1. Why is it important to have a multidisciplinary team in palliative care?

(Write your
answer in 100-150 words.)
A multidisciplinary team will mean different things to different services. For some it will mean
having many specialist palliative care practitioners involved in the service itself. This could be
Pastoral Care Workers, Social Workers, Music Therapists, Bereavement Counsellors or
Occupational Therapists. For others it will mean referring to health professionals within the same
organisation or health service, such as a hospital physiotherapist. For some in more rural and
remote areas this referral to other disciplines may be difficult with long waiting lists and
distances to travel for appointments.

For the specialist palliative care team the term 'interdisciplinary team' is commonly used and is a
common model of practice. An interdisciplinary team is that which has roles that sometimes
overlap between disciplines and generally the team will share information and work
interdependently. While the patient and family may only see one or two members of the team,
those members will be supported by the interdisciplinary team in which they practice.

2. What is the role of rehabilitation in palliative care? (Write your answer in 50-100
words.)

Palliative care requires an interdisciplinary team approach to provide the best care for
patients with life-threatening illnesses. Like palliative medicine, rehabilitation also uses
an interdisciplinary approach to treating patients with chronic illnesses. This review
article focuses on rehabilitation interventions that can be beneficial in patients with late
stage illnesses. Rehabilitation may be useful in improving the quality of life by palliating
function, mobility, activities of daily living, pain relief, endurance, and the psyche of a
patient while helping to maintain as much independence as possible, leading to a decrease
in burden on caregivers and family. Rehabilitative services are underutilized in the
palliative care setting, and more research is needed to address how patients may benefit
as they approach the end of their lives.

Explain in 50-100 words why you would introduce a palliative care client to an
entirely new craft activity.

In an experiment by la Cour K et al (2007) sixteen interviews were conducted with eight

participants over a period of 8-12 months. Participants were asked to narrate about their
engagement in creative activities at a palliative intervention program. Transcribed
interviews were analyzed with a phenomenological method. The results shows that
engagement in creative activities was found to ease life in proximity to death for persons
with advanced cancer and limited survival time. For the participants, creativity meant that
some of the consequences of incurable cancer could be confronted and alternative
potentials could be explored and acknowledged. This occurred in an ongoing process of
creating alternative ways to deal with life. Creative activity is a means for participants to
develop ways to adapt and cope with declining physical abilities and existential concerns
through working with their hands and bodies. This complements the often negative focus
in palliative phases of cancer with an understanding of how enriching aspects of life can
 be maintained. The results highlight how people in palliative care experience their
engagement in creative activity in the form of crafts, and how such engagements may be
a significant tool for finding alternative ways to handle challenges in ongoing life.

3. Part 1: What rights does the client have to receive complementary therapies in a
palliative care setting?
The client should receive skilled control over pain and other symptoms. Next, there
should be maintenance of confidentiality. For this, nurses, physicians and other health
professionals should be involved. The right to non-discrimination and equality, part of
many human rights treaties, is also particularly relevant to palliative care patients.
General Comment 14 provides that health facilities, goods, and services must be
accessible to all, especially the most vulnerable or marginalized sections of the
population, without discrimination on any of the prohibited grounds of “race, colour, sex,
language, religion, political or other opinion, national or social origin, property, birth or
other status”. This means people living with HIV/AIDS, people who use drugs, sex
workers, and ethnic minorities cannot be denied palliative treatment or care and must be
provided with the same level of care, in the same conditions, as other patients. The right
to bodily integrity and the right to information are also relevant in the context of patient
rights and palliative care and are often interconnected. The right to bodily integrity refers
to a patient’s autonomy and self-determination over his/her own body, and deems any
unconsented intrusion—physical or non-physical—to be a violation of this right,
including medical treatment performed without a patient’s informed consent or ignoring
patient wishes regarding treatment.

Part 2: List three complementary therapies that might be used in a palliative care setting,
together with a short description of each therapy.

