end of life

1. End of life care
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2. Session Objectives
• At the end of this session, learners will be able
to:
– Describe what end of life care is?
– Relate end of life care with technological
advancement?
– Discuss palliate care explicitly?
– Provide palliative care for the patient with cancer?
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3. Nursing and end of life care
• One of the most difficult realities that nurses face is
that, despite our very best efforts, some patients will
die.
• Although we cannot change this fact, we can have a
significant and lasting effect on the way in which
patients live until they die, the manner in which the
death occurs, and the enduring memories of that
death for the families.
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4. Comprehensive and humane approach to
care of the dying
• Respecting patients’ goals, preferences, and choices
• Attending to the medical, emotional, social, and
spiritual needs of the dying person
• Using strengths of interdisciplinary resources
• Acknowledging and addressing caregiver concerns
• Building mechanisms and systems of support
The Palliative Care Task Force of the Last Acts Campaign
(Last Acts, 1997)
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5. Technology and End-of-life Care
• In the last century, chronic, degenerative diseases
replaced communicable diseases as the major causes of
death.
• Although technological advances in health care have
extended and improved the quality of life for many, the
ability of technologies to prolong life beyond the point
that some would consider meaningful has raised troubling
ethical issues.
• In particular, the use of technology to sustain life has
raised perplexing issues with regard to quality of life,
prolongation of dying, adequacy of pain relief and
symptom management, and allocation of scarce
resources. 5

6. Technology and End-of-life Care
• The major ethical question that has emerged
concerning the use of technology to extend life is:
• Because we can prolong life through a particular
intervention, does it necessarily follow that we must
do so?
• Decisions to apply every available technology to
extend life have contributed to the shift in the place
of death from the home to the hospital or extended
care facility.
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7. Clinicians’ Attitudes Toward Death
• In an early study of care of the dying in hospital
settings, sociologists Glaser and Strauss (1965)
discovered that health care professionals in hospital
settings avoided direct communication about dying
in hope that the patient would discover it on his or
her own.
• They identified four “awareness contexts,” described
as the patient’s, physician’s, family’s, and other
health care professionals’ awareness of the patient’s
status and their recognition of each other’s
awareness:
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8. Clinicians’ Attitudes Toward Death
• Closed awareness: The patient is unaware of his or
her terminal state while others are aware.
• Closed awareness may be characterized by families
and health care professionals conspiring to guard the
“secret,” fearing that the patient would not be able
to cope with full disclosure about his or her status,
and the patient’s acceptance of others’ accounts of
his or her “future biography” as long as they give him
or her no reason to be suspicious.
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9. Clinicians’ Attitudes Toward Death
• Suspected awareness: The patient suspects what
others know and attempts to find out. Suspected
awareness may be triggered by inconsistencies in
families’ and clinicians’ communication and behavior,
discrepancies between clinicians’ accounts of the
seriousness of the patient’s illness, or a decline in the
patient’s condition or other environmental cues.
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10. Clinicians’ Attitudes Toward Death
• Mutual pretense awareness: The patient, the family,
and the health care professionals are aware that the
patient is dying but all pretend otherwise.
• Open awareness: All are aware that the patient is
dying and are able to openly acknowledge that
reality.
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11. Palliative care
• Palliative care is an approach to care for the
seriously ill that has long been a part of cancer care.
• Both palliative care and hospice have been
recognized as important bridges between the
compulsion for cure-oriented care and physician-
assisted suicide (Saunders & Kastenbaum, 1997).
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12. Palliative care
• While hospice care is considered by many to be the
“gold standard” for palliative care, the term hospice
is generally associated with palliative care that is
delivered at home or in special facilities to patients
who are approaching the end of life.
• Palliative care is conceptually broader than hospice
care, defined as the active, total care of patients
whose disease is not responsive to treatment (WHO,
1990).
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13. Palliative care
• Palliative care emphasizes management of
psychological, social, and spiritual problems in
addition to control of pain and other physical
symptoms.
• As the definition suggests, palliative care is not care
that begins when cure-focused treatment ends.
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14. Palliative care
• The goal of palliative care is to improve the patient’s
and family’s quality of life, and many aspects of this
type of comprehensive, comfort-focused approach to
care are applicable earlier in the process of life-
threatening disease in conjunction with cure focused
treatment.
• However, definitions of palliative care, the services
that are part of it, and the clinicians who provide it
are evolving steadily.
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15. Palliative care for the patient with cancer
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16. Brainstorming, Revision????
• Definition of cancer?
