Palliative medicine study and management of

patients with active, progressive, far advanced

disease for whom a prognosis is limited and the
focus of care is QOL
Palliative care- total care of patients
o Relief of pain and physical symptoms
o Attention to psychologixcal, social and
spiritual problems
o Interdisciplinary
Key points
Palliative nursing reflects whole person care
Palliative nursing combines a scientific
approach with a humanistic approach to care
The caring process is facilitated through a
combination of science, presence, openness,
compassion, mindful attention to detai, and
teamwork
The patient and family are the unit of care

THE NURSE GIVEVS ATTENTION TO THE
PHYSICAL
PSYCHOLOGICAL
SOCIAL
SPIRITUAL
EXISTENTIAL ASPECTS

MIDDLE AGES
Shelters or hospices
Crossroads
Shrines
Pilgrims
Miraculous cures


16th-18th centuries
Religious orders
Sick and dying
Most died at home
Women in the family


1800s
Madame Garnier
Calvier
Lyon, France
Mother Mary Aikengead + Irish Sisters of
Charity
Our Ladys Hospice Dubbin (1879)
Increase infirmaries, almshouses and hospitals
Medical Knowledge begins to expand

EARLY 1900s
Irish Sisters of Charity
St. Josephs Hospice, East London
St. Lukes Hospice of God, London

1935-1990s
Knowledge base increases
Worcester, Bowdly, Lindemann
, Hinton, Parkes, Kubler-Ross, Raphael,
Worden, etc

1960-1970s
Dr. Saunders = St. Christophers Hospice,
London, 1967
Multidisciplinary approach
Regular use of opioids
Uk programs adopted the St. Christophers
model
New Haven Hospice opens in the US
St. Boniface and Roal Victoria Hospital, Canada,
1974

1980s
Europe and North America palliative care
program expands
Medicare program adds a biospice care benefit
in their Palliative care for people AIDS(1984)
Similar programs open in east Asia and
Singapore
80s, the Philippine Cancer Society and PGH
offer hospice program

1990s
WHO convenes an expert committee
2000 ~
More palliative and hospice care specialty
training programs are established
IN 2006, Hospice and Palliative Medicine was
formally recognized in the US as a specialty field

THE PALLIATIVE CARE APPROACH
Traditional approach
o Initiates appropriate and
comprehensive palliative care LATE in
the course of the patients illnes





MODERN APPROACH
Provides patient and family care at the time of
DIAGNOSIS of a life threatening illness, or even
earlier- when it is strongly suspected or
considered
Addresses the pts and familys physical,
psychosocial and spiritual issues and problems
during the ENTIRE course of the illness and after
patients death










MODERN PALLIATIVE CARE
STRUCTURE OF DELIVERY
o SUPPORTIVE CARE: During active
treatment of the disease
o PALLIATIVE: When active treatment
options are exhausted
o HOSPICE:End-of-life care, during
patients final month
o BEREAVEMENT: Provided to the family
after the pts death
HINDI KO MABASA UNG PARANG PATHOPHY -__-

CORE OUTCOMES
1. Care should be coordinated across settings thru
regular high quality communication during
transitions or when needs change and thru
effective case management
2. Control of pain and symptoms, psychological
distress, spiritual issues and practical needs
should be addressed with patient and family
thru the care continuum
3. Patient and family should be prepared for the
process of dying and for death, if anticipated
4. Patient and family should receive ongoing info
to enable full understanding of the condition
and options, values should be elicited, pros and
cons of treatment should be reassessed
regularly, decisions of care should be sensitive
to changes in patients condition.


