hospice and pallative

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Hospice ANDPALLIATIVE

care

Prepared by: AUBREY C. ROQUE RN, MAN Hospice care It is designed to give supportive care to people in the final phase of their lives and focus on

comfort and quality of life rather than cure.

GOAL: To enable patients to be comfortable and free of pain, so that they live each day as fully as

possible.

PHILOSOPHY: To provide support for the patient's emotional, social, and spiritual needs as well as

medical symptoms as part of treating the whole person.

WHO Definition of Palliative Care Palliative care is an approach that improves the quality of life of patients and their families

facing the problem associated with life-threatening illness, through:

the prevention and relief of suffering by means of : Identification of pain Impeccable assessment and treatment of pain Identification, assessment and treatment of physiological, psychosocial and

spiritual problems

Principles of Hospice Care / palliative care Affirms life and regards dying as a normal process Neither hasten nor postpones death Provides relief from pain and other distressing symptoms Integrates the psychological, ethical, legal and spiritual aspects of care Offers a support system to help patients live as actively as possible until death Offers a support system to help patients families to cope during the patients illness and in their

own bereavement.

Principles of Hospice Care / palliative care


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Uses a team approach to address the needs of the patients and their families, includingbereavement counselling, if indicated.

Will enhance quality of life and may also positively influence the course of illness. Is applicable even in the early course of the illness in conjunction with other therapies and

may also involve studies that may better understand and manage the disease.

Objectives of palliative care To palliate physical symptoms To maintain independence for as long and as comfortably possible Alleviate isolation, anxiety and fear associated with advancing disease. Provide a dignified death. Support those who are bereaved. WHO Definition of Palliative Care for Children Palliative care for children is the active total care of the child's body, mind and spirit, and also

involves giving support to the family.

It begins when illness is diagnosed, and continues regardless of whether or not a child receivestreatment directed at the disease.

Health providers must evaluate and alleviate a child's physical, psychological, and social distress. Effective palliative care requires a broad multidisciplinary approach that includes the family and

makes use of available community resources; it can be successfully implemented even if

resources are limited.

It can be provided in tertiary care facilities, in community health centers and even in children'shomes.

PALLIATIVE CARE- is designed to give support and comfortrather than cure of the illness or problem.

SPECIALIST PALLIATIVE CARE Requires a high level of professional skills from trained staff It refers to a service provided by a multiprofessional team led by clinicians led by

clinicians with recognised specialist palliative care training.

The multidisciplinary team includes: Nurses


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Doctors Physiotherapists Occupational therapists Social workers Chaplains and volunteers

Team work is the key to a successful and efficient palliative care.

QUALIFICATION OF A HOSPICE NURSE Current licensure in the state of practice Minimum of one year of clinical practice in nursing.

Oncology Psychiatry Home care experience are prepared

Knowledge of pathophysiology and disease progression Understanding of pain and symptom management QUALIFICATION OF A HOSPICE NURSE Excellent assessment communication skills Ability to work within and contribute to an interdisciplinary team Ability to assist the patient and family in coping with emotional stress Understanding of an aptitude for organization and communication with patient, family and team

members

ATTRIBUTES OF A HOSPICE NURSE Capacity to manage physical , psychological, social and spiritual problems of dying patients and

their families

Ability to coordinate the extended and expanded component1s of hospice service Acquisition of counseling, managing, instructing, caring and communicating skills and knowledge. Ability to balance the nurses self-care needs with the complexities and intensities of repeated

encounter with death.


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Important areas of palliative care 1.) PALLIATIVE CARE IN HOSPITALS

The most common place to die for people The ways in which staff perform their care for the dying is usually determined by the

hospitals policies and routines.

2.) PALLIATIVE CARE IN THE COMMUNITY 20th century majority of people died at home Current trend a rise of 66% of death in institutions Dying patients usually prefer to die in a home setting OTHER AREAS FOR HOSPICE CARE

3.) DAY CARE Units based in hospices where patients with advancing disease can attend on a day

basis.

Care provided includes social and therapeutic benefits for the patient (eg: aromatherapy,wound dressing, bath)

OTHER AREAS FOR HOSPICE CARE CARE HOMES

These nursing homes provide care for elderly patients who require constant medicaltreatment, but do not require advanced care and specialized doctors in a hospital.

Essential Components of Palliative Care

COMMUNICATION- is the essential process by which individual share something of them,

whether it is thoughts, feelings, opinions, ideas, values, or goals. (chapter 5)

The first impression of people towards us is determined by 45% of our verbal communication skills and

55% of non verbal skills.

The greater part of an individuals personality is developed and maintained through social interaction.

Principles of human communication Perception is selective


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Only a part of the information sent is perceived. The idea that what is perceived is not precisely what actually is.

It is an interactive and continuous process The sender is also a receiver of information The receiver is also a sender of information, during the communication process

Its inevitable It is impossible not to communicate, (it is essential for health providers to be

aware that even when words are not used or spoken, communication is

occurring.

Principles of human communication Culture influences communication pattern

It is critical for health provider to recognize their own cultural conditioning inorder to explore the impact it has in their communication with those of another

cultural background.

Culture involves customs, beliefs, values, and relationship patterns, prescribedbehaviors (dress, food preferences and time consciousness).

Principles of human communicationImportance of good communication at the end of life

Honest communication increases the likelihood that the dying experience will be onethrough which all the participants can grow emotionally and spiritually

Families are better prepared for the final death event and have better bereavementexperiences.

One of the most important messages that we need to convey to a person with advancedillness is hope.

Principles of human communicationBarriers to good communication

1. Patients and Families death is considered a taboo subject


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Common reactions are withdrawal from the patient or situation, denial of thereality of a terminal diagnosis, or avoidance of the subject, such as telling jokes

or changing the subject.

