Palliative Care Essay: Goals, Principles, And Challenges.

The Goals of Palliative Care

Question:

Discuss about the Evaluation of Faculty Development Program.

Palliative care can be understood as a specialized type of medical care that is used for patients suffering from serious illnesses. The care focuses to provide relief from the stress as well as the symptoms of the disease, and also allow improvement in the quality of life of the patients as well as their families. The care is usually provided by a team of trained healthcare specialists like doctors, nurses and other support groups, and can be applicable at any age or at any stage of the disease, and can be used along with any curative form of treatment (getpalliativecare.org 2018. Palliative care can be provided in different types of setups like hospitals, outpatient clinics, facilities of long term care and even at home under medical supervision (cancer.gov. 2018).

The goal of this article is to review the literature regarding palliative care that identifies the goals, principles and philosophies of care, discusses the different challenges in the providence of palliative care to Australians, and also evaluates the medications that can be used in the management of death, dying and bereavement.

According to the World Health Organization, Palliative Care has the following goals:

• Relief from pain or other symptoms of the disease
• Affirming life and regarding death as a natural phenomenon
• Does not attempt to either quicken or delay death
• Involve both spiritual and psychological aspects of care
• Providing a support framework for the patients which can assist the patient in leading an active life until death
• Providing a support framework for the families to cope up with the illness of the patient, and in the event of their death
• Involving a team to address the needs of the patients and their families
• Improving quality of life and influencing the development of the disease (who.int 2018).

Bernacki and Block (2014) discussed the different care goals in the communication of serious illness, identifying the best practices through a review of literature regarding conversations about serious illnesses care goal. The guidelines are discussed below:

• Comprehension of Prognosis: An understanding of the prognosis should be explored in order to ascertain the awareness and acceptance of the patient regarding their condition (Sullivan et al. 2005; Alexander et al. 2006; Sullivan et al. 2006; Fallowfield et al. 2002).
• Preference to information by the patient regarding their future regarding any decisions and their involvement can help the professionals to provide the required information, with the patient being in control and also can instil confidence in the healthcare professional to proceed with treatment (Fallowfield et al. 2002)
• Disclosure of prognosis to the patient can be done to the degree desired by the patient who can be useful for them to take decisions and also inform patients regarding what to expect about their condition (Clayton et al. 2005; Steinhauser et al. 2000)
• Patient goals should be addressed in the care can help to address the despair and hopelessness cause by serious illness (Clayton et al. 2005)
• Addressing fears about any future suffering caused by the disease (Larson and Tobin 2000)
• Acceptable function and an acceptable limit of impairments caused by the disease, as deemed by the patient should e considered in the decision making process (Clayton et al. 2005)
• Trade-offs between various forms of management of treatment and the effect on quality of life and time at home should be clarified (Fallowfield et al. 2002)
• Involvement of family as per patient’s request (Sulmasy et a. 2007)

The study also identified the various principles of end of life communication as:

• Providing truth about progress
• Not harming the patient by discussing end of life issues
• Accepting that anxiety is normal feeling
• Acknowledging that the patients can have other goals and priorities apart from a long life
• Understanding the goals and priorities of the patients can help to provide a better care (Bernacki and Block 2014).

Studies by Fitch et al. (2015) discussed the nursing perspectives of palliative care. The study identifies nursing profession as integral in the promotion and providence of early palliative care, which needs to be aligned with the basic tenants of nursing, providing holistic care for patients and their families. The study points out few challenges related to palliative care education. Financial Constraint is a problem faced by healthcare systems globally, which further affects the availability of the service or access to it. A change in the attitude of the patients, who show an increased intention of being in control of their condition as long as possible, necessitates structuring advance care practices. However, several nurses feel uncomfortable having the conversation regarding death, dying and end of life decisions of the patients, like a desire for physician assisted suicide. It has been suggested that such situations can cause moral or emotional distress, vicarious trauma and compassion fatigue among the nurses (Fitch et al. 2007; Vachon 2012).

Principles of End of Life Communication

Another challenge identified by Fitch et al. (2015) is the worldwide problem of shortage of nursing professionals. However, such challenge also provides the scope of creativity and improvises better models of care, and requires a transformational change in the delivery of healthcare and involvement of multi disciplinary, inter-professionals healthcare teams. Also, the short term nature the budgeting cycles and a deficit in leadership can also be a significant challenge in the delivery of palliative care (Baker 2001). Fitch et al (2015) also pointed out a decline in the number of young individuals joining the profession of nursing as well as that lack of retention strategies for new nurses in healthcare organizations.

