Introduction
By definition, palliative care (or hospice care) is among the various forms of medical care or treatment which concentrates in reducing the severity of the symptoms of a disease (Barraclough, 1997, p 1367; Portenoy and Bruera, 1997, Ch 2; Field et al., 2001, pp 8-10). It is often regarded as slowing the progress of a terminal illness rather than providing for a cure (Mcnamara, 2001, p. 121; Geisler, Krabbendam & Schuring, 2003, p. 103). The World Health Organization (WHO, 2005) generally define the term as “an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.”
The Hasting’s Center Report (2003, pp.6-8) enumerated the services in palliative care, which include professional nursing care, personal assistance with activities of daily living, various forms of rehabilitation therapy, dietary counseling, psychological and spiritual counseling for both patient and family, volunteer services, respite care, provision of medical drugs and devices necessary for palliative care, and family bereavement services following the patient’s death. Nurses, social workers, pastoral counselors, nursing assistants, and other health professionals under the management of a physician comprise the interdisciplinary care team.
In palliative care, pain is the most evident symptom that causes difficulty to treat. Palliative care is sometimes used in referral to the addition of symptom control and pain management services with the mainstream health care system (The Hasting’s Center Report, 2003, pp.6-8.) Thus, a health care practitioner or any individual associated with this kind of specialized medical care should be well equipped with the most comprehensive knowledge and application on pain and its management.
Pain and its Management
Pain is one of the most common human experiences, as no one is spared from such suffering, whether such to the physical or emotional. Yet for the longest time, pain has never been fully considered as a medical problem. It may be due to the fact that it is a subjective and a highly personal experience. Though pain can be measured, it cannot diagnose, felt (unless it is your own), imagined or proved its existence. Pain as a sensation differs from one person to another. LaPorte Matzo & Sherman (2001) says “pain is not just from physical disorders but also from combinations of physiological, pathological, emotional, psychological, cognitive, environmental, and social factors.” Hence, no person can exactly feel the same degree of pain at the same time. But pain is as real as the symptoms it shows, it is the reason why approximately 70 million visits were made by people to health care professionals every year (National Women’s Health Resource Center, 2004).
There has been a clear lack of knowledge when it comes to the overall nursing knowledge, whether when it comes to the physical practices that come with nursing care, the attention that they must give to the pharmaceutical concerns for their patient, and especially when it comes to the management of their patients' pains (Buschmann, 2001). Pain and its management is one of the most important parts of the nursing education which has been widely ignored by many nurses that only seek to gain monetary advancements. Palliative care is achieving the best quality of live for the patient and their families. The role of the health care provider like the nurse is to deliver the most effective and maximum utilization of resources and the proper observance of the standard operating procedures of palliative care (Marelli, 1999; Paice, 2005, p. 95). Thus, there are many aspects of caring that have been forgotten or disregarded in the effort to gain more advantage economic-wise. This ensures that the nursing profession continues to be a holistic practice that involves not only one aspect but the whole. Holistic professions do not only provide care for one of the body functions but the entire, which include the emotional health, physical health, and mental health of the patient (LaPorte Matzo & Sherman, 2001). Nurse must remember that care should be provided up to their best efforts in order to ensure that their patients are provided with the care that they are entitled to as their human rights.
At the same time, holistic care also refers to the knowledge concerning the pharmaceutical needs of the patients. Every year there have been several researches done concerning the removal of pain, whether temporarily or permanently (King, 1991) and recent studies have shown that nursing knowledge has continued to increase when it comes to the nurses’ identification of pain (Buschmann, 2001). However, studies also show that despite the knowledge many nurses have when it comes to emotional pain management, they believe that it worries them and does not give them enough to time to complete their work (Buschmann, 2001). At the similar point in time, it was shown that nurses, compared to physicians, therapists, and pharmacists, have more knowledge and experience when it comes to pain assessment, which makes them the best professionals who have the ability to judge the degree of pain that a client may have. Physicians and those in the pharmaceutical business may also be able to offer assistance when it comes to pain relief however they will still have to rely on the nurses’ ability to asses the extent of pain as well as their judgment on the immediate care for the patients once these problems start.