Barriers to good communication

2. Poor communication skills of the health care provider using the dying person's name throughout the conversation making eye contact holding the person's hand placing one's hand on a shoulder or arm smiling gesturing leaning forward caring in what the person is saying (or not saying) and feeling. Asking specific questions such as, "Can you help me understand?" as

well as open-ended questions such as, "What is it that you need to do

now?" are very important, as is being comfortable with silence.


3. Depth of the physicianpatient relationship: Health Care Providers(HCPs) may develop strong bonds with patient and family, whether they

have known them for years or just a short time. These bonds may make

breaking bad news or discussing issues around end-of-life care difficult

since they may find it difficult to contemplate losing a patient they care

for deeply.

4. Personal experiences of illness and death: May affect their ability tocare for a person who is at the end of life.

5. Physical, emotional and psychological stress and depletion: Mayaffect ability to communicate caring, empathy and compassion.



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6. Fears of confronting own mortality and fears of death: Caring forsomeone who is dying leads to physicians confronting their own

mortality and fears of death.

7. Lack of training and poor role models: A lack of training and rolemodels results in poor communication skills and either a lack ofawareness of patients feelings and reactions or inability or fear of

discussing these emotions.

8. Fears of emotional outbursts: HCPs are often not taught how toshow empathy and caring and may fear emotional outbursts.

9. Fears of appearing weak or unprofessional for displaying emotions:Many HCPs have been taught that displaying emotion is a sign of

weakness or unprofessional. These HCPs may have difficulty in

discussing end-of-life issues for fear of feeling or displaying emotion.


10. Guilt and self-blame due to introgenic complications resulting inpoor quality of life, increased severity of illness and/or death: When

illness is due to or has been exacerbated by iatrogenic complications,

HCPs may be consumed with self-blame and guilt which may affect their

ability to consider the patients situation.

11. Communication Problems: Inconsistent approach to the issues,differences in language can lead to confusion (the perception of mixed

messages) and misunderstandings with patients and families.


12. Health Care System fast pace modern health care system, inadequate time to discuss important matters such as death Unclear who is responsible for initiating and providing follow-up-end-of life

conversations?

Practical aspects of communicating at the end of life

Understand oneself and speak honestly (self-awareness) But remember that the key to talking to dying persons is to focus on

their needs, rather than ones own.


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Consider the timing of communication ( ask is this a good time to talk) Provide a setting for open communication

arrange the environment and how to adapt their own behaviorto facilitate conversation

avoid sense of arrogance maintain eye contact


Allow the patient to guide the communication process; patients personalautonomy and control should be preserved.

Use open ended questions (e.g. what is it that you need to know?)Practical aspects of communicating at the end of life

Make no assumptions about what the patient knows; a patient who has not told of theirdiagnosis might be aware that they are dying.

ask and listen, listen and ask, the most important general rule in the end-oflife setting is tolisten more and to talk less

yes or no questions are helpful initially to open a difficult subject, (e.g. have youexperienced the death of a loved one before.. followed by do you feel like

talking about it

attentive listening means no interruption, but listening patiently until there is apause in the conversation before speaking


use understandable terms ask patient what they want use silence liberally support varying emotional response accept denial , usually accept symbolic language encourage patient to tell their life stories


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tell people what to expect at the very end of life, assume that hearing is still intact

Breaking bad news

-- All the communication skills discuss apply to the very difficult task ofbreaking bad news

Factors that add to the distress of the situation:

Fear of being blamed for the bad news Fear of not knowing all the answers Fear of showing emotions Fear of being reminded of ones own mortality

NOTE:it is often the doctors responsibility to break the bad news but it is helpful to be present when

the bad news is initially shared, that is to understand the real situation/condition of the patient.

authoritative interventions through therapeutic communication AUTHORITATIVE INTERVENTIONS are practitioner-led strategies wherein the

practitioner(nurse) takes responsibility for the client, with the aim of guiding their behavior.

PRESCRIPTIVE the helper seeks to direct the nehavior of the client. INFORMATIVE the helper gives the client information CONFRONTINGthe helper tries to raise the clients consciousness about an attitude or

behavior.

facilitative interventions through therapeutic communication FACILITATIVE INTERVENTIONS aim to help patients be more autonomous through emotional

release, self-knowledge and learning, and affirmation of their value and being.

CATHATRTIC the helper encourages the client to release painful emotions such as fear. CATALYTIC the helper elicits self-discovery and problem solving in the client. SUPPORTIVEthe helper affirms the worth of the clients attitudes, qualities and

actions.

Communication and supportIt is a requisite skills for care providers in the end-of-life care to determine the two important

psychological complications of being terminally sick. These skills are:


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Assessing Depression DEPRESSION is a psychiatric disorder characterized by an inability to concentrate,

insomnia, loss of appetite, anhedonia, feelings of extreme sadness, guilt, helplessness

and hopelessness, and thoughts of death. The condition is also called clinical depression.

NOTE: Anhedonia: Loss of the capacity to experience pleasure. The inability to gain pleasure from

normally pleasurable experiences. Anhedonia is a core clinical feature ofdepression,schizophrenia, and

some other mental illnesses.

Subtypes of Depression:

Major depression severe, lasts for at least 2 weeks (decrease energy, feeling ofworthless, guilty)

Dysthymic depression less severe (lasts for 2 years or more).General appearance of a depressed person

Sadness Resignation Apathy Hopelessness Or may become cheerful when decision come to end suffering

2. Assessing Suicide potential Requisite skills for end-of-life care is the ability to identify depression and assess for

suicidal potential

For assessment of suicide potential, a direct approach is recommended.

Eg. Have things gotten so bad that you are thinking of killing yourself.Risk factors for SUICIDE:

S Sex (more female attempts suicide but more malescommits).

