Peculiarities Of Care For Dying Patients Essay

Comfort measures are crucial for the dying patient and their loved ones. Comfort measures, not only, include pain management but also massage, music, position changes, and heat, which are all just as important. Palliative care is an extremely important aspect of nursing. Palliative care “focuses more broadly on improving life and providing comfort to people of all ages with serious, chronic, and life-threatening illnesses” (http://www.WebMD.com). The ultimate goal of comfort measures and palliative care is to ensure that the patient has a more relaxed and peaceful death (End of Life care:

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Supporters of palliative care feel that it is against two of the main ethical principles of healthcare to not recognize the suffering of the terminally ill (End of Life Care: An Ethical Overview, 16). These principles are beneficence and non-maleficence (End of Life Care: An Ethical Overview, 16). Beneficence means that the healthcare provider is helping or attempting to help the patient (End of Life Care: An Ethical Overview, 16). Non-maleficence means that the healthcare provider is not harming the patient (End of Life Care: An Ethical Overview, 16). Palliative care includes an around-the-clock pain management schedule. Those who “received early palliative care actually had lower rates of depression and better quality of life than patients who received standard treatment only” (http://www.WebMD.com). According to WebMD, a study was published August 2010 in the New England Journal of Medicine by researchers at Massachusetts General Hospital which compared palliative care to standard care for lung cancer patients. The study found that those patients who received palliative care lived 2.7 months longer than the patients who only received standard care (www.http://www.WebMD.com). They stated that it could be “due to more effective treatment of depression, better management of symptoms, or less need for hospitalization” (http://www.Web MD.com). This study is a great tool to show how important the treatment for relief Peculiarities Of Care For Dying Patients Essay

Hospice nursing can be difficult. Many times nurses transitioning into hospice care face struggles they would not encounter in other specialties. However there is a level of recognition involved in hospice care as it necessitates better care of patients and a stronger connection to the job and self. Many nurses working in hospices have detailed their work experiences in reflective essays and even journal articles. “Chapter members are nominated by peers in recognition of their contribution to oncology nursing and to ONS, both locally and nationally. The timing of the award prompted me to reflect on my nursing values and the steps that led me to where I am today” (Thompson, 2013, p. 673). This essay will include the experience of one community health nurse by the name of osalind and her struggles and triumphs in hospice nursing.Peculiarities Of Care For Dying Patients Essay

Being available as well as a coordinator characterises the nurse’s role across healthcare systems. The nurse acts as a link between different levels of health care, between different professions and between patient and family, which contribute to ensuring the quality of care to the individual patient. The review illuminates that the basic tenets of care in nursing are also fundamental to the nurse’s role in palliative care. To be able to give individually tailored palliative care to patients with life‐threatening illnesses and their relatives, the nurses need all their knowledge of basic nursing. Situations challenge nurses in practical, relational and moral dimensions of care and make demands on their role in a comprehensive way.

Relevance to clinical practice
Nurses need knowledge and training, guidance and support to fulfil their role.

What does this paper contribute to the wider global clinical community?
Nurses’ availability and competence give them a natural position as coordinator.
Professional knowledge and person‐oriented competence are highly intertwined in the nurse’s role.
The nurse’s role is challenged in all dimensions of care: the practical, the relational and the moral.Peculiarities Of Care For Dying Patients Essay
1 INTRODUCTION
Nurses meet patients who suffer from life‐threatening illnesses in all healthcare settings. This requires knowledge and expertise in palliative care wherever nurses work in the health system. Cicely Saunders (1978, 196), the founder of the modern Hospice movement, emphasised just the need for skilled and experienced nursing as an essential element in the management of terminal malignant disease.