Studies by Clarke and Fasciano (2015) points out long term conditions among young adults can lead to an increased disease burden and therefore continued clinical treatment needs frequent assessment and promotion. This shows that palliative care for young adults needs to incorporate treatment as well as long term care and assessment strategies. This has also been supported by Oishi and Murtagh (2014) who proposed that two main challenges in palliative care are: maintenance of continuity and coordination in care and dealing with uncertainty (Lunney et al. 2003).

Physicians administering palliative medications also have to be involved in the development of services, management of hospice as well as training, education and research. It also requires several core competencies like: core medical care, acute care, anaesthesia, core surgical knowledge, and general practice skills (jrcptb.org.uk 2018).

The medications are administered to manage symptoms like nausea, pain, vomiting, and depression or breathing difficulties. Palliative treatments like chemotherapy, hormone therapy and radiotherapy are aimed to control or slow the progress of the disease instead of eradicating it. The different classes of medications can include: analgesics (for pain management), laxatives or aperients (for prevention or treatment of constipation), antiemetic (for the prevention or treatment of nausea), adjuvant medication (used with analgesics to manage pain or other symptoms), steroids (treatment of inflammation related symptoms), antidepressants (to treat depression or even pain), neuroleptic medication (for anxiety, depression and pain delirium) and sedatives (Caresearch.com.au 2018; Cherny and Christakis 2011; White et al. 2018; Kane et al. 2017; Bruera et al. 2015; Owens 2017; Hui et al. 2017).

It is important to consider that giving palliative medications should be simple and non-traumatic as much as possible, and can be provided in a home setup, even if the route of administration of the medication is different from that used in a conventional setup for care like hospitals. Furthermore, it is also important for long term medications to be reviewed frequently, especially for patients with multiple medical conditions that are unrelated to the palliative care. This can help to understand the burden in terms of discomfort and cost of multiple medications as well as the risks of drug interactions from polypharmacy. The decisions should be made depending upon the prognosis from diagnosis of palliative care with the risks (short term or long term) and stoppage of medication to treat co-morbid conditions (Caresearch.com.au 2018).

Nursing Perspectives of Palliative Care

Conclusion

Palliative care is a specialized type of treatment that is applicable for patients who are suffering from serious, long term and usually fatal diseases. The care aims to promote the well being of the patients through improving their quality of life, and also providing support to the families (of the patients) to cope up with the disease and also to help them to be emotionally prepared for the death of the patient. Healthcare professionals in palliative care and palliative medicine should furthermore be able to understand the prognosis of the disease, and help the patient to understand the same. References of the patients should also be taken into account regarding the future direction of their care, and any information or support needed by the patient to undertake such decisions should also be provided. It is important to acknowledge that the patients often go through anxiety; despair and even depression while coping with their condition, and those patients often have goals apart from the treatment of their conditions and living a long life. Moreover, the patients should be made aware about the care plan as well as the possible outcomes of the care and its effects on the treatment on the level of impairments faced by the patient. Also, apart from the clinical and medical requirements, the psychological, emotional as well as spiritual needs of the patients also need consideration in order to provide holistic care.

References

Alexander, S.C., Keitz, S.A., Sloane, R. and Tulsky, J.A., 2006. A controlled trial of a short course to improve residents' communication with patients at the end of life. Academic Medicine, 81(11), pp.1008-1012.

Baker, A., 2001. Crossing the quality chasm: a new health system for the 21st century. BMJ: British Medical Journal, 323(7322), p.1192.

Bernacki, R.E. and Block, S.D., 2014. Communication about serious illness care goals: a review and synthesis of best practices. JAMA internal medicine, 174(12), pp.1994-2003.

Bruera, E., Higginson, I., Von Gunten, C.F. and Morita, T. eds., 2015. Textbook of palliative medicine and supportive care. CRC Press.

cancer.gov., 2018. Palliative Care in Cancer. National Cancer Institute [online]. Available from https://www.cancer.gov/about-cancer/advanced-cancer/care-choices/palliative-care-fact-sheet [Accessed date: 24 March 2018]

Caresearch.com.au., 2018. Palliative Medications. Caresearch.com.au [online]. Available from https://www.caresearch.com.au/caresearch/tabid/1554/Default.aspx. [Accessed date: 24 March 2018,]

Cherny, N.I. and Christakis, N.A., 2011. Oxford textbook of palliative medicine. Oxford university press.

