What Principles Does Palliative Care Advocate Nursing Essay

What Principles Does Palliative Care Advocate Nursing Essay

Ms. Mary Camilleri, a 65 year old lady, is eligible for palliative care due to her locally advanced pancreatic cancer, which has metastasised to the liver. Palliative care is provided to improve the quality of life of the patient and her family, who are facing a life-threatening illness, and will be provided throughout Ms. Camilleri’s experience with the cancer. The care begins at diagnosis and continues till the end of life of the individual. Palliative care involves prevention and relief of pain and suffering by means of early assessment, identification, and treatment of pain and any other physical, spiritual, and psychological problems. The goal of this care is not to cure, but to support the patient and her family, her husband and three sons, in a holistic aspect through these difficult times, and ease Ms. Camilleri’s transition to end-of-life care (“Palliative Care in Cancer”, 2010).

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In palliative care, a multi-professional approach should be taken, including Ms. Mary Camilleri and her family throughout the whole process of care. Together, an effective care plan is made which includes provision of pain relief and alleviation from any other disturbing symptoms. The multi-disciplinary team will help the patient and her family accept her poor prognosis, regard dying as a normal process, and assure them that palliative care will not hasten nor postpone death. In palliative care, the family is also taken care of, and support systems are offered to help Ms. Camilleri and her family cope during her end-of-life care (“Palliative Care”, 2004). Nurses in particular, are of a huge importance in the interdisciplinary team, since they are continuously in close contact with the patient. Thus, the nurses are the ones which will coordinate the contributions of other health care professionals and services needed (Taylor-East, 2001). They are also responsible for educating the patient and her relatives about the illness, and help with treatment decision making and end-of-life closure. The only way for all of this to succeed effectively, the nurses have to try to understand and appreciate the illness from the patient’s perspective (Smeltzer, Bare, Hinkle, & Cheever, 2010).

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Nyatanga (2012), states that “Effective communication is central to showing empathy at the end of someone’s life, yet it is also perhaps the most difficult skill to get right” (p. 369). Sometimes, even simply through the presence of the health care providers, the patient can feel that she is not alone. That way, Ms.Camilleri feels more confident and able to trust the multi-professional team, and when problems or worries arise, she will feel more at ease to express herself with the team. The information gathered can be then used in further helping and supporting Ms.Camilleri and her family, and help her achieve a dignified death. Here in Malta, there is a range of facilities which are available for palliative care patients, including; home care, night nursing in the home, day therapy, loan of certain specialised equipment, hairdressing, assisted bathing, bereavement support, and family or group support (Taylor-East, 2001).

The benefit of palliative care for patients with cancer is significant. Symptoms like; shortness of breath, pain, vomiting, constipation, and nausea, may be related to cancer and each of them has a negative effect on the quality of life of the patient. The palliative care teams are trained specifically to deal with these problems and any other distressing symptoms. Certain treatments which are used to treat cancer can be also considered palliative. Doctors can recommend radiation and/or chemotherapy not for cancer cure, but for increase in comfort and decrease in disease symptoms of the patient (Morrow, 2010).

How would you assess and manage her current uncontrolled symptoms?

Brescia (2004), states that “Pancreatic cancer is a formidable health problem, representing the 10th most common malignancy in the United States and the 4th most common cause of all cancer deaths” (p. 39). There is an overall 4% five-year survival rate for all stages and races despite of all the advances in technology and understanding of the biology and pathology of the disease (Brescia, 2004). To provide the best end-of-life care, the interdisciplinary team should provide control of pain and other symptoms, and also take care of other social, psychological, and spiritual problems (“British National Formulary”, 2011). For this to occur, the team has to do a full assessment of the symptoms and needs of Ms. Camilleri by looking at the history of the patient, carry out a thorough examination, and where appropriate, they should also include investigations. Consideration and discussion of the underlying causes should be done, which involve; any medications currently taking, observing how the causes relate, and to what extent is the patient affected by them. The influence of the spiritual and psychological issues upon Ms. Camilleri and her problems has to be also considered (Downes, Eccles, Lieth, Hulme, & Wiseman, 2011).

A care plan is developed for each problem which is specifically tailored for Ms. Camilleri, including; symptomatic treatment, treatment of the underlying cause, and non-drug measures. This management plan has to be discussed with the patient and should be accepted only if the multidisciplinary team believes that the management reflects Ms. Camilleri’s priorities and needs. The drugs given to the patient should be prescribed accurately, and any unnecessary medication should be discontinued. Compliance to drug regimens by the ward staff and patient is highly important. The patient is reviewed regularly and symptoms are reassessed so that the multidisciplinary team, including the palliative care team, can modify the care plan according to the current state of the patient (Downes et al., 2011).