Palliative care, which is based on the modern Hospice philosophy movement, provides guidelines for the care of seriously ill and dying patients to improve quality of life for patients and their families. The approach is multidisciplinary to address the complexity of needs for patients and relatives. World Health Organization (2011) underscores that the lack of training and awareness of palliative care among health professionals constitutes a major barrier to the improvement of care. The European Association for Palliative Care (EACP) specifies 10 core competencies for health personnel (Gamondi, Larkin, & Payne, 2013) and states that all personnel need knowledge and competence in these areas but at different levels based on their exposure to various dimensions of practice (De Vlieger, Gorchs, Larkin, & Porchet, 2004; Gamondi et al., 2013).Peculiarities Of Care For Dying Patients Essay

However, efforts to ensure quality of life for patients in need of palliative care are demanding on many levels, due to differences in resource allocation, cultures and healthcare systems. A UN report (UN News Centre, 2014) identifies unmet needs for palliative care worldwide. A current trend is to see palliative care as an approach that should be integrated in a standard of care (Coyle, 2015; World Health Organization, 2011).Peculiarities Of Care For Dying Patients Essay

Such a change can challenge what is seen as specific for palliative care as opposed to basic care. Nevertheless, this change may lead to a focus on the patient’s quality of life at an earlier stage of the course of the disease and not just at the end of life, thus creating a more fluid transition through the various phases in the illness trajectory (from curative treatment to life‐prolonging treatment and end‐of‐life care). As such, a palliative approach is required regardless of where the patient is in the course of a severe disease, although it is, naturally, particularly important at the end of life. However, this review relates to WHO’s definition of palliative care as an approach that improves the quality of life of patients facing the problems associated with life‐threatening illness. Our focus concerning palliative care encompasses seriously ill and dying patients.

Patients receiving palliative care can be encountered anywhere in the health systems. Although nurses make up the largest group of healthcare professionals, there is a scarcity of knowledge of their role in carrying out palliative care across institutions and their place of work in the healthcare system.

However, some studies have looked at the nurse’s role in a specific field or from a specific nursing perspective. Walshe and Luker (2010) did a review of 46 papers to construct a detailed account of the district nurse’s role in providing palliative care. Offen (2015) did a meta‐ethnography on the district nurse’s role in palliative care. The study found, among other things, uncertainty surrounding the nurse’s role. In another literature review of the role of the specialist palliative care nurses in the community (Mulvihill, Harrington, & Robertson, 2010), one of the findings was a need for clarification of the nurse’s role. These reviews, which are all from the same level of health care, namely home care, demonstrate a need for clarification of the nurse’s role. Knowing that the profession of nursing may be difficult to describe, there is a need for clarifying its role and function, not least in the cooperation with other professions in a multidisciplinary team, so crucial in palliative care.Peculiarities Of Care For Dying Patients Essay

Summing up, palliative care is integrated in all levels of the healthcare services: in the community, nursing homes, hospitals and palliative care units and hospices. However, reviews of the nurse’s role in palliative care have mainly been done in one particular context, namely home care. There is a need for descriptions of the nurse’s role in performing palliative care across institutions and wherever nurses work in the healthcare system. On this background we want to illuminate how nurses describe their own role in giving palliative care to patients with severe incurable disease and uncertain life span, across various health levels and institutions. The aim of this review was therefore to explore how nurses, across various healthcare systems, describe their role in providing palliative care.

2 METHODS
2.1 Problem identification and design
Initially, the authors had a long process of narrow down the subject under study, and, in particular, to identify the purpose of the review. After some initial searches and reviews of articles, we decided to do a qualitative review.Peculiarities Of Care For Dying Patients Essay

The meta‐synthesis was inspired by thematic synthesis described by Ring, Ritchie, Mandava, and Jepson (2011). A thematic synthesis identifies recurring themes, analyses these themes and draws conclusions (Ring et al., 2011). The purpose of the method is to develop analytical themes through a descriptive synthesis and find explanations relevant to our particular review questions on how nurses experience their role in palliative care.

Public health approaches to palliative care have a valuable contribution to make in understanding and developing community capacity related to , dying, loss and care acknowledging that carers of the dying and bereaved are an important group who have their own significant needs in end -of-life care.5 Primary care has a vital role in delivering palliative care. 6,7 In most developed countries more people die in hospital than at home 8,although substantially more people would prefer to die at home.9 Primary care professionals play a central role in optimising available care, but they often lack the processes and resources to do this effectively.6,10 The Gold Standards Framework (GSF) for community palliative care 11 is a primary care led programme in the United Kingdom that is attracting international interest.7 The framework enables general practitioners and community nurses to optimise practice by providing guidance through workshops and locally based facilitation on how to implement processes needed for good primary palliative care. It is supported by a plethora of practical tools, guidance documents, and examples of good practice.12 It is regarded by many as “the bedrock of generalist palliative care”. Peculiarities Of Care For Dying Patients Essay  GSF is recommended as best practice by the Department of health End of life care strategy, NICE, Royal College of General Practitioners, Royal College of Nurses and other major policy groups.

