Palliative care

1. PALLIATIVE CARE
~Nirbhay trada 531a

3. What is palliative care?
Palliative care is an approach that improves the quality of
life of patients and their families facing the problems
associated with life-threatening illness, through the
prevention and relief of suffering by means of early
identification and impeccable assessment and treatment
of pain and other problems, physical, psychosocial and
spiritual.

4. Palliative care is a term derived from Latin palliare, "to cloak.“
• Palliative care is a multidisciplinary approach and specialized medical care for
people with serious illness.The goal of therapy is to improve the quality of the
life.
• It's focused on providing patients with relief from the symptoms, pain,
physical stress, and mental stress of a serious illness.A World Health
Organisation statement describes palliative care as "an approach that improves
the quality of life of patients and their families facing the problems associated
with life- threatening illness, through the prevention and relief of suffering by
means of early identification and impeccable assessment and treatment of pain
and other problems, physical, psychosocial and piritual,"

5. Scope of care: Includes patients of all ages with life-threatening illness,
conditions or injury requiring symptom relief from physical,
psychosocial and spiritual suffering.Timing of palliative care: Palliative
care should ideally begin at the time of diagnosis of a life threatening
condition and should continue through treatment until death and into
the family's bereavement.Patient and family centred care: The patient
and family constitute the unit of care which should be managed as a
whole.

6. Palliative care teams specialize in treating people suffering
from the symptoms and stress of serious illnesses such as
cancer, congestive heart failure (CHF), chronic obstructive
pulmonary disease (COPD), kidney disease, Alzheimer's,
Parkinson's, Amyotrophic Lateral Sclerosis (ALS) and other
chronic disorders

7. Key Components of Palliative Care
Recognising symptoms such as pain, nausea, fatigue, breathing or
swallowing difficulties, constipation, and hopelessness.
Identifying the patient's goals and development of a palliative care
plan, specially for the patient.. Understanding that many patients
and their families struggle to make decisions.Assisting with
advanced care directives to help people formulate and
communicate their preferences regarding care during future
incapacity.

8. PRINCIPLES OF PALLIATIVE CARE MANAGEMENT
⚫ Holistic care: Palliative care must endeavour to alleviate suffering in the
physical, psychological, social and spiritual domains of the patient in order to
provide the best quality of life for the patient and family.Multidisciplinary care: A
multidisciplinary team approach is essential to address all relevant areas of
patient care.Effective communication: Good communication skills (including
listening, providing information, facilitating decision making and coordinating
care) are essential tools in palliative care and healthcare providers must develop
this in order to provide fective palliative care.

9. PALLIATIVE CARE PLAN
Palliative care plan includes:
• Care goalsSymptom management
• Advance care planning
• Financial support
• Spiritual care
• Functional status support and rehabilitation Co morbid disease
management

10. Who Provides Palliative Care?
Usually provided by a team of individuals
Interdisciplinary group of professionalsTeam
includes experts in multiple fields:
Doctors
• Nursessocial workers Massage
Therapists
Pharmacists
• nutritionist

11. PALLIATIVE CARE PLAN
• Palliative care plan includes
-care goals
-symptom management
- advance care planning
- financial planningfamily support
-spiritual care-functional status support and rehabilitation-co
morbid disease management

12. COMPONENTS OF SERVICE
• In-patient palliative care service.Out-patient palliative care
service.
⚫ Consultative palliative care service in general wards.
• Consultative palliative care service in other hospitals without
⚫ palliative care units.Community palliative care service.Day
palliative care service.

13. Palliative Care:
Key ComponentsMultidimensional assessment-Sources of distress-
Unmet needsPhysical symptoms
⚫ Psychological issuesSocial concernsFamily difficulties+ Spiritual
distress
⚫ Treatment to improve sources of distress-Skills in pain and
symptom control-Ability to have conversations about tough
issuesKnow about referral resources and be willing to refer for
additional cialist paliative care

14. Why Palliative Care?
Aggressive measures for control of pain and other distressing
symptomsBetter quality and often longer life, with neither quality
or quantity achieved at the other's expense
• More goal centeredInterdisciplinary team of caregivers,
participating in holistic care of patient and family

15. Issues addressed in palliative care
• Palliative care can address a broad range of issues, integrating an
individual's specific needs into care. The physical and emotional
effects of cancer and its treatment may be very different from
person to person.
- Physical
-Emotional and coping
-Practical
- Spiritual

16. Palliative Care
• Pain (continued)Neuropathic painInitiated from the nerves
and nervous systemTingling, burning, or shooting
painsAnticonvulsants may be given as an adjuvant to assist
with pain control.RoutesOral, sublingual, subcutaneous,
parenteral, rectal, or topical

17. Constipation
This is one of the most common
problems of the terminally ill
patient.Factors that contribute to
constipation are poor dietary intake, poor
fluid intake, use of opioids for pain
control, and decrease in physical activityA
rectal exam may be necessary to check for
an impaction along with manual removal
of stool.Fleet enema helps soften and
dissolve a hand impaction

18. Nausea and Vomiting (continued)Nursing Interventions and
Patient TeachingEducate the patient and caregiver regarding the
cause orprevention of nausea and vomitingEncourage the patient
to take the antiemetics 30 minutes before meals and at bedtime.
Eating slowly and in a pleasant atmosphere is a good way to
control nausea.
Patients should not be forced to eat or drink if they have no
desire.