U Unsuccessful previous attempt. I Identification with a family member who committed suicide. C Chronic
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I Illness Ex. Cancer D depression/dependent personality A age (18-25 and 40 above) and alcoholism L Lethality of previous attempts/looses. End of part i prelim topics

thank you...

Levels of palliative Care

Hospice care and palliative care is a model for

Quality and compassionate care at the end of life Based on its definition, it includes a distinct, comprehensive cluster of services

for terminally individual and their families which are provided on a continuum

of intensity or LEVEL OF CARE.

The four levels of care are: 1. Routine Home Care

The most common level of care, the heart of hospice of care The full scope of hospice service is provided in the patients personal

home/residence

Care begins in admission process Assessment and admission of the patients status and appropriateness for hospice care Also focus on the concerns and issues that troubles the patient and family and how

hospice can help them

It is directed towards the relieving of specific problems Pain Symptoms of disease Anxiety


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There is a continuous reevaluation and reappraisal on the specific needs of the patientand family to ensure that support and comfort oriented services are offered in a timely

manner

There is a significant involvement of the family or primary support person in providingdirect hands-on care for the patient

With routine home care the patient are able to die as they prefer at home. The four levels of care are: 2. Continuous Home Care

Is an expanded level of care in the home A skilled nursing of 24 hours is allowed to ease and prevent hospitalization for

management of acute symptoms

The chief reason is management of acute physical symptoms, or may also beused when the burden of care giving for families is greater than their resources

The four levels of care are: 3. Respite Care

Supports the patients family and the caregiver The family can have rest, vacation or attend events while the patient is cared for

in an in-patient setting.

Respite care is limited to five day period Care is similar to home care but is rendered in an in-patient setting in a

contracted room with basic activities of living assisted by nurses and nursing

assistants.

Patients are often very ill or have need for assistance with activities of dailyliving, which is often theprecipitating factor for respite care

Respite care is expensive due to the intensity of care The four levels of care are:

4. In- patient Care or Acute Symptoms Management A short term admission to a medicare certified facility for medical problems

requiring nursing and medical management


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Candidate for in-patient care are those: Whose care are so complex or demanding that the family can no longer

continue to provide home care

PATIENT Problems for in-patient Palliative Care Admission Imminent death under specific condition Active and potential bleeding Sepsis Seizures Impending delirium tremens Uncontrolled pain Any uncontrolled symptoms Central nervous system dysfunction

Delirium Coma Dementia

Fractures of weight bearing bones Management of complex medications Acute cardiac symptoms

Myocardial infarction Arrhythmias

Complex treatment schedule requiring frequent dressing changes orprocedures that require the time, skills and observations of a

professional nurse

Terminal agitation NON-MEDICARE LEVELS OF CARE

NON-MEDICARE LEVELS OF CARE is being provided to expand services to meet identified patient care needs.


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A. Residential Care

- is provided in hospice/palliative inpatient settings for patients who requiresupportive care related to safety needs, weakness or the inability to perform

self-care.

-Also provides a way to offer better continuity for patient who are no longerappropriate for in-patient care status

B. Day Care

Designed to provide relief to the caregiver and diverse activities for the patient There are planned activities, meals, and observation and assistance as needed.

Patients are transported to the day care site by family or by hospice.

C. Extended Caregiver Services or in-home respite care

The programs offers a shift s of nursing assistants to a patient to supplement orsubstitute for family caregivers

The goal is to keep the patient at home Usually used by working families, frail caregivers, and in situations where the

physical demands for care-giving are beyond the strength of the caregiver.

Also a way to supplement care when residential care beds are not available. Providing holistic care

CHAPTER 3 HOLISM It is a philosophy of care based upon a belief that all aspects of a person must be considered

during the treatment of illness and the promotion of quality of life.

This is a recent trend when it comes to principles of treatment in the 21ST century.BIOMEDICINE a medical model that says that illness is a dysfunction of the corporeal body wherein the

mind is separate from the physical body.

The biomedical approach requires the patient to submit their diseased body to the care of health-care

experts for treatment. The view that the mind had no influence upon physical health meant that it was

not usually considered by the physicians.


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Why should we focus on the person and not just the illness?One fascinating area of scientific study that seeks to demonstrate the body-mind link is the

PSYCHONEUROIMMUNOLOGY.

PNI has conducted studies how life events are evaluated as stressors and investigated how

stress alters the effectiveness of the bodys immune system.

Factors that may influence health and the course of the disease according to PNI: Thoughts Feelings Emotions Personality Beliefs

How does a palliative care nurse apply holistic principles to patient care HOLLISTIC ASSESSMENT IN PALLIATIVE CARE

Assessment is the key to effective care plan. It must be a comprehensive and sensitive assessment. Holistic assessment may only be done when the nurse gains idea about personhood.

Personhoodit is ones identity as a social person. Holistic care in a multicultural society CULTURAL COMPETENCE

refers to an ability to interact effectively with people of different cultures. Cultural competence comprises four components:

Awareness of one's own cultural worldview Attitude towards cultural differences Knowledge of different cultural practices and worldviews Cross-cultural skills

culture


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Is a patterned behavioral response that develops overtime and is shaped by the values, beliefs,norms, and practices that are shared by members of the same cultural group.

In the twentieth century, "culture" emerged as a concept central toanthropology,encompassing all human phenomena that are not purely results of human genetics

Dimensions Of Culture Gender Age Differing abilities Sexual orientation Religion Financial status Residency Employment and Educational level Cultural Competence

Refers to a dynamic, continuous process of awareness, knowledge, skills, interaction andsensitivity.