1.3 Care pathways in palliative care
A care pathway is a plan of how someone should be cared for when they have a particular medical condition or set of symptoms. There is increasing evidence that using an integrated care pathway to manage care at the end of life is good way to implement and monitor best practice, and to standardise care in a variety of care settings. The use of pathways to manage the care of dying patients has gained considerable support from the clinical teams who have used them, as there is evidence that use of such pathways improves the quality of care in the last days and hours of life. A number of end of life care pathways have been developed but the first and most well known is the Liverpool Care Pathway for the Dying Patients (known as the LCP).13

A number of other pathways are available in relation to supporting the care of dying patients:Peculiarities Of Care For Dying Patients Essay

– Pathway for Improving the Care of the Dying (PICD) (Australia)

– Palliative Care for Advanced Disease (PCAD) pathway (USA)

– Department of Veteran’s Affairs (DVA) Palliative Care Clinical Pathway (Australia)

– Gold Standards Framework (GSF) for community Palliative Care (UK)

– Preferred Priorities for Care Plan (PPC) (UK)

The Liverpool Care Pathway (LCP) is aimed at improving care and communication in the dying phase. In the UK, the LCP was developed to improve care for dying patients.14 The LCP was developed to take the best of hospice care into hospitals and other settings. It is used to care for patients in the last days or hours of life once it has been confirmed that they are dying. The LCP is designed to enable all healthcare workers to provide optimal care to dying patients, whether they are specialists in palliative care or not, by guiding clinical decision making. The LCP is a legal document which replaces the usual medical record at the end of life, and is structured to facilitate audit and outcome measurement.15 It promotes clear communication around the dying and death of the patient, and it supports psychosocial and spiritual care to the patients and their relatives, for example, by promoting adequate communication and support and giving relatives a brochure for bereavement after the death of the patient.15 The UK and 13 other countries are registered with the LCP Continuous Quality Programme. 16 In Scotland the LCP is applied by 12 of the 13 voluntary hospices; but only a quarter of district nurses reported in 2008 that they are currently using the LCP.17 In NHS Greater Glasgow and Clyde 37% of the GP practices, 33% of the nursing homes and 47% of the wards in the acute operating division are in the process of implementing the LCP. Peculiarities Of Care For Dying Patients Essay

NOW

1.4 Pharmaceutical care context of palliative care
It is estimated that one in three people in the UK will develop cancer and one in four will die from it.19The survival rate for cancer is increasing with more patients being treated as day-case patients. The length of stay for in patients is also decreasing, therefore it is essential to ensure appropriate care continues in the community setting.20 Hepler and Strand defined pharmaceutical care as improves a patient’s quality of life.21 For pharmaceutical care to be successful, a quality system should be implemented to ensure appropriate patient outcomes. It is important that all pharmacy members of the healthcare team in different settings are included in the delivery of pharmaceutical care.22To ensure continuity of care, pharmaceutical care plans require to be updated when the patient’s needs change. Seamless care helps patients to move across healthcare boundaries without experiencing a gap in the standard of healthcare delivery, but this requires effective communication between primary and secondary care.23 In providing pharmaceutical care, pharmacists co-operate with doctors, patients and/or carers in designing, implementing and monitoring a “pharmaceutical care plan”. The pharmaceutical care provided aims to optimize drug treatment and achieve specified therapeutic outcomes. This has the potential to reduce drug-related problems and improve patient’s quality of life Peculiarities Of Care For Dying Patients Essay

