Care Provide to the Patient?

• Helps patients gain the strength and peace of mind to carry on with daily life

• Aid the ability to tolerate medical treatments

• Helps patients to better understand their choices for care

What Does Palliative Care Provide for the Patient’s Family?Helps families understand the choices

available for careImproves everyday life of patient; reducing

the concern of loved onesAllows for valuable support system

Conclusion

Change your life1. Get out of your comfort zone2. Challenge your assumptions so that you can find your

truths3. Speak the language of the person you seek to become 4. Make the little decisions with your brain and big one

with your heart5. How can you create the most positive impact on as

many lives as possible

Conclusion

Transformation (5Ls)• Leave • Learn• Love• Lift• Live

Finally

Today is that day to bring • Hope to hopeless

• Encouragement to the discouraged

Dr Riaz.K.M, Assistant Professor,

Government College of Nursing, Thrissur. +919495837181riazmarakkar@gmail.com

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