It implies not only awareness of cultural differences but also the ability to interveneappropriately and effectively

To become more culturally competent, nurses are required to learn in the Affective (attitudes, feelings, and beliefs) Cognitive or intellectual or psychomotor or behavioral domains and assumes skills in

critical thinking

Cultural competence is demonstrated when the nurse: Shows respect for the inherent dignity of every human being irrespective of their age,

gender, religion, socioeconomic class, sexual orientation and ethnic or cultural group

Accepts the rights of individuals to choose their care provider, participate in care orrefuse care
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Acknowledges personal biases and prevents these from interfering with the delivery ofquality care to persons of other cultures

Recognizes cultural issues and interacts with persons from other cultures in a culturallysensitive way

Incorporates cultural preferences, health beliefs and behaviors, and traditional practicesinto the care management plan.

Four components in pursuing cultural competence 1.) Cultural awareness- examination of ones own heritage, familys practices, experiences,

religious or spiritual beliefs.

Cultural awareness encourages us to examine the influence of cultural stereotypes( stereotyping occurs when one makes an assumption about an individual based solely

on the individuals groups membership) have on our beliefs, values and clinical practice

To avoid prejudice, discrimination and interference with holistic care To find similarities rather than differences An essential skill in the provision of culturally appropriate services, cultural awareness

entails an understanding of how a person's culture may inform their values, behaviour,

beliefs and basic assumptions.

Cultural awareness recognises that we are all shaped by our cultural background, whichinfluences how we interpret the world around us, perceive ourselves and relate to other people.

Four components in pursuing cultural competence 2. Cultural Knowledge- serves as a guide to assist the hospice and palliative care team to gain a

better understanding of the individual and family.

It is to recognize the uniqueness of an individual or the differences that exist evenwithin the group.

Differences must be identified to provide culturally appropriate care to the patient andto the family

Four components in pursuing cultural competence 3. Cultural Skill- is important to assess cultural behavior and beliefs.

such as skills in , cultural assessment, cross-cultural communication, culturalinterpretation and appropriate intervention

Working appropriately and productively with others


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Four components in pursuing cultural competence 4. Cultural encounter the actual experience or immersion to a culture.

When we meet people from other cultures there is the potential for development andchange. How we handle this meeting- or a possible conflict- will often be the

determining factor for the outcome of the cultural encounter.

Cultural phenomenon 1.)Communication-person may cause to return to their most familiar or native language

when they are sick.

Recognize the ways in which people of different backgrounds communicate with eachother, which includes

Identify the language spoken in the home How the patient prefers to communicate Patients speaking or reading ability

Interpreter must be necessary for language barrier Important to recognize the overall characteristics of language and the communication

process:

Respect the way a person wishes to be addressed Be aware of the rules of communication within the culture Listen to the quality of voice to help understand the message

It is necessary to vary the techniques of communication depending on the individual(communicate in a non hurried manner, listen carefully, and speak slowly and distinctly)

Be aware of acceptable practices; the use of touch, eye contact etc. Types of touch:

Functional professional- exam and procedures Social polite greeting, handshake Friendship Warmth hug, arm in shoulder Love intimacy tight hugs and kisses Sexual arousal by lovers


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2.) Space the dimension of comfort zone The intimate zone 0-18 inches (whispering) The personal zone 18-36 inches (family and friends) Social zone 4-12 feet Public zone 12-25 ft.

Proxemics study of distance zones between people during communication.

3.) Social organization - the different structures in various groups such as: family,religious groups, ethnic and racial groups.

4.) Time- implications of how cultural group views the concept of time, is important tounderstand the patients response to prognosis and duration of illness.

Future oriented-defer gratification of personal pleasure until future obligationshave been met

Present-oriented group focus on living on the present and are not overlyconcerned with the future; time is flexible

5.) Environmental control- is the ability of individuals to plan activities that controlnature.

6.) Biological variations- physical differences affects assessment findings of individualswith varying skin color.

Hospice and palliative care issues influenced by culture: Nutrition- dietary pattern of cultural group, food is used to assess, treat and prevent

illness

Decision making- with the Patient Self-determination Act (PSDA) of 1991 decisionmaking shifted from the physician to the patient

Pain management Death rituals in mourning practices End of prelim topics Ethical and legal issues in hospice and palliative care MIDTERM TOPICS


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ETHICAL ISSUES IN HOSPICE CARE(CHAPTER 7)

Clinical encounter is influenced by ; the personal and cultural values of both the patient and the provider moral traditions of the health professions social and political context of the health care system Ethical issues that arise in the care of the dying:

Ethical issues that arise in the care of the dying: truthfulness and confidentiality decision-making authority in the professional patient relationship appropriate use and allocation of technology and other health care resources decision to withdraw life-sustaining treatment decision making for patient who have lost their own decision making capacity request for assistance in suicide active euthanasia

Ethical issues that arise in the care of the dying: Expectation of patients, family and team

The conflicting expectations of patient, family and team is an ethical issue thatneeds to be addressed

It is important to assess and clarify the goals and expectations from thebeginning of the relationship between the patient, family and hospice team

Palliative care is appropriate when a patients disease is no longer amenable tocure, when the burden of life-prolonging treatment outweigh the benefits.

Ethical issues that arise in the care of the dying: Ideally it is the decision of the patient or family to enter hospice The hospice team needs to know about the previous clinical course, and what

the patient and family have been told and the understanding about the course.


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Communication of information (about diagnosis and prognosis) families who insist that the information be withheld from the patient or the

patient insisting that the information be withheld from the family

it is important to remember individuality of patient and families each request should be treated sympathetically and with respect : that is to find

the concern for withholding the information, asked in sympathetic and

understanding manner to elicit information.

Communication of information about illness and prognosis is a process,conversation will have to be repeated several times.