Massage: Massage therapy involves stroking, kneading, tapping or pressing the soft
tissues of the body in a therapeutic way. Some people find massage helps them relax and cope
with symptoms better. Some studies have found that massage therapy could help reduce pain,
anxiety and depression in people with cancer.
Reflexocology: Reflexology involves massage of the feet, and sometimes hands. It’s
based on the belief that every area of your body is linked with a corresponding area on your foot.
Reflexologists believe that by applying gentle pressure to an area of the foot, it may have a
positive effect on the corresponding part of the body. They also believe that the hand is linked
with other parts of the body in a similar way. It’s usually carried out by a reflexologist while you
are sitting or lying down and only very gentle pressure is applied. Some people find that
reflexology helps them relax and feel better
Art Therapy: Art therapy involves creating art with a trained art therapist to express your
thoughts and feelings. You can create pictures or objects that have personal meanings. You don’t
need to be skilled at drawing to take part in, or benefit from, art therapy. Art therapy is usually
described as a psychological therapy rather than a complementary therapy, but it may have
similar effects in helping you relax and cope with your illness.
 4. Part 1 How would you encourage a client in palliative care to tell you about their
life story?

This is a straightforward, fill-in-the-blanks approach to interviewing an adult, and is

especially appropriate for the very old. You can also complete this life story for yourself.
The Legacy Project has a more detailed list of life interview questions, as well as a
simple Generations Scrapbook for children. We offer a Life Interview Kit you can order.
And you can write and permanently record a Life Statement.

The Life Story sheets are also useful in a care setting for older adults who may have
Alzheimer's, other forms of dementia, or other functional impairments. The sheets can be
completed by a family member, staff, or young volunteers from schools.
This fill-in-the-blanks life story has been inspired by an assessment form developed by the
Center in the Woods and published in Beyond Baskets & Beads: A Manual of Activities for
Older Adults with Functional Impairments by Mary Hart et al. Explains Beyond Baskets &
Beads:

Too often we only know people as they are today, failing to recognize that each
person is a sum total of the experiences which make up his or her life. We believe
that this is where many of the usual assessment tools fall short. Most of them are a
checklist format – easy to complete, but almost impossible to recall or use in any
meaningful way. Most of the questions are close-ended, requiring only a brief
response. They don't encourage the in-depth kind of conversation that can get at the
personal and truly pertinent information…. [With this assessment], instead of a cold
list of facts, we have a biography of a fascinating human being.

I've heard comments that older people, especially those with functional impairments, become
"like children." Some of their behavior may be childlike, but they are NOT children. They are
adults with a personal history. Children simply don't have that kind of personal history. After
decades of living, none of us would want our life experiences to be dismissed. Acknowledging a
person's personal history is what allows older adults to maintain their respect, dignity and, often,
their connection to the world around them and the people they love.

At Center in the Woods, a care facility for older adults in California, PA, each staff member or
volunteer who works with an older person is required to read through that person's life story. In
this way, they aren't just an "old man or woman with Alzheimer's" but become "someone's
mother or grandmother, a lady who owned her own business or lived in Paris. The frail elderly
man regains his status as the president of a company or a skilled surgeon. No longer is this
person to be pitied or patronized. Instead, we see a person to be admired and respected, a person
who is approaching the latter part of a full and useful lifetime." The center's activities can then be
planned with people's interests in mind, and information about individuals is much easier to
remember and use during interactions.

The Life Story sheets can be completed by interviewing an older person. Families can complete
the sheets as a personal record, and as information they can pass along to a care facility. Or, staff
or volunteers in a seniors center, nursing home, or other assisted living facility can do the
interview when a resident arrives. If the older person can't answer all the questions on their own,
family members can help provide information. This is also an activity that young people in
schools or community groups, especially teenagers, can volunteer to do in local seniors centers
or care facilities. Many seniors centers/facilities are desperate for volunteers, and this kind of
help is a welcome first step to perhaps long-term volunteering. Doing the interview introduces
young people to the strengths and diversity of older people, even those who may have functional
impairments, and provides a valuable service. For the older people, just going through the
exercise of the interview can mean a great deal. People want to talk about their lives, dreams, and
personal challenges, but they are rarely asked. When a young person takes the time to listen to an
older person, what the young person is really saying is that who the older person is, what they've
done, and the things they care about are important.

