This document discusses palliative care and end of life care. It defines palliative care as an interdisciplinary approach to relieve suffering and improve quality of life for patients with serious illnesses. The goals of palliative care are to control pain and other physical symptoms while providing psychological and spiritual support to patients and families. A multidisciplinary team approach is emphasized to address all aspects of care. Barriers to providing palliative care include fragmented care and ineffective communication, which can be overcome with education, focus on patient goals, and inclusion of families in the process. The document also reviews end of life care, including allowing natural death, advance care planning, and nursing interventions to keep patients comfortable as death approaches.

1. PALLIATIVE
AND END OF
LIFE CARE
CYNTHIA B NEALEGA, RN MN

2. PALLIATIVE CARE
 is an interdisciplinary approach to relieve suffering and
improve quality of life.
 Goal: (switch)
 1. nursing and medical care are geared towards
controlling pain and uncomfortable symptoms.
 - shortness of breath, fatigue
 - constipation, nausea, loss of appetite and difficulty
sleeping

3. Why palliative care?
To deliver high-quality, cost
effective care.
SOURCE: Data from the Center of Palliative Care (2010)
palliative-performance-scale-functional-assessment-1.pdf

4. BENEFITS OF PALLIATIVE CARE IN CCU
Decreased length of patient’s hospital stay
Decreased used of ineffective treatments
Increased family satisfaction and understanding
Decreased family anxiety and depression
Decreased conflict related to goal of care.
Decreased length of time transitioning from poor prognosis to comfort
focus
Increased symptom assessment
Increased patient comfort

5. SERIOUS DISEASE CONDITIONS
ASSOCIATED WITH PALLIATIVE CARE
Illnesses that cause pain and symptoms and interfering the
quality of life.
 Cancer (un operable; too weak for a chemo)
 Cardiac diseases (highly pronounced reduced activities)
 Chronic respiratory disorders ( highly fatigued; mainly in bed )
 Renal failure
 Neurological diseases ( declining steadily;

6. Domains of Palliative Care in the CCU
Symptom management and comfort care.
Communication among team members and with patients and families.
Patient and family centered decision making
Emotional and practical support for patients and families
Spiritual support for patients and families
Continuity of care
Emotional and organizational support for ICU clinicians
Data from Nelson( 2010)
Source: High Acuity Nursing, Kathleen Dorman Wagner and Melanie G Hardin-Pierce; 6th edition. Pearson Education Limited 2015

7. Barriers to Providing Palliative Care
1. The health team and disciplines work
independently with different goals.
2. Fragmented care
3. Ineffective and inconsistent communication

8. Overcoming the barriers
 1. Healthcare professionals must be educated and trained
in all aspects of care;
 Focus on:
 The limitations of critical care therapies
 Embracing treatment goals that are attainable.
 Benefits of palliative interventions
 2. The public in general must be included in the process.

10. MULTIDISCIPLINARY APPROACH
 Formulate a plan of care to address the
patient’s psychological, social, cultural and
spiritual needs.(multifaceted)
 Conferences with families and teams are
necessary and essential to:
 1. clarify goals
 2. support decision making
 3. communication is facilitated

11. CARE AND COMMUNICATION BUNDLE FOR PALLIATIVE CARE IN
CCU/ICU
Identify the patient’s heath care proxy.
Determine the presence of advanced directives.
Clarify the resuscitation status.
Assess pain on an ongoing basis using a validated tool.
Provide optimal pain management.
Offer social service support as necessary.
Offer spiritual support to the patient and family as deemed
necessary.
Conduct ongoing interdisciplinary team/family meetings.

12.  Body map

13. PALLIATIVE PERFORMANCE SCALE (PPSv2)
 https://www.mypcnow.org/wp-content/uploads/2019/02/FF-125-PPS.-3rd-
Ed.pdf
https://www.ottawahospital.on.ca/en/documents/2017
/01/palliative-performance-scale-functional-assessment-
1.pdf/

14. SBAR
 https://www.interiorhealth.ca/sites/Partners/palliative/Documents/855211_SBAR%20for%20C
ommunicating%20Palliative%20and%20End-of-Life%20Care%20Needs.pdf
 A tool to communicate focused concerns about an individual / family
with palliative symptom management concerns, transitional needs, or
distress that requires inter-professional attention. The standardized
Palliative SBAR can be used to present in Whole Community Palliative
Rounds (WCPR), Clinical Huddles, to communicate succinctly with
Physicians or Nurse Practitioners to obtain relevant orders for care, or
for warm and cold handovers of individuals with palliative needs who
are being transferred across the settings to ensure better continuity of
care. This Palliative SBAR is a worksheet. Inclusion in the chart is
optional

