Principles of Palliative Care and How They Can Be Applied to Chronic Illness - Essay Example

?Describe the principles of palliative care and how they can be applied to chronic illness Introduction The term “palliative” is the derivative of Latin “palliare” meaning “to cloak” or to mask, to cover up, or to mitigate (Mitra & Vadivelu, 2013, p. 7). Palliative Principles of palliative care Object of palliative care is to reduce distress and improve quality of life of chronically and terminally ill patients and their families. It has no direct role in curing the disease or its modification. Palliative care is best started early and should become the main form of care as the disease progresses and finally in bereavement. As a continuum, palliative care addresses the physical, psychological, social and spiritual needs of the patient and family which cannot be handled by one single agency lest it would cause fragmentation of care. It therefore follows multidisciplinary/interdisciplinary (integrative) care is the backbone of palliative care. With the integration of inputs from various disciplines in accordance with stage of the disease progression, pain and other symptoms, psychological state of patient and family, social and practical requirements and available resources, palliative care becomes a multifaceted care with the involvement of primary care and specialist doctors, nursing staff, social worker and many others in a coordinated manner ensuring continuity of care (Mitra & Vadivelu, 2013, p. 17). Thus, palliative care has been defined as the patient and family-centered one seeking to optimize their quality of life by treating their suffering which includes anticipation and prevention of the suffering by addressing their “physical, intellectual, emotional, social, and spiritual needs” (NCP, 2013, p. 12) throughout the continuum of illness “ensuring patient autonomy, access to information and choice” (NCP, 2013, p. 12) National Consensus Project for Quality Palliative Care (NCP) formed in 2001 with the participation five major hospice and palliative care organizations issued Clinical Guidelines for Quality Palliative Care containing core concepts and structures of quality palliative care along with eight domains of practice. The eight domains of practice are design of the care known as structure and processes of care, its physical aspects, psychological and psychiatric aspects, social aspects, spiritual, religious and existential aspects, cultural aspects, care at the end of life and ethical and legal aspects. The Patient Protection and Affordable Care Act 2010 (PPACA) also has mandatory provisions for both hospice and curative care under Medicaid or Children’s Health Insurance Program (CHIP). It emerges therefore that philosophy and delivery of palliative care has the following characteristics. 1. Provision of care through coordination by an interdisciplinary team. 2. Care needs are determined by collaboration and communication among the patients, families, palliative and non-palliative care providers. 3. Concurrent availability of services along with curative or life-prolonging care. 4. Provision of support to patient and family throughout the period of illness, dying process, and after death (NCP, 2013) The NCP guidelines were revised in 2009 and 2013. The ten year working of the NCP has witnessed 47 % increase in the number of hospice programs and 148 % increase in non-hospice palliative care programs. It has been reported that in the United States about 1,059,000 deaths out of 2,513,000 deaths occurred under the care one of over 5,000 hospices in the year 2011. That is, 46 % of deaths have been under the care of the hospices. It is also claimed that hospices help reduce Medicare program expenditures. One study reveals that cost for the terminal year of life was reduced by an average $ 2309 per patient under the care of hospice. (NCP, 2013). Integrative care Authors interchangeably use the terms “interdisciplinary” and “multidisciplinary” but they do not mean the same though they represent contributions from variety of disciplines for individual patient care. Multidisciplinary model, members from different disciplines provide expert consultation in their respective fields of expertise and the final decision rests with the leader of the multidisciplinary team (MDT) with a clearly defined hierarchy. Thus the leader integrates inputs from the different disciplines for the purpose. On the other hand, interdisciplinary model of palliative care, it is more of sharing of knowledge and integration from the beginning with no defined role distinction and hierarchy and the leadership is task oriented rather than being hierarchic with the patient at the center of the interdisciplinary approach playing an active part in the decision making process wherever practicable. Current guidelines use the term interdisciplinary while research literature and general clinical practice use the term multidisciplinary (p10). NCP has the participation of The Hospice and Palliative Nurses Association (HPNA) along with other associations such as The American Academy of Hospice and Palliative Medicine (AAHPM), The Center to Advance Palliative Care (CAPC- a palliative advocacy and information organization), Last Acts Partnerships ( a consumer organization since merged with NHPCO), The National Hospice and Palliative Care Organization, The National Palliative Care Research Center (NPCRC) and The National Association of Social Workers (NASW) (NCP, 2013, p. 9). Palliative care aims to cover (a) people with chronic and life-threatening injuries due to accidents and trauma of other forms; (b) Neonates, children, adolescents, and adults suffering from congenital conditions and requiring life-long care with the support of others to carry out their daily routine; (c) Neonates, children, adolescents, and adults with retarded mental conditions with serious and life threatening illness; (d) Individuals regardless of age with life threatening conditions such as trauma, acute stroke and leukemia which are reversible but the conditions pose severe burdens and end up in poor quality of life; (e) Those with progressing chronic conditions such as vascular disease, malignancies, renal