Pain management the patient and the familys attitude towards the use of narcotic analgesics can be a

source of frustrations and ethical concerns for the hospice team: such as

a. patient stoicism b. fear of addiction c. fear that admitting to pain means admitting that the disease has progressed d. reluctance

advance directives Advance care directives allow patients to provide instructions about their preferences regarding

the care they would like to receive if they develop an illness or a life-threatening injury and are

unable to express their preferences.

Advance care directives can also designate someone the patient trusts to make decisions aboutmedical care if the patient becomes unable to make (or communicate) these decisions. This is

called designating power of attorney (for health care).

Federal law requires hospitals, nursing homes to provide written information regarding advancecare directives to all patients upon admission.

Advance care directives can reduce: Personal worry Feelings of helplessness and guilt by family members Futile, costly, specialized interventions that a patient may not want


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Overall health care costs Legal concerns for everyone involved EXAMPLES OF ADVANCE DIRECTIVES

Verbal instructions. These are any decisions regarding care that are communicated verbally byan individual to health care providers or family members.

Organ donation. This may be accomplished by completing an organ donation card and carryingit in your wallet. A second card may be placed with important papers (such as a living will,

insurance papers, and so on). Most hospitals or other major health care centers have organ

donor information available.

Living will. This is a written, legal document that conveys the wishes of a person in the event ofserious illness. This document can speak for a patient who is unable to communicate. A living

will may indicate specific care or treatment the person does or does not want performed under

specific circumstances.

This may include specific procedures, care, or treatments such as the following: CPR(if cardiac orrespiratory arrestoccurs) Artificial nutrition throughintravenousor tube feedings Prolonged maintenance on a respirator (if unable to breathe adequately alone) Blood cultures, spinal fluid evaluations, and other diagnostic tests Blood transfusions Special medical power of attorney. A legal document that allows an individual

to appoint someone else (proxy) to make medical or health care decisions, in

the event the individual becomes unable to make or communicate such

decisions personally.

NOTE: This document provides for power to make medically related decisions only anddoes not give any individual power to make legal or financial decisions.

DNR (do not resuscitate) order. This states that CPR (cardiopulmonary resuscitation) isnot to be performed if your breathing stops or your heart stops beating. The order may

be written by the person's doctor after discussing the issue with the person (if possible),

the proxy, or family.

Assisted suicide
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Assisted suicide is the common term for actions by which an individual helps another personvoluntarily bring about his or her own death.

"Assistance" may mean providing one with the means (drugs or equipment) to endone's own life, but may extend to other actions. It differs toeuthanasiawhere another

person ends the life. The current waves of global public debate have been ongoing fordecades, centering on legal, religious, and moral conceptions of "suicide" and apersonal

"right to death".Legallyspeaking, the practice may be legal, illegal, or undecided

depending on the culture or jurisdiction.

euthanasia Euthanasia: the intentional killing by act or omission of a dependent human being for his or her

alleged benefit. (The key word here is "intentional". If death is not intended, it is not an act of

euthanasia)

Voluntary euthanasia: When the person who is killed has requested to be killed. Non-voluntary: When the person who is killed made no request and gave no consent. Involuntary euthanasia: When the person who is killed made an expressed wish to the contrary. Assisted suicide: Someone provides an individual with the information, guidance, and means to

take his or her own life with the intention that they will be used for this purpose. When it is a

doctor who helps another person to kill themselves it is called "physician assisted suicide."

Euthanasia By Action: Intentionally causing a person's death by performing an action such as bygiving a lethal injection.

Euthanasia By Omission:Intentionally causing death by not providing necessary and ordinary(usual and customary) care or food and water

LEGAL ISSUES INHOSPICE AND PALLIATIVE CARE

A protection for everyone concerned The COMMON LAW The law that affects the entire community

It is a strict, principle-based reasoning that uses the circumstances of a case toevaluate the laws that are applicable.
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Also known as civil law, was used to compensate people who suffered wrongfulacts known as TORTS.

Rules of conduct shared by the community

The common law is a normative system

It creates categories that distinguished one person from another and one situation from anothersituation. It solidifies the lines that draw these distinctions into fences, trying to assure that

everyone understands the either/ or nature of their choices how to behave.

in science it is a result of research and investigations The common law waits for conflicts to ripen A court rules only upon issues that ripened into full conflict and only when the parties whose

actual interests are at stake stand before it.

Are grounded in underlying, discoverable realities from which facts can be established byexperimentation, issues can be discussed and debated in abstract terms , problems can be

anticipated and disputes can be avoided

The common law does not deduce from principle Legal thinking uses inductive reasoning to sort issues by similarities and differences to bring the

right result for the case at hand.

Science relies on logic WHAT IS A RIGHT? Rights are boundaries that others are forbidden to cross Trespass against property or person The current laws that govern the health care practice relies on precedents to the medieval

concept of trespass against a person, a common law tort.

Free from being touched without consent


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The law of negligence was born as a partner concept implying the duty of care for thoseto whom consent to touch is given

It is only through the trial of actual cases, decisions made after actual harm has beendone, that the common law grows and changes.

In the spirit of the modern age, right is now what we called as powers, dignities orprivileges.

and these privileges are: Right to live Right of choice Right to die

The common law rights of a patient 1) Right to receive care in keeping with current professional standards

Governed by the law of professional negligence, sometimes called MALPRACTICE. Negligence-refers to the commission or omission of an act, pursuant to a duty, that a

reasonably prudent person in the same or similar circumstance would or would not do,

and acting or the non-acting of which is the proximate cause of injury to another person

or his property.

The law of professional negligence is all about the right of a patient to receive care thatmeets the objective standards established within the professional community

Four elements of professional negligence What was the duty of care Was the duty breached Was the harm to the patient actually caused by the breach of duty What is the loss or harm

NOTE: the first two questions establish liability for negligence and thefinal two establish damages and the share attributable to the negligence

of the tort-feasor

Punitive damages-extra measure of damages, depending on the facts ofthe case, the skills of the lawyers, and the influential voices of the jury.