To support the local delivery of chemotherapy, models of care need to be developed and remote models of care need to be developed and remote patient monitoring performed which is linked to an electronic health record.24 The use of an electronic record would undoubtedly improve seamless care. It is therefore essential that improvements are made in the transfer of pharmaceutical care. Over the past decade, there has been a large increase in the number of patients receiving cancer treatments and symptom relief treatments at day-case chemotherapy clinics25. With the increase in the prescribing of oral chemotherapy and the use of ambulatory intravenous pumps which allow patients to receive continuous chemotherapy at home, there is increasing need for hospital pharmacists to liaise more closely with general practitioners (GPs) and community pharmacists to explain unusual indications for a drug or unconventional dosage regimens. This liaison is needed to avoid incidents reported through the in-house reporting system such as inadvertent continuation of intended short courses of medication, for example, dexamethasone prescribed for three days as an anti-emetic after chemotherapy. There is a need for the required clinical monitoring to be undertaken in primary care to minimise risks associated with these medicines. It is essential that detailed information on monitoring requirements is conveyed from the day-case clinic to the patient’s GP and community pharmacist, so that both are aware of the therapeutic plan for the patient and management of potential toxicities and possible drug interactions.Peculiarities Of Care For Dying Patients Essay

Methods of transferring care require exploration and hence Julie Fisher et al,in their study examined and designed a documentation system to monitor pharmaceutical care between cycles of chemotherapy for patients who attended an oncology care unit.24 Their study confirmed a recognised need for continuity of pharmaceutical care between hospital and community pharmacists.

The Gold Standards Framework Scotland (GSFS) was introduced in 2003 and is an adapted version of the GSF for implementation within NHS Scotland. The Gold Standards Framework Scotland provides a means of improving the quality of care provided by primary care teams in the final year of a patient’s life. The main differences to the core GSF are : addressing the needs of patients from diagnosis onwards; maintaining a GSF palliative care register, and ; advanced care planning, defined as a process of discussion between an individual and their care providers about individual’s concerns, their preferences for types of care and their understanding of their illness and prognosis.Peculiarities Of Care For Dying Patients Essay

Across Scotland, 75% of GP practices are registered as using the GSFS.17 As of 2009, 80%of GP practices in NHS Greater Glasgow and Clyde are signed up for the GSFS.18 The most recent development in 2009 has been the electronic Palliative Care Summary (ePCS). The ePCS allows, with patient or carer consent, the access to daily updated summary information from GP records for Out of Hours services and NHS 24. This facilitates structured and accurate information to be available in hours and out of hours to support palliative care patients and their families. The ePCS includes: prescribed medication, medication diagnosis, patients’ and carers understanding of prognosis, patient wishes about place of care and resuscitation.26, 18.

The UK department of Health has proposed that Primary Care Trusts across England should invest in pharmaceutical care services giving patients access to more help from pharmacists in using their medicines.27 Evaluation of pharmacists’ interventions has shown that they can make a valuable contribution in secondary care settings such as hospices and hospitals.28 Lucas et al found that more than 60% of pharmacists’ interventions in an inpatient palliative care unit could significantly improve patient care.29 The pharmacist advised on the appropriateness of medication regimens, side effects and contraindication of medication and provided drug and prescribing information to patients and staff. Despite being perhaps the most accessible healthcare professional, there is limited research into the possible contribution of community pharmacists to community-based palliative care in the UK. A recent review showed that the delivery of palliative care to patients in the community is far from ideal.30 Inadequacies in knowledge and training of professional currently providing palliative care to patients at home may prevent the patient receiving optimum pain and symptom control.31, 32 Fragmentation and poor organisation of current palliative care services may result in a loss of continuity of care for such patients or hinder the timely availability of appropriate medication.33,34 Poor communication within existing teams and across organizational boundaries also limits the provision of effective palliative care to patients in the community.35,36 If community pharmacists were included in the local network of healthcare professionals, this would benefit all parties, especially patients and carers, and it would help to share the over-increasing work load in palliative care, due in part to an aging population. Needman et al, 37 assessed the effectiveness of community pharmacists’ clinical intervention in supporting palliative care patients in primary care using an independent multi-professional panel review. In their study, they suggested that when trained community pharmacists are included as integral members of the multi-professional team, they can intervene effectively to improve pharmaceutical care for palliative care patients in the community, providing additional support for them to remain at home; because majority of palliative care patients spend most of their last year at home under the care of their GP and the primary care team.Peculiarities Of Care For Dying Patients Essay  38 It is only when the community pharmacist knows and have the details of the patient’s medical condition and prognosis , that she is able to suggest new therapies or to titrate existing ones. Unfortunately in the present UK community pharmaceutical services system, the community pharmacists are unlikely to know the medical diagnosis of the patients or other essential clinical details.39, 40 As a result, community pharmacists in general are unable to make full use of their knowledge and expertise or to anticipate problems and advice on them. The recent NHS pharmacy plan advocates that personal medicine management services should be provided by community pharmacists in the future.27