As a consequence, nurses should have already trained and prepared for their possible confrontation with several bioethical issues. They must then be prepared to face some matters that will need to be cleared as well as have to do intense soul searching in order to help them achieve better status and deal with their own emotions as well as their patients in order to establish a caring relationship between them. In order for this to happen, it is advised that the nurses avail or establish a team pain management plan which will help standardize their goals and hoped achievements when it comes to their patients’ welfare (Angelucci, Quinn & Handlin, 1998), especially since nurses’ decisions and the patients’ pain management programs may highly affect the patients’ emotions, physical reactions, spiritual beliefs, mental health, and overall quality of life. With such, it is suggested that nursing pain management should be as thorough and ethically charged as possible in order to ensure the best quality of care that the patients will receive.
Pain management, in this case, is an important aspect of caring for patients. However, despite of the available pain management guidelines, many patients complain incessantly about the pain after surgery or as a symptom of a terminal disorder (Buschmann, 2001). This perhaps implies the important correlation of theories and the role of nurses to pain management. Nurses should do more than administer methods or means to control the pain. As care providers, they should feel what their patients are feeling by establishing a personal bond with them and by being effective listeners.
New Breakthroughs in Other Symptoms and Pain Management
Other symptoms such as gastrointestinal, dyspnoea, confusional states, depression and distress are encountered in palliative care (Billings, 2000). Gastrointestinal symptoms include gastroparesis, nausea, and vomiting present in cancer related ailments. Diarrhea is also common to AIDS victims. With the help of new pharmaceutical substances, medicines to alleviate these symptoms are useful. Examples include the use of prokinetic drugs and new serotonin antagonist antiemetics to cancer related symptoms; Octreotide relieves AIDS related diarrhea; and progestational drug, such as megastrol acetate and glucocorticoids improve anorexia (Bruera & Neumann, 1998, pp. 1717-26). Dyspnoea, on the other hand, is perceived as the difficulty or pain in breathing. This is considered to be a common symptom of a serious many disorder. But now, breathlessness is manageable by using opioids and oxygen. Confusional states like delirium are under-recognized and under-treated in terminally ill patients (Billings, 2000). Using some drugs like haloperidol, chlorpromazine, and lorazepam alleviates the delirious behaviour of AIDS patients. Depression is also under-recognized and under-treated although it is very much common to everyone who suffers in a terminal ailment. According to Block SD for the ACP-ASIM End-of-Life Care Consensus Panel (2000), there is a significant number of clinicians who incorrectly presume that the stage of depression is natural and normal or expected to anyone, rather than a biologically based and treatable form of emotional suffering distinct from the state of sadness. J Andrew Billings (2000) affirmed that “the biological signs that usually form the basis of a diagnosis of major depression are often present in a terminal condition but are attributable to the medical illness rather than the psychological state. Clinicians must assess patients for classic depressive signs that cannot be ascribed to the underlying illness (for example, early morning waking that is not due to pain) and rely more on such psychological findings as excessive hopelessness, helplessness, worthlessness, and guilt and suicidal ideation.” With the suppressing effects of psychostimulants like dexamfetamine or methylphenidate, depression to such patients was use as treatment. Other advances on drugs in pain management were comprehensively presented in Billings’ work.
Palliative Care: an ethical “end-of-life” responsibility
"Ethical dilemmas have always been with us, but their nature in health care settings has changed radically with the development of new knowledge and technology" (Thompson & Thompson, 1990, p. 89). Nurses caring for terminally ill patients hold a great responsibility in numerous aspects. The many problems and difficulties encountered by nurses in the course of palliative care are numerous. A survey conducted to identify the five most frequent and five most difficult problems perceived by nurses in hospice, community and acute care settings revealed physical problems, emotional problems, work-related, death-related, and nurse-related problems as a result of caring for dying patients and their families (Copp & Dunn, 1993, pp. 19-25). Central issues are also identified such as talking to patients about dying, the decision to die at home or not, 'difficult' patients (or family), quality-of-life versus prolonging life and pain management (McGrath, Yates, Clinton & Hart, 1999, pp, 17-33).
Nurses handle not only a huge social responsibility by a great moral responsibility as well. In relation to palliative care, Jameton (1984) stated:
Patients, their families, and clinicians make decisions
about the treatment of dying patients against a background of conflicting feelings about death,varying evaluations of death as a way of escaping painand suffering, and great uncertainty aboutits timing. Clinicians now recognize that dying people are still actively engaged in life. Respect for persons demands a response to their needs even if they have a brief future; care is not an investment, but an ongoing human response. (p. 225) With the ethical considerations and debates on palliative care, nurses must handle the severe problems and dilemmas occurring in practice through more research, study, training, and education.