Some basic tips for doing an interview with an older adult to complete the sheets:
 An interview is just like talking with someone, but with prepared questions.
 Ask questions clearly and slowly, giving the person time to answer. Repeat questions if
necessary.
 Listen carefully to what the person says; don't interrupt or correct. Maintain eye contact
and show interest by leaning forward and nodding.
 If someone is talking about an unhappy or painful experience, show that you understand
how they feel (e.g. "That's very sad").
 It's okay for there to be moments of silence or emotion. A person's life is important, and
emotion is natural. Accept emotions as part of the process.
 If the person doesn't want to talk about something, that's okay – just go to the next
question.
 If the person has a lot to say in response to a particular question, summarize the key ideas
to fit in the space available on the sheets.
 An interview shouldn't last more than an hour. People do best when they're not tired. You
can always finish the interview at another time.
 Don't forget to thank the person you've interviewed. Let them know you value what
they've shared.

When the Life Story sheets have been completed for an elder, it's a nice idea for a family
member to read the story on audio or ideally video, with the camera zooming in on specific
photos during appropriate parts of the story (begin and end the video with a current photo of the
person). The video brings more life to the story, and can be played if the older adult is feeling
depressed, bored, restless, or agitated. The sheets and audio/video also become a long-term
family keepsake.

Part 2: What benefit would you expect them to gain from telling you their stories? You
may write your answer in three to four sentences, or list the benefits as goals.
Personal historians—those of us who help others tell or write their life stories, their family
stories, or their organization’s stories—know firsthand how powerful the experience can be for
everyone involved. We know, and research increasingly tells us, that life story writing and
reminiscence can improve the mood and quality of life for adults with more years behind than
ahead of them. This is true for both healthy and unhealthy adults, but especially for the adults
most likely to require the services of geriatric care managers.

In research on “dignity therapy” funded by the Canadian Cancer Society, palliative care expert
Harvey Chochinov (2005) studied the effect of asking 100 terminally ill cancer patients from
Canada and Australia about what issues mattered most to them or what they would most want to
be remembered about their lives. His researchers learned that this 30-to-60-minute therapy
session significantly reduced both suffering and depression. Few drug-based therapies can lessen
a person’s “distress about death or reinforce their sense of worth as they near death,” observed
Chochinov, a professor at the University of Manitoba and a researcher at CancerCare Manitoba.
His study shows that “this relatively simple and straightforward psychotherapy can help patients
attain the sense of peace they need to die with dignity.” In research on “dignity therapy” funded
by the Canadian Cancer Society, palliative care expert Harvey Chochinov (2005) studied the
effect of asking 100 terminally ill cancer patients from Canada and Australia about what issues
mattered most to them or what they would most want to be remembered about their lives. His
researchers learned that this 30-to-60-minute therapy session significantly reduced both suffering
and depression. Few drug-based therapies can lessen a person’s “distress about death or reinforce
their sense of worth as they near death,” observed Chochinov, a professor at the University of
Manitoba and a researcher at CancerCare Manitoba. His study shows that “this relatively simple
and straightforward psychotherapy can help patients attain the sense of peace they need to die
with dignity.”

5. What are some of the reasons why the health of a client’s family might suffer during
a terminal illness?

It can be easy to put your own needs last, but it is important if you are feeling tired or stressed to
look after yourself so you are still able to care for the person that needs you the most.

It is important for you to keep doing the activities you enjoy outside of your caring role. Taking
regular breaks from caring will help you avoid becoming worn out. Eating and sleeping well,
relaxing, being physically active and looking after your own health can give you the energy and
vitality you need for your role as carer. 

Carer support and respite care services can help you to take a break from your caring role. Ask
your palliative care service about your respite care options. You could have a volunteer stay with
your loved one while you take a short break. If you need a longer break, you could book some
time with respite services for the person you are caring for, so you can have some time away to
rest and recuperate. 
If you are feeling distressed, frustrated, guilty, exhausted, or annoyed, it is important to know
that these feelings are normal. If you are finding your role as a carer overwhelming, it may help
to discuss your feelings with your doctor or a counsellor.
6. Outline three strategies for managing your own emotional responses to death and
dying

 Identify and reflect upon your own emotional response to death and dying and the
potential impact of personal responses on you.
 Raise any issues with your Supervisor or an appropriate person.
 Use coping strategies such as exercise, activities, social outings, group
membership, talking with others, movies, faith practices (prayer).
 Many staff find it helpful to be able to just talk and have someone listen to how
they are feeling and in many cases to realise they are not alone and that grief is a
normal process.
 Accept the need for bereavement care and support for yourself and other team
members.

