Palliative Care - ESSENTIALS TOOLS FOR LICENSED PRACTICAL NURSES with Kath Murray
THE SIX VALUES OF MEDICAL ETHICS
The foundation of medical ethics
is supported by four pillars, namely;
Autonomy
- patient has the right to choose or refuse the treatment
Beneficence
- a doctor should act in the best interest of the patient
Non-maleficence
- first, do no harm
Justice
- it concerns the distribution of health resources equitably.
Added to the above four,
are two more aspects
which form the cornerstones
of medical practice:
Dignity
- the patient and the persons treating the patient have the right to dignity
Truthfulness and honesty
- the concept of informed consent and truth telling
All these together constitute
the six values of medical ethics.
Palliative care
is mandated in advanced stage
incurable cancer
and other terminal chronic illnesses.
The different aspects of palliative care
such as pain and symptom control,
psychosocial care,
and end-of-life issues
should be managed
in an ethical manner.
The foundation of medical ethics
is supported by four pillars, namely;
Autonomy
- patient has the right to choose or refuse the treatment
Beneficence
- a doctor should act in the best interest of the patient
Non-maleficence
- first, do no harm
Justice
- it concerns the distribution of health resources equitably.
Added to the above four,
are two more aspects
which form the cornerstones
of medical practice:
Dignity
- the patient and the persons treating the patient have the right to dignity
Truthfulness and honesty
- the concept of informed consent and truth telling
All these together constitute
the six values of medical ethics.
Palliative care
is mandated in advanced stage
incurable cancer
and other terminal chronic illnesses.
The different aspects of palliative care
such as pain and symptom control,
psychosocial care,
and end-of-life issues
should be managed
in an ethical manner.
THE CARDINAL ETHICAL PRINCIPLES
The cardinal ethical principles
to be followed are
autonomy,
beneficence,
non-maleficence
and justice.
The cardinal ethical principles
to be followed are
autonomy,
beneficence,
non-maleficence
and justice.
https://web.archive.org/web/20210125084357/https://www.researchgate.net/publication/45406955_Ethics_in_Palliative_Care/fulltext/5abd2535a6fdcccda65818b5/Ethics-in-Palliative-Care.pdf
Palliative care is provided by an interdisciplinary team that may include a doctor who specializes in palliative medicine, a nurse, pharmacist, social worker, dietitian, and volunteers.
https://palliativedoctors.org/faq
Euthanasia is the act of deliberately ending a person's life to relieve suffering and, in line with the position of the British Government and the NHS, both euthanasia and assisted suicide are illegal under English law.
https://goldstandardsframework.org.uk/international
How is Palliative Care different from Hospice?
- • According to the Center for Medicaid and Medicare Services, Hospice care is available to a terminally ill patient which is defined as a prognosis of less than six months to live if the disease runs its natural course. The philosophy of hospice is comfort care. Both hospice and palliative care focus on person- and family-centered care provided by an interdisciplinary team. Palliative care like hospice focuses on relief from suffering but can include life prolonging medications and treatments. Palliative care is not restricted to the terminally ill and can be offered at the time of diagnosis of a serious illness and intermittently as needed. While hospice is a well-defined benefit, there is wide variation in palliative care services because there are no palliative care specific regulations.
Palliative care in hospice
- If you are in the last few months of your life and feel that you are no longer able to manage at home, hospice may be a good option for you. Hospices are meant to feel more like a home than a hospital. They are designed and furnished to provide a peaceful, home-like environment for you and your family.
- In hospice, you will have your own room where you can bring some of your small personal items. Your family and friends can visit as much or as little as you wish. Nurses and care aides are always around and other members of the team are available as needed, including spiritual care.
QOL Instruments Used in the Palliative Care
https://bit.ly/QOLInstrumentsPC
How palliative care differs from hospice care
- Although you may hear “palliative care” and “hospice care” used in similar ways, they are not the same. Palliative care is given at every step of the treatment process. It provides an extra layer of support for people with any stage of cancer. Hospice care is a specific type of palliative care. It is only provided to people with advanced cancer who are expected to live six months or less.