This amount could be very extravagant


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Compensatory damages- the amount is victim specific, meaning thatthe monetary recovery depends on financial values associated with the

loss to the actual victim and the victims family, including loss of

earnings.

E.g. the younger the victim with promising future is higher incompensation than a poor old person.

2) Right to confidentiality of medical records A patient communication with the physician is privileged, (privilege communication)

The doctor could not disclose the information learned in the course oftreatment to anyone outside of the medical team without the consent of the

patient

The issue in breach of confidentiality only arises if there is financial harm to thepatient as the result of breach.

Judges can do allow queries of the medical team when a medical facts is incontroversy

In Hospice-it is important to recognize that only members of the team shouldhave access to privileged information unless the patient has given permission

for information to be shared with family and friends

The privilege and the right to release it, passes to an appointed surrogate in theevent of a patients incapacity

3) Right of Informed Consent A right to consent or to refuse consent to being touched Touching someone without consent constitutes tort of battery Consent may be implied from circumstances, however when touching can be invasive

and cause pain or harm, the issue of consent come into play

The tort of battery arises most often in contemporary medical case law in instances ofmistaken identity where a patient is subjected to surgery intended for another person.

The tort of battery arises most often in a medical case law in instances of mistakenidentity where a patient is subjected to surgery intended for another person.

The more common issue in hospice is the Doctrine of Informed Consent, thisdoctrine has found ground in malpractice where patients experienced


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unexpected outcomes that in hindsight, they learned foreseeable risk of

treatment.

Courts have ruled that patients must be afforded the choice of alternatives torecommend treatments and a prospective of the risks.

4 ) Right of consent exercise through patients agent Dying patient often lose their mental capacity to make rational choice Durable power of attorney for health care in anticipation of fate- patient appoints

surrogate or proxy decision makers.

The legal document serves to delegate the right of consent to the surrogate orproxy decision makers

5) right to refuse Medical treatment Not only at the end of life but with all the proposed medical treatment to refuse or to

withdraw their consent once given

The right is extended to their surrogate decision maker and was the basis for allowing thediscontinuance of artificial ventilation in the case of Nancy Cruzan also called Right to Die

Not only logically connected to treatment that prolong life but also with regards to patient swith religious or philosophical beliefs that bring moral and ethical criteria to aspect of medical

care

6 ) Physician assisted suicide The common law recognizes NO RIGHT to choose to die and no power to seek the

assistance of a physician to carry out the suicide

The law requires medical service providers to supply more and better information aboutproposed treatments so the patient can exercise judgment and choice.

DOCUMENTING THE EXERCISE OF PATIENT RIGHTS: A GUIDE TO FORM 1. Legal documents that may belong to the patients file are categorized into three (3)

Contracts and agreements Advance directives Releases and consents

2. agreement between the institution that provides health care and the patient is a contract thatclearly stated the contact names and payment procedures


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Agreements that are executed follow a legal standards of mental competence , a spouse mayenter agreement to act for the benefit of a spouse but circumstances of intimacy and specialized

knowledge between patient and her/his health care providers will require special caution in

matters where legal or financial interest of the patient may involved

3.advance directives is a written statement, executed while a patient has legal capacity,containing directions to be followed after capacity is lost and or after death

a.DNR / DNI- part of the treatment plan and are placed prominently in the medical records. The

patients consent to these papers is a refusal of medical treatment in advanced of its proposed

intervention.

b.Right to die statement- a patient may refuse to give consent to the treatment, which remains in effect

even after the patient loses consciousness or capacity and is self-executing.

c. Instructions regarding cremation and embalming- the statement have legal effect over the rights of

survivors to dispose of the body

d.Power of attorney for health care- a power of attorney for health care appoints a surrogate or proxy

to consent to treatment in the event of the lack of capacity of the principal

4. consent and releases the primary purpose for obtaining consent to palliative care treatment plans is to document the

existence of INFORMED CONSENT.

A releases of legal document / medical information, where patient Releases should always be in writing

DEALING WITH PROXY DECISION MAKERS The duty of care of health care providers is to the patient, the consent to treatment or refusal to

treatment is legally considered to be the action of the patient.

Whether the proxy actually carries the wishes of the incompetent patients is not a causethat a court will entertain, however as long as the decision is made by the person with

the legal authority to make.

The court will hear and decide cases when the authority of the proxy is challenged( rather than the proxys decision)

END OF DISCUSSION PART i General issues in Hospice and palliative care CHAPTER FOUR


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How to deal with the general issues: Careful history taking Careful review of symptoms and thorough physical examination Set realistic goals as you plan the care for the client 1. asthenia the absence or loss of energy or strength fatigue

The general causes of fatigue are:

Infection Anemia Chronic hypoxia Metabolic and electrolyte disorder Psychogenic Pharmacologic Malnutrition Treatment = improve the clients sense of well being (address each cause of

fatigue individually)

General measures = goal settingMEDICATIONS:

Corticosteroid- used to produce a feeling of well being and increased energy in patient withterminal cancer (improvement usually seen after 10 to 14 Days of therapy)

dexamethasone and prednisone Psychostimulantsfatigue associated with depression or opiod-induced sedation may respond

to psychostimulants.