20. Anorexia and Malnutrition (continued)Nursing Interventions and
Patient TeachingNutritional assessments must be completed
routinely and applied to the hospice plan of care.Assess and treat
causes such as nausea and vomiting.If related to infection or
stomatitis, good oral hygiene is Important.If the odor of food
causes ancrexia, the patient should not be in the kitchen during
meal preparation.High-protein supplements are helpful.

21. Palliative Care ApproachNot a "one size fits all approach"Care is
tailored to help the specific needs of the patientSince palliative care
is utilized to help with various diseases, the care provided must fit
the symptoms.Delivered by the patient's usual professional carers
as a vital and integral part of their routine care delivery For patients
with low to moderate complexity of needFocuses on the key
principles of palliative care (NCHSPCS, 2002)

22. Barriers to Palliative Care:There are 3 main categories of
obstacles for patients to receive palliative care:Family members
creating obstacles
⚫ Health professionals creating obstacles
• Conflict between ideal care and patient's wishes

23. WHO Definition of Palliative Care"Palliative care is an approach
that improves the quality of life of patients and their families
facing the problems associated with life-threatening illness,
through the prevention and relief of suffering by means of early
identification and impeccable assessments and treatment of pain
and other problems, physical, psychosocial and spiritual (WHO
2002, p 83)"

24. History of Palliative CareIn 1967 Dame Cicely Saunders created
the first hospice program called St. Christopher's Hospice in the
United Kingdom.In 1974 Florence Wald and Chaplain Ed
Dobihal founded the first U.S. hospice program in
Connecticut.Hospice and Palliative care were considered the same
until the 1980's when hospital based palliative care programs were
developed at the Cleveland Clinic and Medical College of
Wisconsin.There are now over 1400 palliative care programs in
the U.S.Over 80% of hospitals with more than 300 beds report to
have a palliative care program.

25. History of Palliative CareIn 1967 Dame Cicely Saunders created the
first hospice program called St. Christopher's Hospice in the United
Kingdom.In 1974 Florence Wald and Chaplain Ed Dobihal founded
the first U.S. hospice program in Connecticut.Hospice and Palliative
care were considered the same until the 1980's when hospital based
palliative care programs were developed at the Cleveland Clinic and
Medical College of Wisconsin.There are now over 1400 palliative
care programs in the U.S.Over 80% of hospitals with more than 300
beds report to have a palliative care program.

26. Government and Palliative CarePatient Protection and Affordable
Care ActSigned by President Obama in March of 2010.⚫ Act
seeks to expand the palliative care system in the U.S.Health Care
Financing AdministrationRegulates amount of reimbursement
from Medicare and Medicaid to palliative care programsJoint
Commission StandardsSet of standards that each hospital with a
palliative care program must abide by in order to maintain their
certification

27. Euthanasia Euthanasia comes from the Greek words:
Eu (good) and Thanatosis (death) and it means "Good Death,
"Gentle and Easy Death" This word has come to be used for "mercy
killingIt is the act or practice of ending a life of a person either by a
lethal injection or suspension of medical treatment.

28. Active euthanasia:-It is when death is brought by an act for example
taking a high dose of drugs-To end a person's life by the use of
drugs, either by oneself or by the aid of a physician.• Passive
euthanasia:-When death is brought by an omission eg: When
someone lets the person die, this can be done by withdrawing or
withholding treatment.. Withdrawing treatment: For example
switching off a machine that keeps the person alive.Withholding
treatment: For example not arrying out a surgery that will extend ife
of the patient for a short time.

29. Voluntary Euthanasia -
When a competent person
makes a voluntary and
enduring request to be
helped to die.Involuntary
Euthanasia- To end a
person's life without their
knowledge or consent

30. Voluntary Euthanasia: The ending of a person's life that entails their
full consent, and enlists the help of another (usually a doctor). Legal in
Belgium, Holland and some states such as Oregon.Non-Voluntary
Euthanasia: A form of Euthanasia where the consent of the patient or
victim is unavailable. An example of this would be child euthanasia
which is legal only in Holland and has many restrictions on it.
⚫ Involuntary Euthanasia: A form of Euthanasia carried out directly
against the patient's wishes. Illegal internationally.