ACTIVE
AGGRESSIVE
INTENT
PALLIATIVE
INTENT
D





E





A




T




H

BEAREAVEMENT
ACTIVE
AGGRESSIVE
INTENT
P A L L I A T I V E
I N T E N T

D
E
A
T
H

BEREAVEMENT
SUPPORTIVE
CARE
ACTIVE
PALLIATI
VE CARE
HOSPICE
CARE
BEREAVE
MENT
CARE
ELEMENTS OF PALLIATIVE CARE
Patient Population
o All, debilitating chronic or life-
threatening illness, condition or injury
Patient-centered and Family-centered care
o Each pt and family is unique, thus must
be respected
o Both are units of care
o Family mems-rel or unrel, provide
support, pt has a significant relationship
Timing of palliative care
o Palliative care IDEALLY begins at
diagnostics, continued thru cure, until
death to bereavement
Comprehensive integrated care
o Multidimensional approach: id and
relief of suffering and improvement of
QOL thru prevention and relief of
physical, psychosocial, social, spiritual
distress
o Integrated and well-coordinated
approach: coordination of care
specialist
Relief of suffering and improvement of QOL
o Primary Goal: Prevention and relief of
distress caused by the disease or
treatments, improve QOL of pt and
family
Respect of the dignity of the patient and family
o Upholds dignity of human life
Communication
o Developmentally appropriate
o Effective sharing of info
o Active listening
o Determination of goals and preferences
o Assisting with DM
o Effective communication with all
individual involved in the patient and
familys care
Terminal and Bereavement care
o Knowledge on prognostication, sign and
symptoms of imminent death, skill in
care and support of patients and family
before and after death
Continuity of care across settings
o Promotion of palliative care across
different settings(hosp, ER, nsg home,
home care, assisted living facilities,
OPD, non-traditional environments)
o Coordination and collaborations with
other professionals
Palliative Care Team
o Palliative care specialist(with other
specialists) + support staff
Equitable access
o To palliative care across all ages and
patient population
Quality improvement
o Commitment to pursuit of excellence
and high quality of care
o Regular and systematic evaluation of
processes and outcomes
Patient populations:
o Congenital injuries/ conditions leading
to dependence on life sustaining
treatments of long term care by others
for support of their ADLs
o Acute, serious and life threatening
illnesses(severe trauma, leukemia,
acute stroke) where cure or
reversibility is a realistic goal but the
condition itself and its treatments
carry significant burden
o Progressive chronic cnondiotns( PVDs,
malignancies, CRF, CLF, stroke with
significant functional impairment,
advanced heart/lung disease, frailty,
neurodegenerative disorder,
dementia)
o Chronic, life-limiting injuries from
accidents or other forms of trauma
o Seriously or terminally ill pts(ends-
stage dementia, terminal cancer,
severe disabling stroke) who are
unlikely to recover or stabilize

FORMS OF PALLIATIVE INTERVENTIONS
1, ACTIVE OR DISEASE-MODIFYING INTERVENTIONS
Aggressive interventions that MODIFY
Chemtx, hormonal tx, aggressive ATB tx, radn
tx, meds used to relieve symps and prolong life
Ttts may be invasive
Complications are tted aggressively
2. CONSERVATIVE COMFORT INTERVENTIONS
comfort measures
Relatively non-aggressive -> Relieve symptoms
Prolongation of life is NOT the goal BUT may be
a result of
Drug tx: analgesics, anxiolytics, antiemetics,
laxatives, antidepressants, antiinflams
Care may be provided at home or at OPD
Complics are tted noninvasively
3. URGENT PALLIATIVE INTERVENTIONS
For severe of rapidly worsening discomfort and
suffering
Goal: to relieve sypms QUICKLY to prevent pt.
suffering for a sig amt of time or may die with
uncontrolled suffering
Drugs: opioids, sedatives, neuroliptics
Mandatory if distressing px occur near at death

THE BOP-PSYCHO-SOCIA-SPIRITUAL APPROACH TO
PALLIATIVE CARE


SOLO SPECIALIST MODEL VS. BASIC TEAM MODEL

SOLO
If resources are limited
Team approach is unsustainable
Assessments, recommendations, care
Main disadvantage: limited number of cases can
be handled
TEAM
Headed by a palliative care specialist,
clinical/nursing support staff, psychosocial and
spiritual support staffs
Can handle more cases
Main disadv: added costs and resources needed
to initiate and sustain team

PHYSICAL
PSYCHOLOGICAL
SOCIAL
SPIRITUAL
qol,dignity,relief
of suffeing and
distress
PHYSICAL
SPIRITUAL
PSYCHOLOGICAL
SOCIAL
COMPREHENSIVE MULTIDIMENSIONAL APPROACH OF
PALLIATIVE CARE
DEVELOPMENTS IN PALLIATIVE CARE
HOSPITAL-BASED PALLIATIVE CARE
Most common place to die
Routine and ritual of hospital care
Roles of personnel
Specialist Palliative care(support
teams)1976, St. Thomass Hospital,
London(1975, St. Lukes Hosp, NY)
Chaplain, SW , N, MD


Problems and Issues
Inadequate and ineffective communication
Conflict between acute and palliative care
Source of stress
Inadequate facilities
Inadequate preparation and support for staffs roles
COMMUNITY PALLIATIVE CARE
Majority died at home
1969, extension to inpatient care ate Sy.
Christophers Hospice, London
Incomplete preference to die at home
1990, Palliative Day Care
Problem and Issues
Nurses need support
Different home and family values,
psych, social , spiritual make up
Symp control is oflen less effective
at home
Comm and coordination is more diff
Fragmentation of care
Marginalization of pt and family in
DM












-`DONDEE<3
PATIENT
AND
FAMILY
Disease
management
Management
of phyical
problem
Mangement of
psychological
problem
Management
of social
problem
Management
of spiritual
problem
Counseling and
DM
Care of family
members,
caregivers and
familt unit
Supportive
care planning
and delivery
End-of-Life
care
management
of terminal
phase
loss,grief,
bereavemment