This learning unit is developed to provide the trainees the necessary information regarding the following content coverage and topics: - Basic concept of palliative and hospice care, Physiological changes of the patient close to death, Palliative principles and approach and Pain management and quality of life

1. Palliative Care and Mortuary Services
By Mr. Gedion Zerihun
(BSc, MSc in Adult health nursing)
For Nursing –Level III
December ,2023
Mizan-Aman, Ethiopia
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2. Outline
Basic concept of palliative and hospice care.
 Physiological changes of the patient close to death
 Palliative principles and approach
Pain management and quality of life
 Lifestyle choices and plan of care
Multidisciplinary palliative care team
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3. Objective
At the end of this session you will be able to:-
Describe the basic concept of palliative and hospice care.
Identify physiological changes patient with dying
Assess client using palliative principles and approach
Describe pain management and quality of life
Explain formulate lifestyle choices and plan care
Identify multidisciplinary health care team when planning palliative
care
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4. Basic concept of palliative and hospice care
Palliative care is an approach that improves quality of life for patients
and their families facing the problems associated with life-limiting
illness.
Palliative care is specialized medical care for people with serious
illnesses.
The term "palliative care" may refer to any care that alleviates
symptoms, whether or not there is hope of a cure by other means.
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5. Basics…. Cont’
Palliative care treats people suffering from serious and chronic illnesses
such as cancer, cardiac disease such as congestive heart failure (CHF),
chronic obstructive pulmonary disease (COPD), kidney failure,
Alzheimer’s, Parkinson’s and many more.
This is accomplished through the prevention and relief of suffering by
means of early identification and comprehensive assessment and treatment
of pain and other physical, psychosocial, and spiritual problems.
It is appropriate at any age and at any stage in a serious illness and can be
provided along with curative treatment.
It focuses on providing patients with relief from the symptoms and stress of
a serious illness.
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6. Basics…. Cont’
The goal is to improve quality of life for both the patient and the
family.
The goal of palliative care is to reduce illness burden, relieve
suffering, and maintain quality of life from the time of diagnosis
onward.
Offers a support system to help patients live as actively as possible
until death;
Medications and treatments are said to have a palliative effect if they
relieve symptoms without having a curative effect on the underlying
disease or cause.
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7. Hospice care
Compassionate care for people facing life-limiting illnesses or
injuries.
Hospice focuses on caring, not curing and, in most cases; care is
provided in the patient's home.
It is a type of care involving palliation without curative intent.
Usually, it is used for people with no further options for curing their
disease.
Hospice care under the Medicare hospice benefit requires that two
physicians certify that a patient has less than six months to live if the
disease follows its usual course.
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8. Hospice care….. Cont’
Palliative care may segue into hospice care if the illness progresses.
Typically, hospice care is provided at home and a family member acts
as the primary caregiver, supervised by professional medical staff.
Hospice services and palliative care programs share similar goals of
providing symptom relief and pain management.
A distinction should be made between palliative care and hospice care.
The biggest difference between hospice and palliative care is the
patient.
Hospice is traditionally an option for people whose life expectancy is
six months or less, and involves palliative care (pain and symptom
relief) rather than ongoing curative measures, but palliative care is
involving the hospice care.
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9. Physiological changes of the patient close to death
Death is part of the cycle of life.
Death from any terminal illness is normally preceded by certain
physical changes.
When a terminally ill person nears the point of death a number of
physical changes take place.
Understanding this process helps to calm fears and assuages anxiety.
As a person approaches the very end of life, two types of changes
occur.
Physical changes: - that take place as the body begins to shut down its regular
functions.
 Emotional and spiritual level as well, in which the dying person lets go of
the body and the material world.
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10. Physical changes
You can expect the following physical changes to occur:
Cooling
Hands, arms, feet and legs begin to cool as the circulation of blood decreases.
Changes in circulation also cause the skin to become discolored in spots.
Sleepiness and loss of consciousness
As death nears, people usually become very drowsy, sleeping more and
becoming hard to wake.