Over the last two days, Ms. Camilleri has been complaining of increasing abdominal pain and nausea. Cancer pain can be a result of direct invasion of the tumour into bones, nerves, soft tissue, fascia, and ligaments; and through obstruction and distension, the tumour can also cause visceral pain (Christo & Mazloomdoost, 2008). Brescia (2004), states that:

Pain syndromes with pancreatic cancer can occur due to the proximity of the organ to a number of other critical structures: the duodenum, liver, stomach, jejunum, and transverse colon. The pancreas itself is innervated by nerve networks that interact with both the parasympathetic and sympathetic systems. (p. 43)

Despite the implementation of the WHO guidelines and decades of work to reduce unnecessary discomfort, there are still reports of under-treatment of cancer pain (Christo & Mazloomdoost, 2008). In a study of 1,107 patients who were admitted to a palliative care setting, roughly 44% of those patients with pancreatic cancer stated that they had severe pain (Brescia, Portenoy, Ryan, Krasnoff, & Gray, 1992). In another study, the results showed that half of the public survey participants believed that the physicians cannot make a difference in pain relief, and this fear caused 20% of the participants to claim that they would avoid cancer treatment (Levin, Cleeland, & Dar, 1985).

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The main problem of inadequate pain relief is the complexity of the human condition and the continuously changing interface between the internal and the external. This complexity causes pain to be experienced in countless different forms and modalities. This continuously-changing dynamic interaction between the external stimuli and the person’s ability to deal with those stimuli may greatly increase the complexity of pain relief. A single experience can cause terrible pain to one individual while, to another it could be nothing. Furthermore, if an individual is presented with the identical painful stimulus at different periods in his life, each stimulus may affect the individual in a completely different way (Watson, Lucas, Hoy, & Back, 2005).

For the multidisciplinary team to be successful in assessing and managing pain and other symptoms, the nurse, the health professional most in contact with the patient, should have a good nurse-to-patient relationship (Smeltzer et al., 2010). When it comes to assessing the patient, the nurse should accurately diagnose the cause of the pain and also the character, frequency, the location of the pain, and any aggravating and relieving factors (Downes et al., 2011). Smeltzer et al. (2010) says that the nurse should do “careful patient observation, noting overall posture and presence or absence of overt pain behaviors. In addition, it is essential to ask the patient to describe, in his or her own words, the specifics of the pain” (p. 237). The nurse should also ask Ms. Camilleri the severity of the abdominal pain by making use of a numerical score that ranges from 0 to 10; zero meaning no pain and ten meaning overwhelming or severe; or a simple verbal rating scale which makes use of words like “none”, “mild”, “moderate”, or “severe”, to describe the level of pain (Downes et al., 2011).

The information obtained is discussed with all the concerned professional members and Ms. Camilleri, who can be backed up by her family, so that realistic goals are set, and a plan is formed. To treat pain, analgesics are prescribed regularly and the doctor may also prescribe other analgesics which are to be given p.r.n., that is, when needed, to be administered if incident pain occurs. If possible, the medications prescribed should be given through the best route of administration, which is the oral route. It is the duty of the nurse to educate Ms. Camilleri and her family, and answer any queries regarding the abdominal pain, and pain management. Continuous encouragement should be given to the patient and her family, so that they take an active role in pain management.

To prescribe the analgesics, the doctor should follow the WHO analgesic ladder backed up by the extensive assessment done, in order to determine the drugs that are to be given to Ms.Camilleri. The analgesic ladder was invented by the World Health Organisation (WHO) to assist the doctor in prescribing analgesic drugs by suggesting a strategy for managing various kinds of pain. The ladder involves a three step approach in which from step one to step three, there is an increase in the drugs’ analgesic potency. Step 1 includes non-opioid drugs, example paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs), which treat mild pain. In Step 2 there is a combination of non-opioid analgesics and weak opioids, like tramadol and codeine, which are used to treat moderate pain. Step 3 of the WHO analgesic ladder, includes a combination of non-opioid analgesics and strong opioids, example fentanyl, morphine, and pethidine; which will treat severe pain. Adjuvants are drugs that contribute to pain relief, which can be used on their own or in conjunction with other analgesics. These drugs can be introduced at any step in the ladder.