• Causes / risk factors of cancer?
• Phases of cancer development?
• Cancer staging and grading?
• Clinical manifestation?
• Diagnostic methods?
• Treatment modalities?
• Prevention methods?
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17. Introduction
• Cancer is largely avoidable and many of them can be
prevented.
• Others can be detected early in their development,
treated and cured.
• Even with late stage cancer, the pain can be reduced,
the progression of the cancer slowed, and patients
and their families helped.
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18. Introduction
• Cancer is a leading cause of death globally.
• WHO estimates that 7.6 million people died of
cancer in 2005 and 84 million people will die in the
next 10 years if action is not taken.
• More than 70% of all cancer deaths occur in low- and
middle-income countries, where resources available
for prevention, diagnosis and treatment of cancer
are limited or nonexistent.
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19. Introduction
• There is limited cancer registry in Ethiopia.
• Extrapolation from clinical records from Tikur
Anbessa Radiotherapy Center estimates that there
are 120,500 new cancer cases/year, although
Globocan estimates are much lower (51,000 per
year).
• Most patients present with advanced disease, and
there is a high rate of abandonment of treatment.
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20. Top priority cancers in Ethiopia
• Cancer of cervix
• Cancer of breast
• Head and neck cancer
• Leukemia and lymphoma
• Colorectal cancer
• Skin cancer
• Bladder cancer
• Esophageal cancer
• Lung cancer
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21. Goal of cancer palliative care
• To prevent or treat, as early as possible, the symptoms
and side effects of the disease and its treatment, in
addition to the related psychological, social, and
spiritual problems.
• The goal is not to cure. Palliative care is also called
comfort care, supportive care, and symptom
management.
• Palliative care is given throughout a patient’s
experience with cancer.
• It should begin at diagnosis and continue through
treatment, follow-up care, and the end of life.
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22. General approach to cancer palliative care
• Prevention of cancer, especially when integrated
with the prevention of chronic disease and other
related problems, offers the greatest public health
potential and the most cost-effective long-term
method of cancer control.
• Early detection detects (or diagnose) the disease at
early stage, when it has a high potential for cure (for
instance, cervical or breast cancer, ...).
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23. General approach to cancer palliative care
• Treatment aims to cure the disease, prolong life, and
improve the quality of life.
• Palliative care: meets the needs of all patients requiring
relief from symptom and the needs of patients and their
families for psychosocial and supportive care.
– Because of the emotional, spiritual, social, and economic
consequences of cancer and its management, palliative care
services addressing the needs of patients and their families,
from the time of diagnosis, can improve quality of life and the
ability to cope effectively.
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24. Scope of palliative care in cancer
• Physical: Common physical symptoms include
pain, fatigue, loss of appetite, nausea, vomiting,
shortness of breath, and insomnia.
• Many of these can be relieved with medicines or
by using other methods, such as nutrition
therapy, physical therapy, or deep breathing
techniques.
• Also, chemotherapy, radiation therapy, or surgery
may be used to shrink tumors that are causing
pain and other problems.
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25. Scope of palliative care in cancer
• Emotional and coping: Palliative care specialists can
provide resources to help patients and families deal
with the emotions that come with a cancer diagnosis
and cancer treatment.
• Depression, anxiety, and fear are only a few of the
concerns that can be addressed through palliative
care.
• Experts may provide counseling, recommend support
groups, hold family meetings, or make referrals to
mental health professionals.
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26. Scope of palliative care in cancer
• Practical: Cancer patients may have financial and
legal worries, insurance questions, employment
concerns, and concerns about completing advance
directives.
• For many patients and families, the technical
language and specific details of laws and forms are
hard to understand.
• To ease the burden, the palliative care team may
assist in coordinating the appropriate services.
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27. Scope of palliative care in cancer
• Spiritual: With a cancer diagnosis, patients and
families often look more deeply for meaning in their
lives.
• Some find the disease brings them more faith,
whereas others question their faith as they struggle
to understand why cancer happened to them.
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28. Causes of pain among Cancer Patients
• Spinal cord compression: When a tumor spreads to the
spine, it can press on the spinal cord which is called
spinal cord compression.
• The first sign of the compression is usually back and/or
neck pain, sometimes with pain or weakness in an arm
or leg.
• Coughing, sneezing, or other movements often make it
worse.
• This compression must be treated quickly to prevent
patient from losing control of bladder or bowel or being
paralyzed.
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29. Causes of pain among Cancer Patients
• Bone pain: This type of pain can happen when
cancer spreads to the bones.