Conclusion
Palliative care is an integral part of all health care. It neither aims to hasten nor to postpone death and involves much more than fast-acting pain relief medications; but a psychosocial and spiritual goal and dimension should be met through the building of trust, communication, and relationships not only for the body but with self of the patient and the system of the family.
The best rationale of palliative care in the society today was captured by science-fiction writer Phillip K. Dick (1965) where he stated that: “Life itself was unendurable and hence had to be ameliorated. As a thing in itself, it could not be actually lived. There had to be some way out (p. 90)”.
Palliative care still challenges the ability of every health care profession to provide the highest quality of life especially to those who are at the end of life. Thus, nurses must be equipped with competent skills acquired from continued education and training along with future researches on the effectiveness of palliative care management. With these, there is an assurance for optimum growth, development and availability of this specialized, comprehensive and functional end of life care.
Reference:
Angelucci, D, Quinn, L & Handlin, D 1998 A Pain Management Relief Plan. Nursing Management, 10th January.
Baily, MA, D’Onofrio, C, Jennings, B & Ryndes, T 2003, ‘Access to Hospice
Care: Expanding Boundaries, Overcoming Barriers’, The Hastings Center Report, vol. 33, no. 2, pp. 3+.
Barraclough, R 1997, ABCs of Palliative Care: Depression, Anxiety, and
Confusion. Journal of the American Medical Association, 279, pp. 1365-1368.
Billings, JA 2000, September 2 ‘Palliative care – Clinical Review’, British
Medical Journal, viewed 25 November 2005, <www.findarticales.com.>
Block SD for the ACP-ASIM End-of-Life Care Consensus Panel 2000 ‘Assessing
and managing depression in the terminally ill patient’, Ann Intern Med, vol.132, pp. 209-18.
Bruera, E & Neumann, CM 1998 ‘Management of specific symptom complexes in
patients receiving palliative care’, Can Med Assoc, vol. 158, pp. 1717-26.
Buschmann, MT 2001 Pain Management: ‘An Assessment of Surgical Nurses' Knowledge’, MedSurg Nursing, 1st August.
Copp, G & Dunn, V 1993 ‘Frequent and difficult problems perceived by nurses
caring for the dying in community, hospice and acute care settings’, Palliat Med, vol. 7, pp. 19-25
Dick, PK 1965 The Zap Gun, Galaxy, New York.
Field, D, Clark, D, Corner, J & Davis, C 2001, Researching Palliative Care,
Open University Press, Buckingham.
Geisler, E, Krabbendam, K,& Schuring, R (eds) 2003, Technology, Health Care
and Management in the Hospital of the Future, Praeger, Westport, CT, pp. 103-131.
Jameton, A 1984 Nursing practice: The ethical issues, Prentice Hall, Englewood,
NJ.
King, E 1991 ‘Communication, Anxiety and the Management of Postoperative Pain’, Health Communication, vol. 3, no. 2, p. 127.
LaPorte Matzo, M & Sherman, DW, eds. 2001 Palliative Care Nursing: Quality
Care to the End of Life, Springer Publishing, New York, NY.
Marrelli, T 1999 Hospice and Palliative Care Handbook, Mosby, St. Louis, MO.
McGrath, P, Yates, P, Clinton, M, & Hart G 1999 ‘"What should I say?":
qualitative findings on dilemmas in palliative care nursing’, Hosp J, vol. 14, pp. 17-33
Mcnamara, B 2001, Fragile Lives: Death, Dying and Care, Allen & Unwin, Crows
Nest, N.S.W. pp. 120-135.
National Women’s Health Resource Center, 2004, Pain Management, viewed 25
November 2005, <http://www.ivillagehealth.com/library/nwh/content>.
Paice, J 2003, Practical Palliative Principles, Journal of Pain and Symptom
Management, vol. 25, pp 93-102.
Portenoy, R & Bruera, E 1997, Topics in Palliative Care, Oxford University Press,
New York.
The Hasting’s Center Report, 2003, ‘What Is Hospice Care?’, vol. 33, no. 2, pp.
6-8.
Thompson, JE, & Thompson, HO, 1990, Professional ethics in nursing, Robert E.
Kreiger, Malabar, FL.
World Health Organization 2005, WHO Definiton of Palliative Care, viewed 25 November 2005,
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