- If you have advanced disease, your doctor may suggest treatments to improve symptoms or treatments directed at the cancer. If you choose to stop treatment for cancer, such as chemotherapy, this does not mean you have stopped “fighting” the disease. It also does not mean that your health care team has abandoned you or given up. Instead, the focus may be on relieving symptoms and allowing for additional support in all areas of your life. If a person decides to begin hospice care, a member of the palliative care team will help with the transition and address the physical and emotional issues that come with that choice.
If cardiac or respiratory arrest is an expected part of the dying process and CPR will not be successful, making and recording an advance decision not to attempt CPR will help to ensure that the patient dies in a dignified and peaceful manner. It may also help to ensure that the patient’s last hours or days are spent in their preferred place of care by, for example, avoiding emergency admission from a community setting to hospital. These management plans are called Do Not Attempt CPR (DNACPR) orders, or Do Not Attempt Resuscitation or Allow Natural Death decisions.
Download the guidance
https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/treatment-and-care-towards-the-end-of-life
https://www.aci.health.nsw.gov.au/palliative-care-blueprint/the-blueprint/essential-components/essential-component-5#resource-291960
Midland Palliative Care Workgroup
https://baynav.bopdhb.govt.nz/media/1302/referral-criteria_specialist-palliative-care_midlands_final_sept_2014_-2.pdf
Symptom Guidelines
BIMTEK PELAYANAN PERAWATAN PALIATIF DAN AKHIR KEHIDUPAN DI RSUD TUGUREJO SEMARANG - 13 FEBRUARI 2020
https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/treatment-and-care-towards-the-end-of-life
Victoria Hospice offers the following useful clinical tools to help healthcare professionals in their assessment or treatment of patients facing advancing illness, death or bereavement.
PALLIATIVE PERFORMANCE SCALE (PPS V2)
In the PPS, physical performance is measured in 10% decremental levels from fully ambulatory and healthy (100%) to death (0%). These levels are further differentiated by five observable parameters:
- the degree of ambulation
- ability to do activities/extent of disease
- ability to do self care
- food/fluid intake
- level of consciousness
Palliative Performance Scale (PPS)
https://bit.ly/PPS_PalliativeCare
Core Palliative Care Tools
The set of tools and resources provided is not intended to be exhaustive, nor is any one tool specifically recommended. https://www.aci.health.nsw.gov.au/palliative-care-blueprint/the-blueprint/essential-components/essential-component-5#resource-291960
Stated another way, referrals to SPC are appropriate where there is an extraordinary level of need and examples of this include:
- o uncontrolled or complicated symptoms;
- o specialised nursing requirements relating to mobility, functioning or self-care;
- o emotional or behavioural difficulties related to the illness, such as uncontrolled anxiety or depression;
- o concern or distress involving children, family or carers, physical and human environment (including home or hospital), finance, communication or learning disability;
- o unresolved issues around self-worth, loss of meaning and hope, suicidal behaviours, requests for euthanasia and complex decisions over the type of care, including its withholding or withdrawal.
Midland Palliative Care Workgroup
https://baynav.bopdhb.govt.nz/media/1302/referral-criteria_specialist-palliative-care_midlands_final_sept_2014_-2.pdf
Symptom Guidelines
- These best practice guidelines are a result of a collaboration of the following organizations: The BC Centre for Palliative Care, Fraser Health, First Nations Health Authority, Interior Health, Island Health, Providence Health, Vancouver Coastal, and Northern Health.
- These guidelines are intended for inter-professional clinicians working with adults living with advanced life-limiting illness. Though these guidelines were created for adults, the symptoms may also be experienced by children with advanced illness. See additional resources within each guideline specific to pediatrics, illnesses such as cancer, and your organization / region.
