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David Gonçalves Nordon , Mirian Soriano Moreno , Marco Tullio de Assis Figueiredo , Maria das Graças Mota Cruz de Assis Figueiredo
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Rev. Fac. Ciênc. Méd. Sorocaba, v. 12, n. 2, p. 1 - 3, 2010
Comfort for a patient in palliative care is very important. fecaloma, using oral laxatives may cause severe pain and lead to
Although in the first stages of the disease the patient is not no result at all. Then an intestinal cleanser or manual removal of
seated all the time, as the disease progresses (and also as a side the feces is needed; and
effect of medication) it will be natural for him to stay seated in - In case of delusions the cause must be identified
the same position for long periods of time. Therefore, it is (alterations of the medication dosage, medications interaction,
important to stimulate the patient to change position when dehydration or organic diseases, psychiatric commorbidities or
possible or to change it passively, so as to avoid pressure ulcers. delirium) and the correct treatment must be made.
Comfort must be evaluated and aimed for, for there is no use if in
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order to avoid an ulcer the patient must stay in a painful position Delirium
for a long time.
Delirium is the alteration of the conscience level,
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Feeding quantitatively (when there is lowering of the level) and/or
qualitatively (changes of the conscience and its clearness). It is
As often as possible the patient should be stimulated to often characterized by time and space disorientation, delusions
feed him/herself, or if it is not possible, to be fed orally by a and/or hallucinations, and fluctuating course during the day,
caretaker no matter how long it takes. Patients with being worse at sundown (sundown effect). It may be
neurodegenerative diseases generally present some kind of hyperactive, hypoactive (when it causes more lethargy and
swallowing difficulty, so it is natural that they take longer to be drowsiness) or both.
fed. As a result, diet must be adequate, being prepared in such a The main causes of delirium are organic and must be
way it is easy to be swallowed (in the form of a cream or liquid, thus looked for: dehydration, constipation, urinary retention
when necessary). and infections in general, being urinary the most prevalent.
Feeding is the first stage in the human being's Drug induced causes cannot be overlooked; besides, it is
development and is an essential part of his/her psychic possible that an elderly embedded in a room without stimuli or
constitution. To be deprived of this pleasure is practically the with excessive stimuli comes to develop delirium without any
same as being deprived of his/her own humanity, even for a causal factor in a matter of hours.
patient who is not lucid enough to communicate. Feeding The treatment must firstly be directed to the cause in
through nasogastric tube or even parenteral nutrition must be, order to stop it; secondly, in case it is not enough neuroleptic
thus, restricted to when there is no other option. and/or benzodiazepines may be used to control the crisis.
In these cases when the patient is in an Intensive Care Always remember to use those with shorter half-life, which
Unit, for instance, the time he/she is going to spend there must cause fewer side-effects.
be taken into account. It is recommended that if he/she is It is possible to prevent it by preventing the above
expected to stay longer than two weeks, a colostomy be made, related causal factors and keeping the patient with adequate
instead of a nasogastric tube, in order to avoid lesions and/or stimuli and information, such as day, hour and sunlight, apart
stenosis of the esophagus and subsequent incapacity of oral from the constant contact with the caretakers.
nutrition.
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Patients with Alzheimer's disease in its final stage Spirituality
presenting secondary parkinsonism will mandatorily need a
bigger intake of calories and proteins than normal. Nevertheless The spirituality of patients in palliative care must be
these patients are usually fed even less than normal due to the always taken into account. What is important for the patient in
difficulties related to this condition. It is essential that attention the process of sickness and death? It may be a hastening
be paid to this difficulty and that it be avoided at all cost. These question when we think of a patient at the beginning of the
patients, when lucid, may claim that they are hungry all the disease; however, when we think that the natural course of this
time; when they do not, it is possible to perceive so their disease results in a progressive cognitive deterioration it is
constant loss of weight, in spite of being fed. important for the Alzheimer's patient, to have a course of action
laid out bearing in mind since the beginning what is important
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Medication for him/her.
Does he/she have any religious belief? Any ritual? How
Patients with Alzheimer's disease usually take important is religion to him/her? Would it be benefitial to take
anticholinesterasic medication. It is known that such drugs him/her to church? Or to make a religious reunion in the long-
cause cholinergic symptoms and may predispose to dry mouth, stay institution?
constipation and delusions. Some special care must be taken: Besides, as soon as it is necessary and preferably before
- Constant hydration, especially because the elderly are the patient becomes irreversibly demented, it is important to
more prone to developdehydration as they tend to feel less know what he/she wishes for his death: to be buried or
thirsty; cremated? How will his/her funeral be? Who should be present
- Measures to stimulate defecation such as laxatives that at the moment of his/her death? Does he/she want any religious
increase the volume of feces (fibers) or that facilitate their leader to be called?
movement (surfactants, such as sodium docusate; lubricating During the progression of a terminal disease, it is quite
laxatives must be avoided in patients with swallowing visible that the patient becomes gradually more aware of his/her
difficulties, due to the possibility of aspiration); colonic mucosa terminality, thus making it important for the caretaking team to
stimulants (bisacodil), which are particularly useful in help the patient then. The Alzheimer's patient, however, may
constipation due to opioids; and, finally, rectal laxatives when somehow seem spared of it, since in the final stages he/she may
all other measures have proved ineffective or cannot be used or be so little lucid that seem unable to understand what is
there is feces impaction. It is important to note that, in case of happening.
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Revista da Faculdade de Ciências Médicas de Sorocaba
In these cases it is up to the caretaking team, which simple and small things, such as basic hygiene, adequate
probably has known the patient for several years by then, to nurturing, comfortable furniture, adequate and smooth stimuli
evaluate how he/she is feeling; if he/she is spiritually comfortable and most important of all human attention and care it is possible
and if all his/her wishes, previously determined, have been for us, health professionals as a group, to promote a comfortable
answered, beforethemomentof death comes. and honored care for those who are so loved by their families.
We cannot forget that, eventually, we might be the ones on the
The Namaste Care Program9 other side in need of the same care.
Diretoria
Enio Marcio Maia Guerra
João Luiz Garcia Duarte
Celeste Gomes Sardinha Oshiro
José Eduardo Martinez
Dirce Setsuko Tacahashi
Nelson Boccato Jr.