31. ⚫ Passive Euthanasia: The withholding of treatments
necessary to the person's survival in order to end their life.
This may include antibiotics or feeding tubes, as well as
extraordinary treatments such as surgery. The church strays
away from this terminology when defining its position.
⚫ Active Euthanasia: The use of lethal forces or
substances to end a patient's life.

32. Voluntary euthanasia is committed with the willing or
autonomous cooperation of the subject. This means that the
subject is free from direct or indirect pressure from others.Non
voluntary euthanasia occurs when the patient is unconscious or
unable to make a meaningful choice between living and dying,
and an appropriate person takes that decision for him/her.
• This is usually called murder, but it is possible to imagine cases
where the killing would count as a favor the patient.

33. EuthanasiaThe act of inducing painless death
• The decision
• SufferingThe perception may vary from client to
client•Providing information about the pet's condition
• This allows the client to make a well-informed decision
• Technicians can aid in providing information about the
euthanasia processDon't make the decision for the client
• Convenience?

34. Religion
Most religions disapprove of euthanasia.Some of them absolutely
forbid it."You must not kill"

35. Some Eastern religions takeTen Commandmentsa
different approach.
☐Their attitudes to death areachieving freedom
frommortal life, and not-harmingliving beings.

36. Options for Euthanasia
• Pain Killer or Medication Overdose
• Also known as active euthanasiaPhysician's are not
actively "killing", but aware of inaction on their behalf
will ultimately be the death of the patient.Lethal
Injection
• Withdrawal of Treatment/Withholding TreatPassive
Euthanasia

37. Title- Medication Given for Euthanasia (options for Euthanasia)
• Nembutal (Pentobarbital)o A barbiturate, administered in rapid
overdoseo Causes rapid unconsciousness, followed by respiratory distress,
paralysis of the diaphragm, and finally collapsing of lungs.
⚫ Seconal (Secobarbital)o Originally used in patients to treat long standing
insomnia
• These patients are already taking barbiturates of some kind.o An
extremely strong sedativeLethal Injection (3 drugs are used)o Sodium
Thiopental-induces unconsciousnesso Pavulon (pancuronium bromide)-
causes muscle paralysis and respiratory distresso Potassium Chloride- to
stop the heart.

38. Other Options
⚫ Pain Management
• Palliative SedationWithdrawing life-sustaining treatments dialysis,
where a machine takes over thefunctions of your kidneys
ventilators, where a machine takes over your breathing

39. Other OptionsDNRADVANCE DIRECTIVERefusing Treatment
Advance DirectiveDNR2.LIVING WILL
• allows you to document your wishes concerning medical
treatments at the end of life
.⚫ DNR Order (Do Not Resuscitate)
• Not to do cardiopulmonary resuscitation (CPR

40. Make a choice
⚫ YesFrees up hospital bedsa Relieves sufferingGives the right to
choosea Reduces the spread of diseasesRemoves the economic burn
from relativesa Relatives spared the agony of watching their loved
ones.deteriorate beyond recognition
•NoVoluntary Euthanasia givesdoctors too much powerVoluntary
Euthanasia canbring non-voluntary #Society having a distortedview
of the seriously ill, disabled or elderMedical advances /curesmay
come before deathDead people cannot changetheir minds

41. Justifying choiceCAMPAIGN FOR DIGNITY IN DYING.
• Euthanasia also known as mercy killing is a way of painlessly
terminating one's life with the "humane" motive of ending his
suffering.Legalizing euthanasia
• would help alleviate suffering of terminally ill patientswould be
inhuman and unfair to make them endure the unbearable painIn case
of individuals suffering from incurable diseases or in conditions
where effective treatment wouldn't affect their quality of life; they
should be given the liberty to choose induced death

42. Prevention in Unnecessary DeathsA patient must be
given 6 months or less to liveMedical and Technological
advancesAdvances in palliative medications have been
able to relieve pain

43. PreventionTime ConstraintTerminally Ill patients lose
motivation
• Takes time for medical advances
⚫ Is 6 months long enough

44. PreventionExamples of Medical AdvancesHere are some
examples of Medical Advancesover the last decade:Smoke Free
LawsTargeted Cancer Therapies

45. Can a Child Choose the Right to Die?
If a child is suffering and in pain, do the same
concepts apply?Should parents be able to make the
decision for the child?
⚫ This all depends on the age that the child fully
grasps the concept of death

46. How can this be Prevented?
Better training in long-termpain managementDeveloping
treatments withless debilitating side effects

47. What to Do?
CARE NOT KILLING
Help them feel useful
Give loveEncourage them to live
• Educate yourself to make the
right decision