Methylphenidate may be initiated at 5 mg in the morning and at noon, avoiding doseslater in the day to prevent interference with sleep and titrated to 40 mg per day


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Erythropoietin ( the growth factor) to increase hemoglobin, hoping to reverse thefatigue associated by anemia

Antibiotics to all episodes of infection for it does not only causes fatigue but they arealso often life threatening

2. DYSPNEA Associated with clinical conditions where

Respiratory system is subject to an increased mechanical workload Ventilation needs to be increased There is respiratory muscle weakness due to fatigue, paralysis or lung volume

increase

Treatment = treat the underlying causes of dyspnea

3. constipation the infrequent, difficult passage of small hard stool. Probable Causes of Constipation:

Decreased fluid and fiber intake in the diet Poor blood circulation in the GIT Decreased physical mobility Medication (eg. Calcium supplements) Any condition that increases colonic absorption What are the principles in using Laxative Therapy

It is better topreventconstipation than wait to treat it. If there is fecal impaction, evacuation will not occur until manual rectal

disimpaction is performed

Intestinal obstruction must be ruled out Combining agents with different mechanism of action often will improve results

Types of laxative therapy Bulk forming laxative


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-Contains polysaccharide or cellulose derivatives resistant to bacterial breakdown, more than 24

hours to effect and often Ineffective in the terminally ill patient.

- Inappropriate for use in opiod-induced constipation

Emollient laxative (eg. Mineral oil)-this lubricate the stool surface and penetrate the feces to soften and promote easier passage.

-Also acts to decrease colonic absorption of water.

-15 to 30 cc daily is given which takes effect in 8 to 48 hours, given at bedtime but caution

should be observed for aspiration is a common problem in the elderly that might cause acute or chronic

lipid pneumonitis.

Fecal softeners-composed of surfactant agent not absorbed by the gut.

-Act as detergent to increase water penetration in the stool bolus, making it softer and easier to

expel.

-Also promote water and electrolyte secretion, with an effect from 24 to 72 hours

- Docusate, Poloxamer

Stimulant or irritant laxative-stimulate the myenteric plexus to induce peristalsis, commonly used preparations to stimulate

bowel movement.

-Include senna, bisacodyl (brown discoloration of acidic urine may occur in senna or cascara

sagrada.)

- All stimulant may cause severe cramping and abdominal discomfort, but may be avoided by

careful dosage titration and by using in combination with stool softeners

Osmotic laxative- exert osmotic effect by increasing the intra-luminal volume by retaining water, increase water

secretion and stimulate increase peristalsis.

-Lactulose and sorbitol

-15 to 30 cc one to two times daily.

- Flatulence is the undesirable effect.

-Glycerin is the rectal preparation


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Saline laxative- sulfate and citrate salts of magnesium

-Continuous use may lead to electrolyte imbalance for patient with hypertension, CHF or

significant renal dysfunction

Enemas-enemas may be available formulated with sodium phosphate, bisacodyl or mineral oil.

-Oil retention enemas are especially useful in the setting of very hard impacted stool

-should be used as an adjunct to a prophylactic oral regimen

Uses of enema includes:for surgical preparation and diagnostic purpose Pain

management

Health care providers are now required to do the ff: To recognized patients rights to pain assessment and management Assess the nature and intensity of pain Record results of assessment to aid in follow-up Ensure competency in pain assessment and management Support appropriate prescribing of pain medications Address the need for pain management in discharge planning

Unrelieved pain is associated with considerable detrimental physiologic andpsychosocial consequences

Pain can affect every aspect of a persons quality of life Unremitting pain can consume every aspect of life Pain may lead to feelings of isolation Emotionally: pain can be an expression of

hopelessness, helplessness, anger,


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anxiety, depression, and frustration

according to McCafferys (1968) Pain is: Whatever the person says it is, and existing whenever the person says it does This definition of pain designates the patient as the authority about pain Pain is inherently subjective phenomenon It is a sensation that is influenced by physical, psychosocial and spiritual circumstances. Examples:

the experience of pain can be impacted by knowledge and beliefs about pain; Previous pain experiences Particular styles of coping Educational level Age . gender Availability and type of social support systems Role models and family members Cultural, religious and social influences

Types of pain ACUTE- pain typically has a well-defined onset, lasts a relatively short period of time, and

responds well to treatment

Often signals an injury and when the injury heals, the pain disappears CHRONIC- or persistent pain may have a defined onset, can be mild or severe, and is present for

an extended period of time.

Often responds unpredictably to treatment In the dying, this pain can be unrelenting and is often progressive


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A person in painbody attempts to respondbrain (pituitary gland) produces protective

natural opioids (endorphins and enkephalins) to lessen the perception of painful nerve signalsthis

chemicals help to stop neuron from sending a pain message

Non-physiologic cause of pain Somatization disorder

Characterized by multiple physical symptoms Pain disorder

Has primarily physical symptom of pain, unrelieved by analgesic Palliation in Non-cancer Disease Palliation - easing the severity of a pain or a disease without removing the cause. To palliate a disease is to treat it

partially and insofar as possible, but not cure it completely.

The challenge of prognostic uncertainty In hospice enrollees should be terminal or having a prognosis of six months or less In palliation of non-cancer it is unpredictable for they tend to become stable until exacerbation

occurs.

Cancer patient responds to definitive therapy e.g. surgery. Radiation, chemotherapyfor only a period of time, it can be discontinued.

In non-cancer disease active treatment is effective until very near death Example of active treatment is the use of diuretics for CHF to relieve pulmonary

edema,

Intubation and mechanical ventilation for COPD Prognostic uncertainty makes it difficult to determine when non-cancer patients are

actually dying

It reduces the length of stay in hospice programs, almost one third of the patient diebefore the end of their first week in hospice.

It is important to remember that symptom management, advance care planning andpsychosocial/spiritual support are appropriate regardless of apparent stage of disease.