7. List four activities that may help with pain management.

Key pain management strategies include:
 pain-relieving medicines
 physical therapies (such as heat or cold packs, massage, hydrotherapy and exercise)
 psychological therapies (such as cognitive behavioural therapy, relaxation techniques and
meditation) 
 mind and body techniques (such as acupuncture)
 occupational therapy
 community support groups

8. Explain what an advanced care directive is.

An advance healthcare directive, also known as living will, personal directive, advance
directive, medical directive or advance decision, is a legal document in which a person specifies
what actions should be taken for their health if they are no longer able to make decisions for
themselves because of illness or incapacity. In the U.S. it has a legal status in itself, whereas in
some countries it is legally persuasive without being a legal document.

Case Study 1: Mrs D.S. Williams

Anxiety is common in adults with advanced life-limiting disease, adversely affecting quality of
life, social relationships and daily functioning at a critical time. It impairs the individual’s ability
to cope with their illness, erodes their trust in physicians, reduces treatment compliance and
makes physical symptoms more difficult to manage . Estimates of the prevalence of anxiety
disorder in the palliative care setting range from 6.8 to 13.3% , while significant anxiety
symptoms are more common (24–48%. However, anxiety is frequently unrecognised and
untreated.
Reactions to anxiety can vary. Some may be able to verbalize what they are feeling and others
may not. It's important to know what anxiety looks like so you can easily recognize it when it
happens.
Anxiety is driven by adrenaline, and its symptoms indicate that the body's "flight or fight"
response has been initiated.
Anxiety has cognitive, emotional, behavioral, and physical manifestations ranging from mild to
severe.
Cognitive Symptoms
Mild anxiety: The patient may be hyper-alert and have narrowed focus.
Moderate anxiety: She may have difficulty concentrating and be easily distracted.
Severe anxiety/panic: The patient may not be able to focus, even when clear directions are given.
Severe anxiety may lead to a disconnected state.
Emotional and Behavioral Symptoms
Mild anxiety: The patient may be irritable or mildly upset. She might be short-tempered or easily
annoyed.
Moderate anxiety: The patient may be restless, visibly upset, and have increasing irritability. She
may be tearful and express feelings of worry or uneasiness.
Severe anxiety: The patient may be crying uncontrollably, appear greatly agitated, and even yell
and scream. She may express feelings of doom, dread, or terror, or exhibit irrational or repetitive
self-soothing behaviors.
Physical Symptoms
Many of the physical manifestations of anxiety listed below are similar to those caused by the
underlying illnesses and treatments.
Mild anxiety: The patient may have insomnia and difficulty resting.
Moderate anxiety: She may have an increased heart rate or palpitations. Her breathing may be
faster, and she might complain of feeling nauseated or have diarrhea.
Severe anxiety: The patient may have all the above symptoms, but more severe. She may vomit
or soil herself. She might hyperventilate or have chest pains. Her pupils will dilate and she may
sweat profusely.
Other physical symptoms of anxiety include dry mouth, muscle twitching or trembling, and
abdominal pain.
Management
If your loved one is beginning to show signs of anxiety, the first thing you should do is try to
calm him down. Sometimes simple distraction could be enough to reduce anxiety level and keep
him calm. Try discussing something other than their illness or symptoms — perhaps the latest
ball game or celebrity gossip.
Simple interventions that can be done at home to help with anxiety include:
Distraction: Be careful with this, however, as patients nearing end of life will experience normal
anxiety that needs to be validated and not only replaced with different thoughts.
Deep breathing: The power of mindful breathing is endless. Making the simple effort of
gathering up your breath and allowing your exhalation (breathing out) to be longer than your
inhalation, will increase the activity of your vagal nerve, which will help you relax.
Naming: Simple naming games—e.g., name five things you can see in the room, four things you
can feel, three things you can hear, etc. These allow the patient to feel grounded in the moment,
which is usually not as overwhelming as the mind can make it appear. Once we are more present,
anxiety naturally dissipates.
Whether the anxiety passes or continues to increase, it's important to call the treating doctor to
report the symptom and get medical advice. If your loved one is in hospice care, contact the
hospice agency and report to the nurse that he is showing signs of anxiety. The hospice
nurse will give you specific instructions and may send a nurse out to evaluate the situation.
Most hospice agencies supply their at-home patients with a special kit of medications to be used
in case of emergency. These kits, sometimes called comfort kits or emergency kits, most often
contain at least one medication to treat anxiety. The hospice nurse may give you instructions to
start one of the medications and record it on a medication log.
If your loved one isn't on hospice care, you'll need to get instructions from the treating doctor or
the doctor on-call. She may call in a prescription to the pharmacy or request to see the patient in
the office
Medications
When it comes to medications for anxiety at end of life; there are usually two lines of care;
Benzodiazepines: These are used intermittently for episodes of anxiety severe enough to
interrupt a patient's day-to-day life and that have not responded to relaxation measures. The type
of medications used will usually belong to the benzodiazepine family and include:
 Ativan (lorazepam)
 Klonopin (clonazepam)
 Xanax (alprazolam)
 Valium (diazepam)
Antidepressants: By regulating brain chemistry, antidepressants like Prozac (fluoxetine),
Remeron (Mirtazapine), Effexor (Venlafaxine) and many others, can be used when patients have
recurrent episodes of anxiety.
Even thought their label as "antidepressants" points to their use for depression instead of for
anxiety, these medications can have a powerful effect on chronic anxiety. By regulating brain
chemistry these agents help further prevent episodes of anxiety, and might help patients rely on
benzodiazepines less. Since excessive use of benzodiazepines can cause sedation and steal
valuable moments of with a loved one nearing end of life, taking a preventative medication may
be a better option. The limitation to the use of antidepressants for chronic anxiety at the end of
life, is that they need time to work, taking up to six weeks for full clinical effect. Some patients
reaching the end of their lives might not have this much time, and should rely solely on as
needed medications like benzodiazepines.
Treating Underlying Causes
Two of the most common causes of anxiety are pain and shortness of breath (dyspnea). If your
loved one is experiencing one of these symptoms, it's important that it be treated along with the
anxiety.
Individual Activity: Use aromatherapy
Whether they’re in oil form, incense, or a candle, scents like lavender, chamomile, and
sandalwood can be very soothing.
Aromatherapy is thought to help activate certain receptors in your brain, potentially easing
anxiety.
When in a team: Go for a walk or do 15 minutes of yoga
Sometimes, the best way to stop anxious thoughts is to walk away from the situation. Taking
some time to focus on your body and not your mind may help relieve your anxiety.