or liver failure, heart and lung diseases in advanced stage, frailty, neurodegenerative disorders and dementia of different forms; (f) Terminally ill patients such as with conditions of end-stage dementia, terminal cancer or sever debilitating stroke for whom intensive palliative care is the primary goal for the remaining part of their lives; (g) Serious or life threatening illness suffered by vulnerable and under-served and under-resourced populations. They include) homeless individuals, immigrants, low income people, oppressed racial and ethnic groups, veterans, prisoners, older adults, individuals with mental illness.” (p12) (NCP, 2013). Palliative nursing’s goal is to improve quality of life during the period of illness through relief from suffering that include care of the dying and follow-up in bereavement. The healing relationship is comes from the palliative or hospice nurse who provides warm, genuine and compassionate relationship with the suffering. The palliative nurse pays attention to physical, psychological, social, spiritual and existential aspects of the patient and family which results in a “whole person care”. Thus, palliative nursing is a combination of clinical competence and fidelity to the patient, listening and communication skills so as to be able to remain with the patient and family throughout their suffering and provide best possible comfort at a deeply personal level. The palliative nursing involves taking of genuine interest in the individual patient and giving hope even in the prospect of death. As such, advancements in heath care have changed the trajectory of the dying through improved nutrition and sanitation, preventive medicine, use of vaccinations, broad-spectrum antibiotics. Early detection and treatment have resulted in fewer deaths in infancy and childhood and fewer deaths from acute illness (Ferrel & Coyle, 2010, p. 3) Selected two conditions for palliative care are (1) Pain at the end of life, (2) Fatigue. Pain at the end of life: Pain at the end of life is the most common and most feared. But it is unfounded as most of the patients with terminal illness can receive relief. Nurses form critical part of palliative care team especially in respect of pain management. Nurse’s role starts with the assessment and continues during the formulation of care plan and implementation. The nurse educates and counsels the patient, family and other team members. They also play important role in the formulation of institutional policies and means to monitor outcomes that result in best pain management. In order to achieve pain control, all health care professionals must be aware of the frequency of pain at the end of life and the obstacles in management of the pain. Pain prevalence in the terminally ill varies because of diagnosis and other factors. About one third of patients with cancer treatment and two thirds of patients with advanced stages of malignancies experience pain. Elderly, minorities and women have the risk for under-treatment. Pharmacological management of pain in the advanced and end-stage disease requires knowledge of the medication related adverse effects, drug-drug and drug-disease interactions. This helps in the assurance of comfortable process of dying for the well-being of the patient and for those in attendance. Non-opioid analgesics are Acetaminophen, Aspirin, Ibuprofen, Naproxen, Choline magnesium and trislicate, Indomethacin, Ketorolac, Celecoxib. These are non-steroidal anti-inflammatory drugs (NSAIDs). These drugs affect analgesia by reducing biosynthesis of prostaglandins and preventing cascade of inflammatory events that cause, amplify or maintain nociception. These drugs reduce pain by influencing peripheral or central nervous system apart from their anti-inflammatory mechanism of action. Opioid analgesics are useful in that they decrease pain signal transmission and perception throughout the nervous system. Moderate to severe pain is the clinical indication for the administration of opioid analgesics (Paice, 2010, p. 161). Fatigue Chronically ill patients most often cannot communicate with their healthcare professionals for want of energy. They cannot communicate about their exhaustion and hence fatigue is a devastating and multidimensional symptom that involves the entire person affecting every aspect of their daily routine. Fatigue is the most common symptom associated with clinical course of cancer and other chronic diseases. Fatigue forms major part of the prolonged period before death. Fatigue management includes pharmacologic interventions and non-pharmacologic interventions. The former include antidepressants, psycho-stimulants, progestional steroids, tumor necrosis alpha and micronutrients. The latter include management of disrupted sleep pattern and deficient nutritional status (Anderson, Dean, & Piech, 2010, p. 187) Integrative care Palliative care involves management of the end-of-life stage of the patient. Rather than curative aspect of the care, the other aspects described above such pain management and management of other physical aspects that could mitigate the suffering, psychological support, support from social workers for both the patients and their families which are major part of palliative care have been made possible through integrated plan of care facilitated by the NCP guidelines. It is by coming together of various interested health care and social care groups, integrative care of chronically and terminally ill has become a reality. References Anderson, P. R., Dean, G. E., & Piech, M. A. (2010). Fatigue. In B. R. Ferrell, & N. Coyle, Oxford Textbook of Palliative Nursing. New York: Oxford Univesrity Press. Ferrel, B. R., & Coyle, N. (2010). Oxford Textbook of Palliative Nursing. New York: Oxford University Press. Mitra, S., & Vadivelu, N. (2013). In N. Vadivelu, A. D. Kaye, & J. M. Berger, Essentials of Palliative Care. New York: Springer. NCP. (2013). Clinical Practice Guidelines for Quality Palliative Care 2013 edition . Pittsburgh: National Consnesus Project for Quality Palliative Care . Paice, A. J. (2010). Pain at the end of life. In B. R. Ferrel, & N. Coyle, Oxford Textbook of Palliative Nursing. New York: Oxford University Press. Read More