Severity indicators:


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This will determine which patients have end-stage illness. It will also help with the cost/benefit analysis of palliative intervention Criteria as adapted from the National Hospice Organization:

1. End-stage heart disease Usually manifested by heart failure

For those with systolic failure- left ventricle has become weakened anddilated

For those with preserve systolic function who have a small poorlycompliant(stiff) left ventricle that cannot tolerate pressure or volume

stress and cause multiple episodes of flash pulmonary edema, without

ventricular enlargement

Treatment for end-stage heart disease Diuretics and angiotensin converting enzymes (ACE) inhibitors -- (ACE inhibitors are

medications that slow (inhibit) the activity of the enzyme ACE, which decreases the

production of angiotensin II. As a result, the blood vessels enlarge or dilate, and blood

pressure is reduced. This lowers blood pressure and makes it easier for the heart to

pump blood and can improve the function of a failing heart.

angiotensin receptor blockers (ARBs)- Theangiotensin receptor blockers(ARBs), alsocalled angiotensin (AT1) receptor antagonists or sartans, are a group ofanti-

hypertensivedrugs that act by blocking the effects of thehormoneangiotensin II(Ang II)

in the body, thereby loweringblood pressure.

2. Heart failure is advance if patients continue to decline after hospitalization thatinvolved invasive monitoring with Swan-Ganz catheter.

Any patient failing an inotropic infusion of dobutamine ( stimulates the B-receptors of the heart, increasing myocardial contractility thereby increasing

cardiac output) should be considered for hospice evaluation or a primarily

palliative approach

3. Lung disease- considered advance when patient have disabling dyspnea, with bloodgas deficit, arterial pO2 below 60 on room air and pCO2 above 50.

Intubation and mechanical ventilation are necessary because the patient is already resistant to

bronchodilators.

4. Dementia including Alzheimer - is difficult to determine the prognosis.
http://en.wikipedia.org/wiki/Angiotensin_II_receptor_antagonisthttp://en.wikipedia.org/wiki/Angiotensin_II_receptor_antagonisthttp://en.wikipedia.org/wiki/Angiotensin_II_receptor_antagonisthttp://en.wikipedia.org/wiki/Anti-hypertensivehttp://en.wikipedia.org/wiki/Anti-hypertensivehttp://en.wikipedia.org/wiki/Anti-hypertensivehttp://en.wikipedia.org/wiki/Anti-hypertensivehttp://en.wikipedia.org/wiki/Hormonehttp://en.wikipedia.org/wiki/Hormonehttp://en.wikipedia.org/wiki/Angiotensin_IIhttp://en.wikipedia.org/wiki/Angiotensin_IIhttp://en.wikipedia.org/wiki/Angiotensin_IIhttp://en.wikipedia.org/wiki/Blood_pressurehttp://en.wikipedia.org/wiki/Blood_pressurehttp://en.wikipedia.org/wiki/Blood_pressurehttp://en.wikipedia.org/wiki/Blood_pressurehttp://en.wikipedia.org/wiki/Angiotensin_IIhttp://en.wikipedia.org/wiki/Hormonehttp://en.wikipedia.org/wiki/Anti-hypertensivehttp://en.wikipedia.org/wiki/Anti-hypertensivehttp://en.wikipedia.org/wiki/Angiotensin_II_receptor_antagonist


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The dementing process is not fatal but medical complications are. ,that thepatient is said to be nearing death.

Indicators of severe dementia increased incidence of complication,they become bed ridden prone to pneumonia, lung atelectasis, sepsis

etc.) Loss of the ability to ambulate independently and loss of the abilityto carry on meaningful conversation.

5. End-stage liver disease Bleeding from esophageal varices particularly for advanced liver disease Elevation of prothrombin time due to shortage of liver-dependent clotting

factors

6. End-stage renal disease (ESRD) Treated with dialysis For severe renal function abnormalities without dialysis, and to those whose

serum creatinine is over 6.0 or creatinine clearance under 10 ml/min (15 ml/min

for diabetics) short term mortality

Grief and Bereavement Issues in Hospice /Palliative Care Grief

Refers to the subjective emotions and affect that are a normal response to theexperience of loss.

Grieving/Bereavement Refers to the process by which a person experiences the grief.

Anticipatory grieving Is when people facing an imminent loss begin to grapple with the very real possible loss

or death in the near future.

Mourning Is the outward expression of grief. Theories of grieving process

Kubler-Ross stages of grieving 1.Denialis shock and disbelief regarding the loss NO NOT ME.


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2. Angermay be expressed toward God, relatives, friends or health care providers.WHY ME

3. Bargainingperson asks God or fate for more time to delay inevitable loss. WHYME.

4. Depressionresults when awareness of loss becomes acute. STAGE OF SILENCE 5. Acceptanceshows evidence of coming to terms with death. YES, ITS ME. NOTE: it is important that grief and bereavement is a normal transition or opportunity

to grow rather than a problem

To provide care in the end of life it is important to recognize suffering (grief and bereavement)and what are the growth opportunities it may afford the patient

Byock s areas for patient to grow and find meaning: Sense of completion with wordly affairs Sense of completion in relationships with community Sense of meaning about ones individual life Experienced love of self Experienced love of others Sense of completion in relationship with family and friends Acceptance of the finality of life- of ones existence as an individual Sense of a new self beyond personal loss Sense of meaning about life in general Surrender to the transcendent, to the unknown- letting go

It is not necessary for patients to examine each of these areas. The goal is to develop sense of closure or resolution, the patient may find

meaning and identity at a time when his or her connection to the world is

slipping away.

Techniques to develop the sense of closure: Storytelling Life review


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Reframing problemsIn hospice we aim for our patient to die well- which suggest that some preparation and work

may be necessary in order to realize the ending state.

The process of dying well is living life fully while dying. Principles of nursing care:

Be physically present. Be non-judgmental. Encourage verbalization of feelings. Allow the patient to cry. Recognize your own thought about death and dying.

hospice and pallative

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