Palliative care

Dr Riaz.K.M,
Assistant Professor,
Government College of Nursing,
Thrissur.

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.
2Palliative care .... Dr. Riaz.K.M1/18/2017

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 die
2. Dying is not a medical experience;
it’s a human experience
1. We all act like we are not (most of the time)
2. 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 12Palliative care .... Dr. Riaz.K.M1/18/2017

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

Palliative care- Beware
• More you do
more you decrease the quality
• Stealing from you
what you want to do
• Too much focused on disease
miss to focus human being
• Dealing with sickest of the sick

Palliate = to make less severe
In 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.
OR

In a nutshell
Palliative 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 Model
World 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
and
Family
Volunteers
Physicians
Spiritual
Counselors
Social Workers
Pharmacists
Home Health
Aides
Therapists
Nurses

Principles
1. Caring attitude
2. Consideration of individuality
3. Cultural considerations
4. Consent
5. Choice of site of care
6. Communication
7. Clinical context: Appropriate treatment
8. Comprehensive inter-professional care
9. Care excellence
10. Consistent medical care
11. Coordinated care
12. Continuity of care
13. Caregiver support
14. Continued reassessment 34Palliative care .... Dr. Riaz.K.M1/18/2017

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

Palliative Care Patient Support Services
2. Symptom management
–Nausea,
–Weakness,
–Bowel and bladder problems,
–Mental confusion,
–Fatigue, and
–Difficulty breathing

Palliative Care Patient Support
Services
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 Management
Delirium
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 Management
Anorexia/Cachexia
Causes
• 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 Management
Anorexia/Cachexia
Identify 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/Cachexia
Dietary 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 Management
Anorexia/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 Management
Anorexia/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 care
Improves everyday life of patient; reducing
the concern of loved ones
Allows for valuable
support system

Conclusion
Change your life
1. Get out of your comfort zone
2. Challenge your assumptions so that you can find
your truths
3. Speak the language of the person you seek to
become
4. Make the little decisions with your brain and big
one with your heart
5. 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. +919495837181
riazmarakkar@gmail.com

Palliative care

More Related Content

What's hot

Viewers also liked

Similar to Palliative care

More from Riaz Marakkar

Recently uploaded

Palliative care

Editor's Notes