16. Assessment of source of conflict
 3 essential components of professional nursing practice
are:
 Care, cure, coordination
 A critical care nurse must have a thorough knowledge of
interrelatedness of body systems; recognition and
appreciation of a person’s wholeness, uniqueness and
significant social environmental relationships;
appreciation of the collaborative role of all health team
members. (AACN, 2002)

17.  While working in the high acuity areas, the nurse are faced
with ethical dilemmas.
 The exposure to death and saving life requires the nurse to
 -evaluate frequently personal values, which often influence
decision making.
 It is important that the nurse does not impose his/her personal
values.
 The health care team must honor end-of-life cultural and
religious preferences of the patient( Wingate and Weigand,
2008)
 If conflict arises between the nurses worldview and that of the
patient – must transfer care to other qualified high acuity
nurse. (ANA, 2003)

18. End of Life Care
 Right to Self-Determination.
 The patient has the right to avail himself/herself of any recommended diagnostic and
treatment procedures. Any person of legal age and of sound mind may make an advance
written directive for physicians to administer terminal care when he/she suffers from the
terminal phase of a terminal illness: Provided, That
1. He is informed of the medical consequences of his choice;
2. He releases those involved in his care from any obligation relative to the consequences
of his decision;
3. His decision will not prejudice public health and safety.
4. He/she is informed of the medical consequences of his/her decision;
5. He/she releases those involved in his/her care from any obligation relative to the
consequences of his decision;
6. His/her decision will not prejudice public health and safety.

19. End-of-life Care
 http://docshare01.docshare.tips/files/5652/56525886.pdf

20. Barriers to end of life care
 Nursing time constraints
 Staffing Patterns
 Communication Challenges
 Treatment decisions based on physician,
not patient needs

21. Suggestions for improving care for the
end of life
 Changing the environment to accommodate
families
 Improve management of pain and discomfort
 Knowledge for patient’s wishes for end-of-life
care ( advanced directives that are legally
binding)
 Early cessation of treatments or not initiating
aggressive traetments ( when continued medical
care seems futile)

22. INTERVENTIONS AT THE END OF LIFE CARE
TOPIC Intervention
Changes in Treatment
Plan
Ask questions about stopping or stopping/ withdrawal/ withholding life sustaining
therapies; review adjust meds is patient is to be discharged.
End-of-life discussion Keep communication open; include key health care team; build on previous discussions;
provide clear basic information about present condition and prognosis; establish goal of
care; regular family meetings.
Treatment decisions Involve patient in decision making if capable; use advance directives if available; assist
patients and families in shared decision making.
End-of-life-care Honor patient’s preferences for location of death; religious/cultural preferences; presence
of family members and pets; remove non essential monitors and equipment; turn off alarm
on remaining equipment; analgesics or sedatives or anxiolytics for pain, discomfort and
anxiety;O2, position of comfort, fans to circulate air for dyspnea; prepare family for
course of dying process, physical changes, provide families unlimited access to the
patient.
Bereavement Provide resources as available; pastoral care; follow up appointments with care providers,
follow up telephone calls
Consider participation in group discussion of family member who caredfor the patient.

23. Allow Natural Death
 DNR ( Do not resuscitate)
 DNI ( Do not intubate)
 CMO ( Comfort Measures Only)
 AND ( Allow Natural Death) – Patient is dying however,
everything possible is being done to keep patient
comfortable and allow the dying process to occur
naturally.
 Goal: to prevent unnecessary suffering and allow nature
to take its course.

24. Palliative care is a systematic approach
that leads to which results? ( SATA)
 1. Decreased bed availability.
 2. Increased bed availability
 3. Improved quality of care.
 4. decreased cost
 234

25. A palliative care plan should include
which components? (SATA)
 1. management of symptoms and side
effects.
 2. Funeral arrangements.
 3. Advanced Directives
 4. Patients and family preferences
regarding treatment goals.
 134

26. Which statement best described end-of-
life care?
 1. It has no place in the high acuity environment.
 2. It is taught extensively in undergraduate programs.
 3. It advocates respects for the patient’s wishes.
 4. It is not an issue in the media.

27. End-of-life nursing interventions would
include which intervention?
 1. Ensuring monitoring alarms are on.
 2. Removing non essential monitors and equipment.
 3. Avoiding analgesics and sedatives.
 4. excluding family members from decision making.

28. Source/ Reference
 High Acuity Nursing. Global Edition
Kathleen Dorman Wagner, Melanie G Hardin-Pierce, Pearson limited 2015