They might also be less able to communicate.
Eventually, they may reach a point where they can no longer be awakened.
Confusion and delirium
A person near death may become disoriented or agitated.
This can occur as less blood flows to the brain or because of other physical
changes.
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11. Physical changes cont’..
Reduced intake of food and fluid
The person who is dying may want little or no food or drink, a change that
may begin days or weeks before the final hours of life.
No harm will come from this and there is no need to force the issue.
In fact, forcing a dying person to eat or drink can actually cause discomfort.
Loss of ability to swallow
Swallowing becomes more difficult as weakness increases.
As saliva and other secretions build up, you may hear a gurgling or rattling
sound with each breath the dying person takes.
Changing the person’s position may improve drainage and reduce the
disconcerting noises.
Loss of bowel and bladder control
As muscles weaken, the person who is dying may no longer be able to control
bowel and bladder functions.
The healthcare team can suggest ways to maintain cleanliness and comfort.
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12. Physical changes cont’..
Changes in breathing
Breathing patterns begin to change near death.
Eyes
When a person is dying, the eyes may remain open and seem to become glassy
and stare.
It may appear that the loved one sees something in the distance and may even
reach out towards this vision.
When the eyes are glassy and fixed, death normally occurs within hours.
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13. Emotional and Spiritual Changes
Withdrawal
A person who is very close to death may want few people around
or simply to be left alone much of the time.
Confusing Statements
Sometimes people close to death say things that seem to make no
sense, or indicate they are unaware of their true condition.
But these statements are often very much about the fact of dying,
although they may come in a sort of code.
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14. The death vigil
A vigil, from the Latin vigilia meaning wakefulness is a period of
purposeful sleeplessness, an occasion for devotional watching, or an
observance.
Vigils at the time of death
Vigils extend from eventual death to burial, ritualistically to pray for a
loved one, but more so their body is never left alone.
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15. 1.3. Palliative care principles and approach
Palliative care needs assessment is an individualized assessment of
palliative care based on the principles/ domains of palliative care.
It should a take place.
At a diagnosis of life limiting conditions
At episodes of significant progression or exacerbation of a disease
At a significant change in a person’s family or social support
At significant in functional status
When a person or a family make a request
At the end of life
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16. There are four domains of a palliative care needs
assessment
1. Domain 1: Physical wellbeing
2. Domain 2: Social and occupational wellbeing
3. Domain 3: Psychological wellbeing
4. Domain 4: Spiritual wellbeing
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17. Palliative Care Principles
Affirms life and regards death as a normal process
Neither hastens or postpones death
Provides care that is person-centered and focused on the whole person
Provides relief from pain and other distressing symptoms
Offers a support system to help individuals live as actively as possible until
death
Promotes quality of life and choice for the individual and family
Offers a support system to help families cope during the person’s illness
and during their own bereavement
Values and promotes interdisciplinary team-working
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18. Pain management and quality of life
Pain is unpleasant sensory and emotional experience associated with
actual or potential tissue damage.
It is a subjective complex bio psychosocial event.
Classification of Pain
Nociceptive
Neuropathic
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19. Nociceptive versus Neuropathic pain
A. Nociceptive
This type of pain is further classified in to two subtypes
Somatic- pain is a well localized, aching, gnawing, sharp, movement
Visceral-less localized, usually constant and may be referred
B. Neuropathic
Is a burning pain distributed along path of nerves roots?
This sub type of pain is associated with
Dysphasia (numbness and tingling)
Hyperalgesia (exaggerated response)
Allodynia (pain from stimuli which should not normally cause pain
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20. Pain evaluation and measurement
Pain Evaluation
Health professionals should ask about pain, and the patient’s self-
report should be the primary source of assessment.
Clinicians should assess pain with easily administered rating scales,
and should document the efficacy of pain relief at regular intervals
after starting or changing treatment.
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21. Systematic evaluation of pain involves the following steps
Evaluate its severity.
Take a detailed history of the pain, including an assessment of its
intensity and character.