Case Study 2

Metastasis—also referred to as “metastatic cancer”—is the medical term for cancer that has
spread to a part of the body outside its origin. With regards to prostate cancer, the terms
“metastatic prostate cancer”, “advanced prostate cancer”, and “stage 4 prostate cancer” generally
refer to cancer that has spread beyond the lymph nodes and tissues immediately surrounding the
prostate.
Metastasis most commonly occurs when cancer cells break away from the main tumor and are
circulated throughout the body via the bloodstream or lymphatic system. During this process,
these cancer cells can collect and grow in different parts of the body, forming metastases.
Several factors influence the likelihood of metastasis in prostate cancer, including the cancer’s
aggressiveness, indicated by its Gleason score, and the point at which treatment begins.
Theoretically, any cancer can spread to any part of the body. In reality, certain types of cancer
tend to spread to specific places. Prostate cancer most commonly spreads to the bones, followed
by the lymph nodes, lungs, liver, and brain. Regardless of where metastases form, the type of
cancer remains the same; prostate cancer that has metastasized to the bones is still prostate
cancer, not bone cancer.
alliative care is given to improve quality of life for someone with a serious or life threatening
disease such as advanced prostate cancer. It can help patients carry on and enjoy their daily life.
The goals of palliative care include:
Treating and preventing symptoms such as pain, nausea, fatigue and other physical symptoms
caused by cancer or its treatment
 Treating a patient’s emotional and social needs
 Addressing a patient’s spiritual needs or concerns
 Addressing a patient’s practical needs, such as transportation and financial concerns
 Providing support for the patient’s family, friends, and caregiver
Cure is not the goal with palliative care, it is to provide comfort. You may also hear words such
as comfort care, supportive care and symptom management used to describe palliative care.
Prostate cancer can cause problems with urination. You may feel the need to urinate all the time
or have trouble urinating. You may have a weak or interrupted flow of urine, difficulty starting
or stopping urination, and painful or burning urination.
You may experience other symptoms too. These prostate cancer symptoms can include pain in
the lower back, hips, or upper thighs; difficulty having an erection; pain with ejaculation; and
blood in the urine or semen. Early prostate cancer, however, does not usually cause symptoms.
Your doctor will perform several tests to detect prostate cancer. After first performing a physical
exam, your doctor will give you a PSA (prostate-specific antigen) blood test. Other tests may
include an ultrasound, x-ray, CT scan, MRI or biopsy (removal and analysis of a tissue sample).
There are several options for treating prostate cancer. In the early stages, it may be removed with
surgery; but if the tumor is too large, or too close to any set of nerves, surgery may not be an
option. Radiation therapy and hormone therapy may also be used to treat prostate cancer. If it is
at an early stage and growing slowly, you may have the option of watchful waiting (monitoring
the cancer with regular checkups).
Palliative care specialists will explain to you all your different options, and then help you to
make an informed choice. They do this by helping you to match your treatment options with
your personal needs and goals. They will spend a great deal of time with you to ensure that you
and your family fully understand your disease.
Palliative care specialists are experts in treating the symptoms of a serious illness like prostate
cancer. Bone pain, for example, is common with prostate cancer. The specialists in your
palliative care team will work with you to find the best medicines for your pain. They may
recommend using a number of medicines and steroids that would help you reduce treatment with
opiates.
Fatigue (feeling weak or tired) is a common side effect if you are undergoing hormone therapy,
as it decreases testosterone. Radiation treatments can also cause fatigue and other symptoms.
Palliative care specialists can help you boost your energy by adjusting hormone levels with
medicines, and suggesting specific exercises and other lifestyle changes.
Common prostate cancer side effects, such as incontinence and loss of sex drive, are often hard
to deal with. They may affect your self-esteem and create anxiety for both you and your loved
ones. Your palliative care team will help you to discuss your situation with your family, to help
ease any emotional issues that may be related to side effects.
Physical therapists play a vital role in the rehabilitation of patients with prostate cancer by
teaching and implementing weight-bearing and gentle exercise, resistive exercises, and vibration
exercises which transmit energy to the body with special techniques that strengthen the posture,
balance, and body fitness, maintain or improve bone density, and prevent falls [6, 7]. In addition,
pelvic floor training helps alleviate symptoms of urinary incontinence and maintain normal
pelvic floor muscle functions [8]. Physical therapy also focuses on restoring the cardiovascular
system which helps improve blood flow; this has been shown to improve symptoms associated
with cancer-related fatigue and erectile dysfunction. Physical therapists assess the patients and
develop individualized intervention programs including exercise programs to increase the
endurance, muscle strength, mobility, and balance of patients with prostate cancer
Occupational therapists play a vital role in increasing the occupational participation of the
patients with prostate cancer. Occupational therapists use training in activities of daily living,
assistive technology approaches, education of energy conservation techniques, management of
treatment-related problems such as pain, fatigue, and nausea. Moreover, occupational therapists
give occupational balance training for regaining value of engagement in meaningful activities
with a holistic view of creative and therapeutic use of activity. Occupational therapists focus on
adaptations and offer education assistance for sexual activity for patients where certain sexual
positions are limited or impossible due to pain, fatigue, or positioning issues. This complication
in prostate cancer treatments is one of the most important limitations of activities of daily living
that men face.