The study of Needman et al showed that the personal palliative pharmaceutical care services are feasible in everyday practise when community pharmacist is included in the multidisciplinary palliative care team.37

In 2002, the Scottish Government through its publication “The Right Medicine: A Peculiarities Of Care For Dying Patients Essay

strategy for pharmaceutical care in Scotland”, proposed a better use of pharmacists’ professional competence in planning and delivering services, especially in priority areas such as cancer, heart disease and mental health.41This policy document placed emphasis on the continued development of Pharmaceutical Care Model Schemes including palliative care, initiated in 1999 in collaboration with the Royal Pharmaceutical Society in Scotland. This work has developed and now all NHS Boards have developed Community Pharmacy Palliative Care Networks. Access to specific palliative care medicines within and out with working hours via this network is quality standards in all NHS Board areas.42 Within the NHS Greater Glasgow and Clyde area 71 of the current 312 pharmacies are involved in the Community Pharmacy Palliative Care Network. This network was established in 2001 and is funded by NHS Greater Glasgow and Clyde18, 43, 44. The purpose of the project is to increase awareness of the community pharmacist’s role, their capacity to manage patients requiring cancer and palliative care support, reduce risks and effectively manage anticipatory care needs to minimise out of hours issues. The services of the network pharmacies includes: retailing a stock of more specialized medication which may be required for palliative care; a courier service for transport of urgent prescriptions and medicines, and ; provision of advice and support to other pharmacies, GPs and district nurses.Peculiarities Of Care For Dying Patients Essay

In 2006, a new community pharmacy contract was agreed with the Scottish Government to modernise community pharmacy practice and to support the delivery of pharmaceutical care. The contract is based on four core services, namely the acute medication service, the minor ailment service, the public health service and chronic medication service (CMS) 45 of which palliative care is one. The Chronic Medication Service (CMS) will also require patients to register with a pharmacy. It will enable a pharmacist to manage a patient’s long-term medication for up to 12 months. Under this service, a patient can have his or her medicines provided, monitored, reviewed and, in some cases, adjusted as part of a shared care agreement between the patient, the GP and the community pharmacist. It is in this service that an emphasis on the systematic approach to pharmaceutical care is particularly apparent; it will incorporate the pharmaceutical care model schemes, serial dispensing and supplementary prescribing.

In October 2008, the Scottish Government published “Living and Dying Well in Scotland. ‘Living and Dying Well’ is the first plan for the development of a single, cohesive and nationwide approach to ensure the consistent, appropriate and equitable delivery of high quality and person centred palliative care based on neither diagnosis nor prognosis but on patient and carer needs. The concepts of assessment and review, planning, coordination and delivery of care, of communication and information sharing and of appropriate education and training are addressed in this Action Plan. The Action Plan states that NHS Boards and Community Health Partnerships (CHPs) should take steps to ensure that patient with palliative care needs are included in a palliative care register and are supported by a multidisciplinary team. The Action Plan also emphasises the importance of proactive care planning and anticipatory prescribing to aid the prevention of unnecessary crisis and unscheduled hospital admissions, particularly out of hours. This also includes the planning for stages of illness trajectories that are likely to produce changing patient needs in the future.Peculiarities Of Care For Dying Patients Essay

Key to the progress of “Living and Dying Well” is its emphasis on a person centred approach to care and care planning and on the importance of communication, collaboration and continuity of care across all sectors and all stages of the patient journey. In order to fully realise the necessary improvements in palliative and end of life care, NHS Boards should review their projects the “Living and Dying Well” actions and the actions set out in Living and Dying Well: Building on Progress – with particular priority on the following areas. Peculiarities Of Care For Dying Patients Essay

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