Evaluate the psychological state of the patient, including an
assessment of mood and coping responses.
Perform a physical examination, emphasizing the neurological
examination.
Perform an appropriate diagnostic work-up to determine the cause
of the pain, which may include tumor markers.
Perform radiological studies, scans, etc.
Re-evaluate therapy.
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22. Pain evaluation and measurement cont’
The initial evaluation of pain should include a description of the pain
using the PQRST characteristics:
P-Palliative or provocative factors: ‘What makes it less intense?
Q-Quality: ‘What is it like?’
R-Radiation: ‘Does it spread anywhere else?’
S-Severity: ‘how severe is it?’
T-Temporal factors: ‘Is it there all the time, or does it come and
go?’
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23. Pharmacological and non pharmacology pain
management
Pharmacological Options of pain management
Non Opioid Analgesics
Adjuvant Drugs
Opioid Analgesics
Non Pharmacological options
Radiation therapy.
Relaxation therapy-Mindfulness.
Transcutaneous electrical nerve stimulation.
Acupuncture.
Interventional – Good immediate relief but long term relief usually
lacking
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24. 1.5. Lifestyle choices and plan of care
End-of-life plans
Circumstances and opinions may change, especially when death seems
imminent, so the palliative care team may arrange a conference with the
doctor and the family to make sure the goals of care are agreed on, and
to check that the person’s preferences remain current.
Consider the following seven strategies when meeting with the person,
their family and careers to discuss the process for making end-of-
life ethical decisions.
1. Ways to help a person and their family make end-of-life ethical
decisions
Suggest involving others suggest to the person that they involve family
members, careers or others close to them, so as to minimize the
decision-making burden.
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25. Lifestyle choices and plan of care cont’..
2. Encourage the person to make directives
Some individuals may not have an eligible substitute decision-
maker or person responsible, or may prefer that no-one makes
medical decisions on their behalf.
Encourage the person to consider making a more detailed directive
in these circumstances, if appropriate.
3. Choose care team members carefully
The care team member/s selected to conduct discussions about
end-of-life care with a person should be those who are identified as
significantly involved in the active care of the person.
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26. Lifestyle choices and plan of care cont’..
4. Be aware of opportunities for end-of-life discussions
Opportunities for you to begin end-of-life discussions may arise
when the person and/or their family or careers inquire about
palliative care; when a person says they want to forego
recommended life-sustaining treatment; or when they express a
wish to die.
5. Consider timing and environment
Advance care planning is most easily accomplished during stable health or
after a person has adjusted to a new illness.
Utilize a non-threatening environment such as the person’s room or a quiet
meeting room
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27. Lifestyle choices and plan of care cont’..
6. Ensure the person understands advance care planning
Find out how familiar the person is with advance care planning and explain the
goals.
For example, plan for the potential loss of their capacity to make decisions,
either temporarily or permanently, to ensure they are protected from either
unwanted treatment or under treatment.
7. Explain the details
The person usually needs information from you to understand the meaning of
the types of therapeutic and comfort scenarios that may arise in their situation,
and the benefits and burdens of various treatment options.
Key medical terms should be explained in plain English.
Allow time for reflection and discussion after this information has been
provided
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28. 1.6. Multidisciplinary palliative care team
Palliative care is provided by a team of healthcare professionals with a
range of skills to help you manage your life-limiting illness.
Your palliative care team works together to meet your physical,
psychological, social, spiritual and cultural needs and also helps your family
and careers.
Palliative care is a team approach to care.
The core team includes doctor, nurse and social work palliative care
specialists, massage therapists, pharmacists, nutritionists and others may
also be part of the team.
Nurses manage most of your ongoing care and treatment while you receive
palliative care in a hospital and they can also provide palliative care nursing
services to you at home.
They assess, plan and administer your daily treatment and manage your
symptoms.
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29. Summary questions
1. Discuss on difference between palliative and hospice care
2. Describe palliative care principles
3. Discus on pain management
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Thank you!!!!