• Treatment may be aimed at controlling the cancer, or
it can focus on the affected bones.
• External radiation may be aimed at the weakened
bone.
• Pain from procedures and surgery
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30. Causes of pain among Cancer Patients
• Procedures and testing: Some tests used to diagnose
cancer and to see how well the treatment is working
are painful.
• Surgical pain: Surgery is often used to treat cancers
that grow as solid tumors, but other treatments such
as radiation or chemotherapy may also be given.
• Depending on the kind of surgery, some amount of
pain is usually expected.
• Pain due to surgery can last from a few days to a few
weeks, depending on how extensive the surgery was.
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31. Causes of pain among Cancer Patients
• Phantom pain: This is a longer-lasting effect of surgery,
beyond the usual surgical pain.
• If the patient had an arm, leg, or even a breast removed,
he/she may still feel pain or other unusual or unpleasant
feelings that seem to be coming from the absent
(phantom) body part.
• HCP are not sure why this happens, but phantom pain is
real; it is not "all in your head."
• No single pain relief method controls phantom
pain in all patients all the time.
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32. Causes of pain among Cancer Patients
• Pain from other cancer treatments
• Some of the side effects that occur with chemotherapy
and radiation treatments may cause pain for some
people.
• Peripheral neuropathy (PN): This condition refers to
pain, burning, tingling, numbness, weakness,
clumsiness, trouble walking, or unusual sensations in
the hands and arms or legs and feet.
• It can be caused by certain types of chemotherapy,
though vitamin deficiencies, the cancer, and other
problems can also cause it.
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33. Causes of pain among Cancer Patients
• Mouth sores (stomatitis or mucositis): Chemotherapy can
cause sores and pain in the mouth and throat.
• The pain can be bad enough that people have trouble
eating and drinking.
• Radiation mucositis and other radiation injuries: Pain
from external beam radiation depends on the part of the
body that is treated.
• It can cause skin burns, mucositis (mouth sores), and
scarring -- all of which can result in pain.
• The throat, intestine, and bladder are also prone to
radiation injury, and you may have pain if these areas are
treated.
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34. Factors influencing perception of Pains
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35. Pain Assessment
O onset
When did it begin? How long does it last? How often does it occur?
PProvoking / Palliating
What brings it on? What makes it better? What makes it worse?
Q quality
What does it feel like? Can you describe it?
R Region /Radiation
Where is it? Does it spread anywhere?
SSeverity
What is the intensity of this symptom (On a scale of 0 to 10 with 0 being
none and 10 being worst possible)? Right now? At best? At worst? On
average? How bothered are you by this symptom? Are there any other
symptom(s) that accompany this symptom?
TTreatment
What medications and treatments are you currently using? How effective
are these? Do you have any side effects from the medications and
treatments? What medications and treatments have you used in the past?
U Understanding or
Impact on you
What do you believe is causing this symptom?
How is this symptom affecting you and / or your family?
VValues
What is your goal for this symptom? What is your comfort goal or
acceptable level for this symptom (On a scale of 0 to 10 with 0 being none
and 10 being worst possible)? Are there any other views or feelings about
this symptom that are important to you or your family? 35

36. Pain Assessment
• Changes in behavior - indicators would be if the
resident has become more confused, refusing to eat,
or any alteration in their usual behavioral pattern
• Vocalizations: indicators include signs of
whimpering, groaning, crying
• Facial expressions: indicators include the resident
looking tense or frightened, frowning, or grimacing
• Observations of caregivers/relatives - asking careers
/ relatives, someone who knows the resident well to
identify changes is helpful
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37. Pain Assessment
• Changes in physiological responses - increase in
pulse rate or, increase or decrease in blood pressure
• Response to a trial dose of analgesia - monitoring
the response to analgesia.
• Several case studies in aged care facilities have
reported successfully managing severe vocalization
or behavior issues (resulting from pain) with small
doses of opioids.
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38. Pain management guidelines (DACA, 2004)
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39. WHO pain management ladder
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40. Non-pharmacological methods of pain relief
• Massage: can reduce muscle tension, relieve
headaches and for the anxious resident, gentle touch,
by providing a hand or foot massage, can provide
reassurance and decrease anxiety.
• Heat & cold applications: can reduce muscle spasm
• Distraction: listening to music or using imagery
techniques can be helpful during brief episodes of pain
or painful procedures.
• Dementia residents have used music therapy
successfully to reduce disruptive behavior or
aggression.