At every step of the WHO analgesic ladder, the non-opioid analgesics form the basis of pain management. Therefore, paracetamol and NSAIDs, if not contraindicated, should always be prescribed with opioid analgesics, irrelative if weak or strong (Downes et al., 2011). This is called multimodal analgesia, which is a concept that involves a combination of different classes of analgesic drugs to maximise the efficacy of pain relief and management whilst keeping side effects low (Joshi, 2005). The WHO advocates that these analgesics should be given “by the clock”, that is every three to six hours, rather than “on demand.” This stepped approach of administering the right drug in the right dose and at the right time, is inexpensive and normally effective in managing acute pain (“Cancer: WHO’s pain ladder”, n.d.).

The WHO analgesic ladder will aid pain relief in conjunction with other palliative treatments for relief of cancer pain including; surgical, tumouricidal, interventional, psychological, and radiotherapeutic treatments. This multidimensional method offers the best probability for maximizing the analgesic effects and minimizing the adverse effects. These therapies affect the source of the cancer pain, which may enhance the patient’s longevity, comfort, and function (Christo & Mazloomdoost, 2008). Despite the fact that hormone therapy, radiation, chemotherapy, and other palliative treatments can reduce the size of the tumour thereby reducing the symptoms of the disease, increasing the patient’s comfort and reduce pain; they can cause other problems that also need to be dealt with. Some of the symptoms caused by cancer treatment include; nausea, vomiting, oral thrush infections, appetite loss, decreased sexual function, and skin problems. Thus, expert assessment and planning should be done so that these side effects are reduced or prevented (Morrow, 2010). Unfortunately, cancer pain does remain ineffectively controlled despite the effective assessment and management of pain to ensure that patient feels comfortable. Therefore, the multidisciplinary team has to put control of cancer pain as the most important duty, even if it means that they have to resort to the least expensive and most basic analgesics such as; codeine, morphine, and acetaminophen; in order to reduce the patient’s suffering (Christo & Mazloomdoost, 2008).

To control the nausea that Ms. Camilleri is having, a similar procedure of examination, assessment, planning, implementation, and re-examination is done; always with a multi-disciplinary team effort together with the patient and her family. It is common that patients with advanced cancer have nausea as one of the side effects. For nausea, anti-emetics are given in conjunction to the other drugs prescribed depending on the cause which is triggering nausea. Nausea may be produced by opioid therapy, particularly in the first stages when the therapy is started, but this can be prevented if the doctor prescribes the patient anti-emetics like metoclopramide or haloperidol. It is important that anti-emetic therapy is reviewed every twenty four hours so that if necessary, the drug is substituted with a different anti-emetic drug, or another anti-emetic drug is given as an addition (“British National Formulary”, 2011). Watson et al. (2005), state that:

Antiemetics should be prescribed for the first five to ten days of a strong opioid being started or a higher dose being initiated, but after five days can, and should be, stopped as nausea due to the opioid side-effects may wear off. In practice, if patients have tolerated analgesics on step two of the analgesic ladder, they will probably not need antiemetics when changing to strong opioids. (p.237)

Nausea can also be caused by uncontrolled pain, urinary retention, cough, constipation, raised intracranial pressure, upper respiratory tract infection (URTI), urinary tract infection (UTI), gastritis, electrolyte disturbances, oral or oesophageal candidosis, hypercalcaemia, drug therapy, and anxiety. For uncontrolled pain, analgesics are given, avoiding the oral route to prevent vomiting. For urine retention, the patient is catheterised; for cough, cough suppressants are given; for constipation, laxatives are given, and a bowel intervention is done. If the cause of nausea is raised intracranial pressure, corticosteroids, example dexamethasone, are given (Downes et al., 2011).

If the patient’s nausea is due to URTIs or UTIs, antibiotics are given; and for gastritis, any irritant drug that is being given should be stopped if possible, and proton pump inhibitor drugs are prescribed. If electrolyte disturbances are the cause, they are to be corrected if appropriate and possible. For oral or oesophageal candidosis, an antifungal drug, example fluconazole and nystatin, is given; for hypercalcaemia, the patient is rehydrated and given intravenous bisphosphonate; and any drug therapy that is causing nausea, unless essential, should be stopped or an alternative therapy is prescribed (Downes et al., 2011). Nausea may also be caused by anxiety, but before starting pharmaceutical management by giving anti-emetics and anxiolytics (Downes et al., 2011), it is highly important that the patient is comforted, empathised, educated, supported; and if necessary, encouraged to attend support sessions.