Clark, J.K. and Fasciano, K., 2015. Young adult palliative care: Challenges and opportunities. American Journal of Hospice and Palliative Medicine®, 32(1), pp.101-111.

Clayton, J.M., Butow, P.N., Arnold, R.M. and Tattersall, M.H., 2005. Discussing life expectancy with terminally ill cancer patients and their carers: a qualitative study. Supportive Care in Cancer, 13(9), pp.733-742.

Challenges in Providing Palliative Care

Fallowfield, L., Jenkins, V., Farewell, V., Saul, J., Duffy, A. and Eves, R., 2002. Efficacy of a Cancer Research UK communication skills training model for oncologists: a randomised controlled trial. The Lancet, 359(9307), pp.650-656.

Fitch, M.I., 2007. Understanding oncology nurses' experiences talking about death and dying. Canadian Oncology Nursing Journal, 17(3), p.132.

Fitch, M.I., Fliedner, M.C. and O’Connor, M., 2015. Nursing perspectives on palliative care 2015. Annals of palliative medicine, 4(3), pp.150-155.

getpalliativecare.org., 2018. What Is Palliative Care?. Get Palliative Care [online]. Available from from https://getpalliativecare.org/whatis/. [Accessed date: 24 March 2018,]

Hui, D., Valentine, A. and Bruera, E., 2017. Neuroleptics for delirium: more research is needed. JAMA internal medicine, 177(7), pp.1052-1053.

 jrcptb.org.uk., 2018. Palliative Medicine. JRCPTB [online].Available from https://www.jrcptb.org.uk/specialties/palliative-medicine. [Accessed date: 24 March 2018,]

Kane, C.M., Mulvey, M.R., Wright, S., Craigs, C., Wright, J.M. and Bennett, M.I., 2017. Opioids combined with antidepressants or antiepileptic drugs for cancer pain: Systematic review and meta-analysis. Palliative medicine.

Larson, D.G. and Tobin, D.R., 2000. End-of-life conversations: evolving practice and theory. Jama, 284(12), pp.1573-1578.

Lunney, J.R., Lynn, J., Foley, D.J., Lipson, S. and Guralnik, J.M., 2003. Patterns of functional decline at the end of life. Jama, 289(18), pp.2387-2392.

Oishi, A. and Murtagh, F.E., 2014. The challenges of uncertainty and interprofessional collaboration in palliative care for non-cancer patients in the community: a systematic review of views from patients, carers and health-care professionals. Palliative medicine, 28(9), pp.1081-1098.

Owens, S., 2017. Antipsychotics Found Ineffective for Patients with Delirium in Palliative Care: Strategies Offered for Better Management. Neurology Today, 17(4), pp.1-24.

Steinhauser, K.E., Christakis, N.A., Clipp, E.C., McNeilly, M., McIntyre, L. and Tulsky, J.A., 2000. Factors considered important at the end of life by patients, family, physicians, and other care providers. Jama, 284(19), pp.2476-2482.

Sullivan, A.M., Lakoma, M.D., Billings, J.A., Peters, A.S. and Block, S.D., 2005. Teaching and learning end-of-life care: evaluation of a faculty development program in palliative care. Academic Medicine, 80(7), pp.657-668.

Sullivan, A.M., Lakoma, M.D., Billings, J.A., Peters, A.S. and Block, S.D., 2006. Creating Enduring Change: Demonstrating the Long?Term Impact of a Faculty Development Program in Palliative Care. Journal of general internal medicine, 21(9), pp.907-914.

Sulmasy, D.P., Hughes, M.T., Thompson, R.E., Astrow, A.B., Terry, P.B., Kub, J. and Nolan, M.T., 2007. How would terminally ill patients have others make decisions for them in the event of decisional incapacity? A longitudinal study. Journal of the American Geriatrics Society, 55(12), pp.1981-1988.

Vachon, M.L., 2012. Reflections on compassion, suffering and occupational stress. In Perspectives on Human Suffering (pp. 317-336). Springer, Dordrecht.

White, P., Arnold, R., Bull, J. and Cicero, B., 2018. The use of corticosteroids as adjuvant therapy for painful bone metastases: a large cross-sectional survey of palliative care providers. American Journal of Hospice and Palliative Medicine®, 35(1), pp.151-158.

Who.int., 2018. WHO | WHO Definition of Palliative Care. Who.int [online]. Available from https://www.who.int/cancer/palliative/definition/en/. [Accessed date: 24 March 2018,]