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41. Non-pharmacological methods of pain relief
• Transcutaneous electrical nerve stimulation (TENs) -
these small devices have demonstrated some
improvement in chronic pain such as sciatica.
• However, a TENs machine and morphine should not
be used in conjunction as there is thought be a
degree of competition for the same pain pathways.
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42. Non-pharmacological methods of pain relief
• Complementary and alternative therapies (CAM) -
there are an increasing use of CAMs in the elderly.
• Some examples include the use of ginkgo for the
treatment of dementia, magnet therapy for arthritis
or St John’s wort for depression.
• While the use of CAMs is not condoned, it is
important to ask seniors if they are using any CAMs
as some can interact with other traditional
medications.
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43. Non-pharmacological methods of pain relief
• Aromatherapy - The use of lemon balm has
demonstrated a reduction in behavioral aggression of
dementia residents.
• Lavender and chamomile essential oils provide a
therapeutic effect inducing a calming and soothing
reaction.
• Peppermint and ginger have been effective in relieving
nausea.
• However, care should be taken when initiating the use
of essential oils as residents may react differently from
the expected outcome.
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44. Integrating natural and conventional
therapies for cancer management
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45. Integrating natural and conventional therapies for
cancer management
• Ten facts to know:
• Mitochondria (energy factory, power house)
– Cancer cells use sugar than healthy cells and less
oxygen
– This way of energy generation weakens the body
– The patient becomes weak and tired
• Free radicals (reactive chemical particles)
– Produced due to environmental toxins, stress,
processed food and pollutions are direct causes for
mutation and cancer.
– Blending optimum amount of antioxidant in cancer
therapy is a cornerstone
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46. Integrating natural and conventional therapies for
cancer management
• Matrix (cancer cells are commonly harmless)
– But, this benign nature starts to secrete toxins to
the nearby cells and damages protective parts.
– Hence, reinforcing this matrix is very important.
• Temperature sensitive
– Cancer cells less tolerate high temperatures
– Hyperthermia (increasing body temperature) can
kill cancer cells.
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47. Integrating natural and conventional therapies for
cancer management
• Angiogenesis (formation of new blood vessels)
– masses of cancer cells become like parasites
developing their own network ...taking vital nutrients
from the cells. Stop this by non toxic compounds!
• Toxins
– Many cancers result because of heavy accumulation
of toxins and compromised toxin clearance.
– Detoxification is a key factor! (liver, kidney, skin,
lung...)
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48. Integrating natural and conventional therapies for
cancer management
• Internal terrain
– Our body is an internal closed ecosystem
– Properly balance the equilibrium (acid-base)
– Preventing build up of bacteria, fungus, proteins
• Immunity
– It is our first line defense against any assault
– Better immune system...better chances of
surviving from cancer
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49. Integrating natural and conventional therapies for
cancer management
• Hormones
– Most cancers have hormonal components /
imbalances ...like breast, prostate,.../
– Naturally modulate and correct the imbalances
• Inflammation
– Infection, poor dietary habit/high sugar, and trans
fat are potential carcinogens that can cause
inflammation.
– Minimize risks of inflammation.
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50. Natural medicine – Your choice
• Step 1 - face the reality
– You are not alone! Do you want to beat it?
• Step 2 – do your home work
– Gather much knowledge, options and data
• Step 3 – make the decision
– Interventions
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51. Seven things to do to beat cancer naturally
• Starving cancer cells
– Cut down sugar intake (by 90% like soda products,
factory results...)
– Rely on low glycemic diets
• Oxygenate the body
– Cancer cells hate oxygen
– Simple to moderate regular exercise is vital
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52. Seven things to do to beat cancer naturally
• Avoid malnutrition (40% of pts dies b/c of it)
– Stay with organic whole diets, plenty of green
leafy vegetables, low glycemic fruits, beans and
legumes
• Use nutritional supplements (blend 30-50%)
– Prevent mutation with therapeutic doses
– Enhance mitochondrion function
– Prevent cancer growth
– Enhance immune function
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53. Seven things to do to beat cancer naturally
• Balance internal terrain
– Probiotics, enzymes, green food, and fibers are four
key pillars rebuild internal terrains
– Use them daily
• Balance toxin load
– Use pure filtered water
– Enhance liver function
– Use chelating agents to bind to wastes and remove it
from the body
– Drink fresh vegetable juices
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54. Seven things to do to beat cancer naturally
• Balance the hormones
– Vital in preventing breast, ovary, uterus, and
prostate cancer
• NB: Consider the natural remedies together
with modern medicine! Refer more!!
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