Palliative Care Symptom Control Guidelines
https://bit.ly/SymptomControlGuidelinesPC
Recognising that a child or young person is entering the last days of life is difficult. Advance care planning prior to this stage ensures that children and young people have plans in place in order to manage emergency care and the terminal stages of their illness. The child’s main consultant, key worker and the family, along with the wider MDT should be involved in discussions to help recognise and plan for end of life from the earliest appropriate opportunity. The following documents may be helpful in recognising EoLC:
- The Royal College of Paediatrics and Child Health (RCPCH) document ‘Making Decisions to limit treatment in life-limiting and life-threatening conditions in children: a framework for practice’: http://adc.bmj.com/content/100/Suppl_2/s1.full.pdf+html
- The General Medical Council (GMC) booklet ‘Treatment and care towards the end of life: good practice in decision making’: http://www.gmc-uk.org/guidance/ethical_guidance/end_of_life_contents.asp
- Together for Short Lives Core Care pathway. http://www.togetherforshortlives.org.uk/assets/0000/4121/TfSL_A_Core_Care_Pathway__ONLINE_.pdf
- Together For Short Lives Guide to End of Life Care. http://www.togetherforshortlives.org.uk/assets/0000/1855/TfSL_A_Guide_to_End_of_Life_Care_5_FINAL_VERSION.pdf
What is a palliative care physician?
A palliative care physician is a doctor who specialises in the care of dying patients.
They often coordinate a multidisciplinary team that ensures optimisation of care around the time of death.
Their role includes supporting the emotional as well as medical and physical wellbeing through the dying process.
https://healthengine.com.au/info/palliative-care
Care of dying patients and those close to them is central to this specialty. Doctors in palliative medicine also provide supportive care at earlier stages in an illness, alongside active treatments and interventions.
https://www.healthcareers.nhs.uk/explore-roles/doctors/roles-doctors/medicine/palliative-medicine
Palliative care teams focus on quality of life. They treat 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 many more.
https://getpalliativecare.org/whatis/
Pros of working in this specialty
NICE Pathways bring together everything NICE says on a topic in an interactive flowchart. NICE Pathways are interactive and designed to be used online.
They are updated regularly as new NICE guidance is published. To view the latest version of this NICE Pathway see:
http://pathways.nice.org.uk/pathways/end-of-life-care-for-people-with-life-limiting-conditionsA palliative care physician is a doctor who specialises in the care of dying patients.
They often coordinate a multidisciplinary team that ensures optimisation of care around the time of death.
Their role includes supporting the emotional as well as medical and physical wellbeing through the dying process.
https://healthengine.com.au/info/palliative-care
Care of dying patients and those close to them is central to this specialty. Doctors in palliative medicine also provide supportive care at earlier stages in an illness, alongside active treatments and interventions.
https://www.healthcareers.nhs.uk/explore-roles/doctors/roles-doctors/medicine/palliative-medicine
Palliative care teams focus on quality of life. They treat 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 many more.
https://getpalliativecare.org/whatis/
Pros of working in this specialty
- Being able to look after the whole patient, rather than one system; it is probably one of the few remaining general medical specialties that does this
- Having time to address issues important to the patient
- Helping to ease distressing symptoms (and optimise quality of life) throughout a patient’s disease trajectory, not just in the terminal phase
- Facilitating dignity and comfort at the end of life.
- Building effective working relationships with a wide range of professionals
- Ample opportunity to educate staff about the benefits of symptom control and the purpose of palliative care
Eligibility criteria for referral to specialist palliative care services, Patients with both:Palliative Care Best Practice Guidelines
https://bit.ly/BestPracticePC
- • a life-limiting condition and,
- • current or anticipated complexities relating to symptom control, end of life care planning or other physical, psychosocial or spiritual care needs that cannot reasonably be met by the current care provider(s).
- • Is progressive and fatal; and
- • The progress of which cannot be reversed by treatment
- Doctors do not have to give you treatment just because you ask for it. Doctors decide whether treatment is medically appropriate for your condition and then you decide whether or not you want that treatment.
- Dokter tidak harus memberi Anda perawatan hanya karena Anda memintanya. Dokter memutuskan apakah perawatan medis sesuai untuk kondisi Anda dan kemudian Anda memutuskan apakah Anda ingin perawatan itu atau tidak.
NICE Pathways bring together everything NICE says on a topic in an interactive flowchart. NICE Pathways are interactive and designed to be used online.
They are updated regularly as new NICE guidance is published. To view the latest version of this NICE Pathway see:
Here are seven of the most frequently asked questions surrounding palliative care services.
Palliative care offers several benefits to patients who have been diagnosed with a chronic medical condition.
https://ardenthapc.com/
Palliative care offers several benefits to patients who have been diagnosed with a chronic medical condition.
https://ardenthapc.com/
- Conversations about dying and end-of-life (EOL) care are the most challenging of all communication scenarios. These conversations include discussions about diagnosis and prognosis, treatment goals, and EOL wishes, goals of care, and plans for the future.
Clinicians have the responsibility to provide opportunities for discussion and information to patients, caregivers, and surrogates throughout the trajectory of serious illness; such conversations occur in the context of an uncertain, emotional environment and require core communication skills of sensitivity and empathy—skills that professionals in all disciplines should cultivate.
- Dying involves much more than medical concerns and decisions—there are psychological, social, spiritual, and financial concerns that require the efforts of an interdisciplinary team. The ideal team would include professionals from medicine, nursing, chaplaincy, and social work or similar fields to address the medical and psychosocial and spiritual needs of the patient and family.
Team-based efforts hold the most promise for facilitating the communication needed to provide information, explore options, develop plans and goals, and ultimately provide holistic, patient-centered care.
The focus of this guidance is on administration by subcutaneous (SC) injection and SC syringe pump over 24 hours, recognising that the dying person may be unable to take or tolerate oral medicines.
It includes the management of the following five symptoms:
- Pain
- Breathlessness
- Nausea and vomiting
- Anxiety, delirium and agitation
- Noisy respiratory secretions
When it is recognised that a person may be entering the last days of life:
• Review their current medicines.
• Stop any prescribed medicines not providing symptomatic benefit or that may cause harm.
• Discuss and agree any medication changes with the dying person and those important to them (as appropriate).
Anticipatory prescribing by the subcutaneous route to cover the five symptoms above ensures a supply of medicines are available to relieve symptoms as soon as they occur.
WHAT IS IMPORTANT TO ME?
What choices are important to me at the end of life and after my death?
Taken from:
The Care Review: A Review of Choice in End of Life Care (2015).
https://web.archive.org/web/20210613084249/https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/407244/CHOICE_REVIEW_FINAL_for_web.pdf
What choices are important to me at the end of life and after my death?
I want to be cared for and die in a place of my choice.
I want involvement in, and control over, decisions about my care.
I want access to high quality care given by well trained staff.
I want access to the right services when I need them.
I want support for my physical, emotional, social and spiritual needs.
I want the right people to know my wishes at the right time.
I want the people who are important to me to be supported and involved in my care.
I want involvement in, and control over, decisions about my care.
I want access to high quality care given by well trained staff.
I want access to the right services when I need them.
I want support for my physical, emotional, social and spiritual needs.
I want the right people to know my wishes at the right time.
I want the people who are important to me to be supported and involved in my care.
Taken from:
The Care Review: A Review of Choice in End of Life Care (2015).
https://web.archive.org/web/20210613084249/https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/407244/CHOICE_REVIEW_FINAL_for_web.pdf
Palliative care addresses the physical, psychosocial and spiritual needs of people with a life-limiting illness, to allow them to live as well and as comfortably as possible.
https://palliativecarensw.org.au/
https://palliativecarensw.org.au/
Recent Clinical Research on Advance Care Planning: 7 Key Takeaways
Advance care planning (ACP) is defined as “a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care. The goal of advance care planning is to help ensure that people receive medical care that is consistent with their values, goals and preferences during serious and chronic illness.”
Research has found numerous benefits to ACP discussions, including improved quality of life, greater likelihood that healthcare wishes are fulfilled, and less distress among family members and caregivers.
https://acpdecisions.org/recent-clinical-research-on-advance-care-planning-7-key-takeaways/
Advance care planning (ACP) is defined as “a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care. The goal of advance care planning is to help ensure that people receive medical care that is consistent with their values, goals and preferences during serious and chronic illness.”
Research has found numerous benefits to ACP discussions, including improved quality of life, greater likelihood that healthcare wishes are fulfilled, and less distress among family members and caregivers.
https://acpdecisions.org/recent-clinical-research-on-advance-care-planning-7-key-takeaways/
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